The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

Pallor and/or cyanosis of extremities

Orthopnea, peripheral edema, crackles

Dizziness, syncope. palpitations

PAWP of 12 and CVP of 6

Answer and Explanation

The Correct Answer is B

A. Pallor and/or cyanosis of extremities: While pallor and cyanosis can indicate severe heart failure, they are not early signs. These symptoms usually appear later in the disease process.

B. Orthopnea, peripheral edema, crackles: These are early signs of heart failure indicating fluid overload due to decreased cardiac output. Orthopnea is difficulty breathing when lying flat, peripheral edema is swelling in the limbs, and crackles indicate fluid in the lungs.

C. Dizziness, syncope, palpitations:These symptoms can occur in heart failure but are not specific to fluid overload; they are more indicative of decreased cardiac output and possible arrhythmias.

D. PAWP of 12 and CVP of 6: These values are within normal limits. PAWP (Pulmonary Artery Wedge Pressure) and CVP (Central Venous Pressure) would be elevated in fluid overload.

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Correct Answer is D

Explanation

A. "Controlling my blood pressure will decrease my risk of having a heart attack to some degree." This statement is accurate. Controlling blood pressure reduces the risk of developing ACS.

B. "Because I'm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk." Research indicates that even modest reductions in blood pressure can significantly lower the risk of cardiovascular events, especially in older adults.

C. "High blood pressure will increase my body's need for oxygen and increase my heart's workload." High blood pressure increases myocardial oxygen demand and can lead to ischemia, which is a precursor to ACS.

D. "My high blood pressure has no relationship to the severity of heart disease or its outcomes." This statement is false. High blood pressure is a major risk factor for heart disease, including ACS, and it directly affects the severity and outcomes of heart disease.

A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Chronic pain related to appendicitis D. Constipation related to decreased bowel motility and decreased fluid intake

Correct Answer is B

Explanation

A. Imbalanced nutrition: Less than body requirements related to decreased oral intake: While this may be relevant, it is not the highest priority in acute appendicitis. Infection prevention is more critical.

B. Risk for infection related to possible rupture of appendix: The primary concern in appendicitis is the risk of rupture, leading to peritonitis and sepsis. This makes infection control the top priority.

C. Chronic pain related to appendicitis: Pain in appendicitis is acute, not chronic. Managing infection risk is more urgent.

D. Constipation related to decreased bowel motility and decreased fluid intake: Constipation is not a priority concern in the context of acute appendicitis. The risk of infection takes precedence.

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The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

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Naxlex Comprehensive Predictor Exams

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