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The nurse is caring for a client who was diagnosed with left-sided heart failure and states, "I do not understand why I have so much trouble breathing if I have heart failure.”. Which of the following responses should the nurse make?

"I am going to notify the healthcare provider because you should not have trouble breathing with left-sided heart failure.”.

"The right side of your heart fails first and causes a back-up of blood in the left side of the heart and then the lungs.”.

"When the left side of your heart does not pump enough blood out, it gets backed up in your lungs and causes shortness of breath.”.

"Typically, clients with left-sided heart failure have difficulty breathing with exertion, but not when resting.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Trouble breathing is a hallmark symptom of left-sided heart failure. Suggesting that it should not occur would be inaccurate. The failure of the left ventricle leads to blood accumulation in the pulmonary vessels, creating pulmonary congestion and shortness of breath. Prompt provider notification may be necessary but does not address the underlying pathophysiology. Pulmonary symptoms are expected in this type of heart failure.

Choice B rationale

While left-sided heart failure can eventually lead to right-sided heart failure, the initial problem is with left ventricular dysfunction. This causes reduced forward blood flow and pulmonary congestion due to backflow of blood into the lungs. Right-sided heart failure is not the primary event leading to pulmonary symptoms in left-sided heart failure.

Choice C rationale

The left ventricle's inability to pump effectively results in blood backing up into the pulmonary circulation, causing pulmonary congestion and symptoms like shortness of breath. This is consistent with the hemodynamics of left-sided heart failure. Pulmonary capillary pressure increases, leading to fluid leakage and impaired gas exchange, explaining the client's breathing difficulty.

Choice D rationale

Although difficulty breathing with exertion (dyspnea on exertion) is common, resting symptoms, including orthopnea and paroxysmal nocturnal dyspnea, can also occur in left-sided heart failure due to fluid redistribution. Limiting symptoms to exertion inaccurately portrays the clinical presentation and disregards other significant pulmonary signs.

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Correct Answer is B

Explanation

Choice A rationale

Assessing energy levels provides indirect information about cardiac output but lacks specificity regarding fluid overload or pulmonary congestion, which are key indicators of heart failure exacerbation. It is a relevant question but not the best for evaluating treatment outcomes.

Choice B rationale

Asking about pillow use evaluates orthopnea, a common symptom of heart failure due to fluid buildup in the lungs when lying flat. It provides a direct assessment of fluid status and the effectiveness of heart failure management, making it the best question.

Choice C rationale

Exercising regularly is an important lifestyle aspect for heart failure patients but does not directly assess the status of symptoms such as fluid overload or cardiac function. Thus, it is not the most critical outcome measure.

Choice D rationale

Chest pain can indicate ischemia or worsening cardiac function but is not specific to fluid status or pulmonary congestion in heart failure. Therefore, it is a relevant but less optimal question for evaluating treatment goals.

A. Venison stew and ice cream. B. Poached salmon and green beans. C. Spinach salad and rhubarb pie. D. Sautéed mushrooms and fried rice.

Correct Answer is A

Explanation

Choice A rationale

Venison stew and ice cream are high in animal protein and calcium. Excess dietary calcium and animal protein can increase the urinary excretion of oxalate, contributing to kidney stone formation. Hyperoxaluria leads to the precipitation of calcium oxalate crystals in the renal tubules, exacerbating stone development.

Choice B rationale

Poached salmon and green beans are suitable because salmon is low in oxalate content, and green beans are unlikely to contribute significantly to oxalate excretion. Low-oxalate foods help reduce the recurrence risk of kidney stone formation and support overall renal health.

Choice C rationale

Spinach salad and rhubarb pie are rich in oxalate. Spinach contains 970 mg per 100 g, and rhubarb contributes significantly to dietary oxalate, promoting hyperoxaluria and increasing kidney stone risks. These foods should be avoided by individuals prone to oxalate stones.

Choice D rationale

Sautéed mushrooms and fried rice are acceptable choices, as mushrooms have negligible oxalate content and fried rice does not contribute significantly to oxalate excretion. Both options support balanced nutrition while minimizing renal stone risks.

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The nurse is caring for a client who was diagnosed with left-sided heart failure and states, "I do not understand why I have so much trouble breathing if I have heart failure.”. Which of the following responses should the nurse make?

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