The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Ascending edema

The client has no desire to eat.

The client sleeps on three pillows at night.

The client has a five pound weight gain.

Answer and Explanation

The Correct Answer is C

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

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Correct Answer is D

Explanation

A. "Hypertension is the leading cause of death in people your age.": While hypertension is a significant risk factor for cardiovascular events and mortality, stating it as the leading cause of death without specific context or statistical data may not provide the most informative response to the client's question.

B. "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.": Hypertension is primarily associated with cardiovascular risks such as stroke, heart disease, and kidney disease. While it can contribute to overall health risks, it is not typically linked directly to type 1 diabetes or cancer in the context of this client's question.

C. "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.": While hypertension can contribute to cardiovascular complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE), these are not the primary risks that are typically emphasized when discussing the importance of treating hypertension.

D. "Hypertension greatly increases your risk of stroke and heart disease.": This response is the most relevant and specific to the client's question. Hypertension is a major risk factor for stroke, heart disease (including heart attack and heart failure), and other cardiovascular complications. By treating hypertension and controlling blood pressure within recommended targets, the client can significantly reduce the risk of these serious and potentially life-threatening conditions.

A. Whether the client and involved family members understand dietary changes and the role of nutrition B. Whether the client and involved family members understand the role of genetics in the etiology of the disease C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately D. Whether the client and involved family members understand the importance of social support and community agencies

Correct Answer is C

Explanation

A. Whether the client and involved family members understand dietary changes and the role of nutrition:

This assessment is important as diet plays a crucial role in managing coronary artery disease (CAD) and preventing further complications. Understanding dietary changes, such as reducing saturated fats, sodium intake, and incorporating heart-healthy foods like fruits, vegetables, and whole grains, is essential. Nutrition education can help clients and their families make informed choices that promote heart health and improve overall well-being. However, while understanding dietary changes is significant, it may not be the most critical determination during the initial intake assessment, especially when compared to immediate concerns like recognizing acute cardiac symptoms.

B. Whether the client and involved family members understand the role of genetics in the etiology of the disease:

Understanding the genetic factors contributing to coronary artery disease can provide valuable insights into the client's risk factors and potential hereditary predispositions. This knowledge can help guide screening, prevention, and management strategies tailored to the client's specific genetic profile. While genetic factors are important considerations in CAD, they typically require a more detailed evaluation and may not be the primary focus during the initial intake assessment, especially compared to immediate concerns related to symptom recognition and response.

C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately:

This is a crucial assessment because recognizing symptoms such as chest pain, shortness of breath, nausea, sweating, and arm or jaw pain is essential in identifying a potential heart attack or unstable angina. Knowing when to seek emergency medical assistance and how to respond appropriately can significantly impact outcomes and reduce the risk of complications. Immediate response to acute cardiac symptoms is a critical aspect of CAD management, making it a top priority during the intake assessment.

D. Whether the client and involved family members understand the importance of social support and community agencies:

Social support and community resources play a valuable role in CAD management, providing emotional support, access to education programs, rehabilitation services, and other supportive resources. Understanding the importance of social support and knowing how to access community agencies can enhance the client's overall well-being and facilitate long-term management.

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The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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