The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5-pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition?
Myocardial infarction
Left-sided heart failure
Acute pericarditis
Right-sided heart failure
The Correct Answer is D
A. Myocardial infarction: While this patient has significant cardiovascular risk factors, the clinical presentation does not describe acute substernal chest pain or EKG changes. The presence of 4+ peripheral edema and jugular venous distention points toward a chronic congestive process rather than acute coronary occlusion. Weight gain and exhaustion are symptoms of volume overload.
B. Left-sided heart failure: Left-sided failure typically presents with pulmonary congestion, characterized by crackles, orthopnea, and paroxysmal nocturnal dyspnea. While it often precedes right-sided failure, the specific findings of jugular distention and lower extremity edema are hallmarks of systemic venous congestion. This choice does not align with the predominant systemic symptoms described.
C. Acute pericarditis: Pericarditis usually presents with sharp, pleuritic chest pain that improves when leaning forward, often accompanied by a pericardial friction rub. It does not typically cause massive peripheral edema or rapid weight gain unless it progresses to cardiac tamponade. The clinical signs in the stem indicate high systemic venous pressure.
D. Right-sided heart failure: This condition results in the inability of the right ventricle to pump blood into the pulmonary circulation, causing systemic backup. Jugular venous distention, 4+ pitting edema, and rapid weight gain are classic signs of systemic venous hypertension. The exhaustion stems from decreased cardiac output during physical exertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Maintain pressure over the insertion site: The femoral artery is a high-pressure vessel, and the puncture site is at significant risk for hematoma or hemorrhage. Applying a pressure dressing or sandbag helps ensure hemostasis during the initial recovery period. Monitoring the site for bleeding is a critical nursing priority to prevent hypovolemic complications.
B. Assist with amputation 2 hours after recovery: Amputation is not a standard or expected outcome of a cardiac catheterization procedure. This intervention would only be considered in the case of extreme, irreversible limb ischemia, which is a rare and severe complication. Nursing care focuses on preserving the limb through vigilant neurovascular assessment.
C. Place the client in semi-Fowler's position: Following a femoral artery catheterization, the patient must remain supine with the affected leg kept straight for several hours. Elevating the head of the bed to semi-Fowler's position increases intra-abdominal pressure and the risk of bleeding at the groin site. Hip flexion is strictly contraindicated until the artery has sufficiently healed.
D. Assess pedal pulses bilaterally: Frequent assessment of distal pulses is necessary to ensure that the catheterization did not cause an arterial occlusion or thrombosis. Comparing the pulses in both feet allows the nurse to detect subtle changes in perfusion to the affected extremity. Weak or absent pulses require immediate notification of the surgical team.
E. Monitor color and warmth of the left leg frequently: Skin temperature and color are essential indicators of arterial blood flow and tissue oxygenation. A cold, pale, or cyanotic limb suggests compromised circulation distal to the femoral insertion site. These neurovascular checks are vital for early detection of vascular complications following the invasive procedure.
Correct Answer is D
Explanation
A. Discourage walking in order to limit pain: Physical inactivity promotes further vascular stasis and muscle atrophy in the lower extremities. While claudication causes discomfort, complete avoidance of movement prevents the development of collateral circulation. Reduced mobility exacerbates the underlying pathology of arterial insufficiency and impairs long-term functional outcomes.
B. Encourage extended periods of sitting or standing: Prolonged static positioning increases hydrostatic pressure and can worsen peripheral tissue perfusion. Dependency or stasis does not facilitate the arterial inflow required to oxygenate ischemic tissues. Frequent position changes are necessary to prevent localized pressure and maintain adequate circulatory flow.
C. Elevate his legs and arms above his heart when resting: This position hinders gravity-assisted arterial flow to the distal extremities, worsening ischemia. Unlike venous insufficiency, arterial disease requires the limbs to be maintained in a neutral or slightly dependent position. Elevation significantly reduces the perfusion pressure needed to reach peripheral tissues.
D. Encourage the client to engage in moderate amount of exercise: Structured walking programs stimulate the formation of collateral vessels to bypass occluded arteries. Physical activity improves oxygen extraction by the muscles and increases the pain-free walking distance. This intervention remains a cornerstone of conservative management for improving peripheral arterial circulation.
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