The nurse is performing an assessment of a client admitted with left sided heart failure. Which dinical manifestation(s) would the nurse expect to identify? SELECT ALL THAT APPLY)

Tachycardia

Crackles

Ascites

Dyspnea

Peripheral edema

Answer and Explanation

Correct Answer : A,B,D

A) Tachycardia: Tachycardia is commonly seen in left-sided heart failure as the heart attempts to compensate for the reduced cardiac output. To maintain adequate perfusion, the body increases the heart rate. The sympathetic nervous system is activated, causing an increase in heart rate to try to pump blood more efficiently despite the reduced pumping ability of the left ventricle.

B) Crackles: Crackles (also known as rales) are typically heard upon auscultation of the lungs in patients with left-sided heart failure. When the left ventricle fails to effectively pump blood, it causes blood to back up into the lungs, resulting in pulmonary congestion. This leads to fluid accumulation in the alveoli, causing crackling sounds during inhalation.

C) Ascites: Ascites is more commonly seen in right-sided heart failure or in cases of congestive heart failure where both sides of the heart are affected. Ascites is the accumulation of fluid in the abdomen, which is a consequence of right-sided heart failure causing blood to back up into the abdomen. In left-sided heart failure, ascites is generally not a primary symptom unless the failure becomes severe and involves both sides of the heart.

D) Dyspnea: Dyspnea, or shortness of breath, is a hallmark symptom of left-sided heart failure. The left ventricle's inability to pump blood efficiently leads to pulmonary congestion, which causes fluid to accumulate in the lungs. This fluid buildup reduces the lung's ability to exchange oxygen, resulting in difficulty breathing, especially on exertion or when lying down (orthopnea).

E) Peripheral edema: Peripheral edema is more characteristic of right-sided heart failure due to the backup of blood in the systemic circulation. While it can occur in cases of biventricular heart failure (both right and left sides of the heart are affected), it is not the primary finding in left-sided heart failure. Left-sided heart failure typically presents with pulmonary symptoms rather than systemic symptoms like peripheral edema.

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Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

A. “I will be able to recall events from childhood after completing rehabilitation B. "I will display all of my preinjury traits and characteristics. C. I will regain complete motor and sensory functions after rehabilitation D. I should actively participate in the rehabilitation process as appropriate

Correct Answer is D

Explanation

A) “I will be able to recall events from childhood after completing rehabilitation”:
This demonstrates an unrealistic expectation. While rehabilitation can significantly improve cognitive functions, a serious brain injury may affect memory and recall to a degree that may not be fully reversible. Complete recovery of specific memories, such as childhood events, is not guaranteed.

B) "I will display all of my pre-injury traits and characteristics.":
This also reflects an unrealistic goal. Brain injuries can result in permanent changes to cognitive, emotional, and physical functioning. While rehabilitation can help a patient regain many abilities, it is unlikely that they will fully return to their pre-injury state, particularly in terms of personality traits and behaviors.

C) “I will regain complete motor and sensory functions after rehabilitation”:
This is also unrealistic. While rehabilitation aims to help patients regain as much motor and sensory function as possible, it is often not possible to fully restore complete function after a significant brain injury. Recovery may be partial, and some deficits may remain, depending on the extent of the injury.

D) “I should actively participate in the rehabilitation process as appropriate”:
This reflects a realistic and positive approach to recovery. Active participation in rehabilitation is essential for maximizing recovery after a brain injury. The process involves setting attainable goals based on the patient’s current abilities and gradually working toward improving those functions.

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The nurse is performing an assessment of a client admitted with left sided heart failure. Which dinical manifestation(s) would the nurse expect to identify? SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

After sustaining a serious brain injury, the patient has recovered enough to be transferred to a rehabilitation unit for continued care. Which statement by the patient indicates that they understand realistic goal setting?

Correct Answer is D

Explanation

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