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
Explanation
A. "I will take another tablet every 5 minutes if the pain continues up to 3 doses and then I will call 911 if the chest pain does not go away.": This statement reflects the standard emergency protocol for managing acute anginal episodes at home. It ensures the patient receives maximum pharmacological benefit while establishing a clear timeline for seeking emergency medical intervention. Adhering to this 15-minute window is crucial for preventing extensive myocardial damage.
B. "I take this medication at bedtime everything.": Nitroglycerin tablets are intended for the PRN treatment of acute chest pain, not as a scheduled nightly medication. Taking the drug without active symptoms can lead to significant hypotension and unnecessary side effects like headaches. Bedtime dosing is not the indicated use for sublingual nitroglycerin therapy.
C. "I will swallow the tablet whole with grapefruit juice.": Sublingual nitroglycerin must be dissolved under the tongue to bypass first-pass hepatic metabolism and enter the bloodstream rapidly. Swallowing the tablet significantly reduces its effectiveness and delays the onset of action during an ischemic event. Furthermore, grapefruit juice can interact with various cardiovascular medications and should be avoided.
D. "I take three tablets all at one time if I have chest pain.": Taking multiple doses simultaneously can cause a profound and dangerous drop in blood pressure. The doses must be spaced 5 minutes apart to allow the nurse or patient to evaluate the effectiveness and monitor for adverse effects. Proper titration is essential for safe and effective vasodilation.
Correct Answer is C
Explanation
A. Give 2 rescue breaths: In cardiac arrest due to V.Fib, the priority is circulation. High-quality chest compressions are initiated immediately to maintain perfusion until defibrillation can be performed. Rescue breaths are not the first step.
B. Start chest compressions: V.Fib is a lethal rhythm with no effective cardiac output. Immediate chest compressions are essential to circulate oxygenated blood to vital organs while preparing for defibrillation. This is the first action in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS).
C. Assess the client: While assessment is important, in the context of a witnessed rhythm strip showing V.Fib and an alarm, the nurse should assume cardiac arrest and act immediately. Delaying compressions to reassess wastes critical seconds.
D. Call a code blue/call 911: This is necessary, but it comes after starting chest compressions. The priority is to begin CPR without delay, then activate emergency response and prepare for defibrillation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
