The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Edema

Shortness of breath

Increase in appetite

Extreme weight loss

Jugular vein distended (enlarged)

Answer and Explanation

Correct Answer : A,B,E

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

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Correct Answer is C

Explanation

A. Asthma typically presents with wheezing, not fine crackles.
B. Pneumothorax usually presents with decreased or absent breath sounds rather than crackles.
C. Atelectasis, which is common after surgery, can cause fine crackles at the lung bases due to collapsed alveoli reopening during inspiration.
D. Emphysema generally results in diminished breath sounds and hyper-resonance rather than crackles.
E. Bronchitis typically produces coarse crackles or rhonchi, not fine crackles.

A. Supine B. Trendelenberg C. High-Fowler D. Semi-Fowler E. Left-lateral

Correct Answer is C

Explanation

A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.
B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.
C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.
D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.
E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.

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The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Nursing Test Bank

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Explanation

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