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. The closure of the pulmonic and mitral valves corresponds to heart sound S1, not S2.
B. The tricuspid and mitral valves close with S1.
C. Heart sound S2 represents the closure of the aortic and pulmonic valves, signaling the end of systole and the beginning of diastole.
D. The mitral valve closes with S1, not S2.
E. The pulmonic and tricuspid valves do not correspond with S2.

A. Inquire about personal and family cardiac history B. Ask about fatigue and chest pain C. Inspect for intercostal retractions and nasal flaring D. Palpate the chest for any thrills and heaves E. Auscultate the heart with the diaphragm and bell of stethoscope

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

Explanation

A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.
B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.
C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.
D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.
E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.

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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

The nurse is asked to describe what the heart sound S2 represents. What would be the correct response by the nurse?

Correct Answer is C

Explanation

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

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

Explanation

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