The nurse is assessing a newly admitted client diagnosed with left ventricular failure.
Which of the following findings should the nurse expect during the assessment?

Edema of the lower extremities.

Pulmonary crackles auscultated.

Ascites.

Jugular vein distention.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Edema of the lower extremities suggests right-sided heart failure, not left ventricular failure. Fluid backs up into systemic circulation in right-sided failure, while left-sided failure primarily affects pulmonary circulation. Differentiating between these conditions is essential for targeted management.

Choice B rationale

Pulmonary crackles result from fluid accumulation in alveoli due to left ventricular failure, where decreased cardiac output causes blood to back up into pulmonary vasculature. Crackles indicate pulmonary congestion or edema. Prompt identification aids in early intervention. Normal respiratory assessment excludes crackles.

Choice C rationale

Ascites is more indicative of chronic right-sided heart failure or liver disease, not acute left ventricular failure. Ascites results from systemic venous congestion, which is less common in isolated left-sided heart failure. Differentiating causes helps refine diagnostic focus.

Choice D rationale

Jugular vein distention is associated with elevated central venous pressure, typical of right-sided heart failure or combined heart failure. It does not specifically characterize left ventricular failure. Accurate recognition of findings ensures precise diagnosis and management.

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Correct Answer is B

Explanation

Choice A rationale

Magnesium levels and bilateral lower extremity ultrasounds are not specific for assessing target organ damage in hypertension. While magnesium may influence cardiovascular health, it is not a primary indicator of organ damage. Ultrasounds evaluate arterial or venous abnormalities, not hypertension’s systemic effects.

Choice B rationale

Urinalysis, blood chemistry, and a 12-lead electrocardiogram assess renal, metabolic, and cardiac effects of hypertension. Proteinuria in urinalysis indicates kidney damage. Electrolyte imbalances or creatinine elevations suggest renal impairment. An ECG reveals left ventricular hypertrophy or ischemia. These tests comprehensively evaluate hypertension-related complications.

Choice C rationale

A complete blood count evaluates blood cell counts but does not directly assess target organ damage from hypertension. An electroencephalogram assesses brain activity, not hypertension-induced injury. These tests are inappropriate for this diagnostic goal.

Choice D rationale

Troponin, calcium, and partial thromboplastin time evaluate myocardial infarction, bone health, and coagulation, respectively. They do not provide information about hypertension’s systemic organ effects. Accurate test selection ensures appropriate diagnostic focus.

A. Ask if the client took any medication to treat the headache. B. Refer the client to see an eye specialist. C. Obtain the client's blood pressure. D. Obtain a full history and physical.

Correct Answer is C

Explanation

Choice A rationale

Asking about medication use for headaches provides insights into pain management strategies but does not directly address underlying causes of symptoms. Vision changes and headaches may indicate neurological or cardiovascular issues, which require immediate investigation of vital signs like blood pressure to rule out hypertension or increased intracranial pressure.

Choice B rationale

Referring the client to an eye specialist addresses vision changes but neglects the acute nature of headaches. Hypertension or elevated intracranial pressure can affect both vision and cause headaches, and immediate assessment of these factors through blood pressure is more urgent.

Choice C rationale

Obtaining blood pressure evaluates for hypertension, which can manifest with headaches and visual disturbances due to increased arterial pressure affecting cerebral and ocular vessels. Normal blood pressure ranges are typically 120/80 mmHg. Immediate blood pressure measurement prioritizes acute care and mitigates potentially life-threatening conditions.

Choice D rationale

Obtaining a full history and physical is valuable for comprehensive care but delays immediate assessment of critical symptoms such as visual changes and headaches. Measuring blood pressure provides faster evaluation of acute conditions like hypertensive crisis or stroke risk.

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The nurse is assessing a newly admitted client diagnosed with left ventricular failure.Which of the following findings should the nurse expect during the assessment?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with hypertension who is being assessed for possible target organ damage.The nurse should monitor the results of which of the following diagnostic tests?

Correct Answer is B

Explanation

The nurse is performing a health screening for a client at a local clinic and the client states, "I have noticed changes in my vision recently and I have also had some bad headaches.”. Which of the following actions should be a priority for the nurse to take?

Correct Answer is C

Explanation

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The nurse is assessing a newly admitted client diagnosed with left ventricular failure.
Which of the following findings should the nurse expect during the assessment?