The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?
"I feel short of breath when I lie down flat."
"The sputum I have been coughing up is pink."
"The nurse I had yesterday said she could hear fluid in my lungs."
"I feel like fluid has been building up in my abdominal area."
The Correct Answer is D
A. This symptom is consistent with orthopnea, which is common in left-sided heart failure rather than right-sided heart failure. In orthopnea, patients experience shortness of breath when lying flat because fluid accumulates in the lungs due to impaired left ventricular function.
B. Pink-tinged or blood-tinged sputum, known as hemoptysis, can occur in left-sided heart failure due to pulmonary congestion and elevated pressures in the pulmonary circulation. This symptom is not typically associated with right-sided heart failure.
C. This finding suggests pulmonary congestion, which is more indicative of left-sided heart failure. In left- sided heart failure, fluid backs up into the lungs, leading to crackles or rales on auscultation.
D. This statement is consistent with right-sided heart failure. In right-sided heart failure, the right ventricle fails to effectively pump blood into the pulmonary circulation, causing fluid to back up into the venous system. This can lead to peripheral edema (such as in the legs and abdomen) and abdominal distension due to ascites (fluid accumulation in the peritoneal cavity).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Cancer cells typically lose their specialized functions and characteristics that normal cells have. This loss of differentiation is known as dedifferentiation, where cancer cells become less specialized and more primitive in nature. This allows them to proliferate rapidly and invade surrounding tissues.
B. Contact inhibition refers to the normal process where cells stop dividing when they come into contact with neighboring cells. In cancer cells, this mechanism is disrupted, leading to uncontrolled cell growth and proliferation. Cancer cells continue to divide and grow even when they are in close contact with other cells, which contributes to tumor formation and progression.
C. Cancer cells often acquire mutations that impair their ability to repair DNA damage effectively. This can lead to an accumulation of genetic mutations over time, which is a hallmark of cancer development. While some cancer cells may still have mechanisms to repair DNA damage, they are often less efficient compared to normal cells, leading to genomic instability and further mutation accumulation.
D. Normal cells follow a tightly regulated cell cycle with specific checkpoints that ensure orderly progression through phases such as G1, S, G2, and M phases. In contrast, cancer cells often have dysregulated cell cycle control. They may bypass checkpoints that normally control cell division, leading to uncontrolled proliferation and growth.
Correct Answer is C
Explanation
A. Medicare does cover individuals under 65 years old who have end-stage renal disease (ESRD) and meet certain criteria.
B. There are programs that allow individuals with both Medicare and low income to qualify for Medicaid, which can help cover additional healthcare costs that Medicare may not fully cover.
C. While Medicare does provide significant coverage for healthcare services, it is not entirely free of out- of-pocket costs. Medicare Part A typically covers hospital stays, skilled nursing facility care, hospice, and some home health care services with no premiums for most people.
D. Medicare is indeed federally-funded health insurance primarily for individuals aged 65 and older. It also covers certain younger individuals with disabilities and those with ESRD.
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