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. CVA tenderness is associated with renal issues, not directly with congestive heart failure.
B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.
C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.
D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.
E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.

A. Considered normal part of aging B. Can be non-pathologic C. Heard just after S2 D. Caused by a dilated (more complaint) ventricle E. An expected finding in children

Correct Answer is ["A","B"]

Explanation

A. S4 is often considered a normal finding in older adults due to decreased ventricular compliance.
B. While it can be non-pathologic, it is more commonly associated with underlying conditions such as hypertension or heart failure.
C. The statement about being heard just after S2 is incorrect; S4 can be heard in various populations, particularly older adults.
D. An S4 sound is associated with a stiff or hypertrophied ventricle, not a dilated ventricle.
E. An S4 sound is not typically an expected finding in children; it is more common in older adults.

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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.

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Naxlex Comprehensive Predictor Exams

When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

Correct Answer is C

Explanation

When performing a cardiovascular assessment, what would the nurse understand about an S4 heart sound?

Correct Answer is ["A","B"]

Explanation

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