The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

normal sinus rhythm that becomes sinus tachycardia

Onset of a cough with pink, frothy sputum

presence of dyspnea at rest

falls asleep when not disturbed

urine drainage is increased in amount

Answer and Explanation

Correct Answer : A,B,C,D

A. Normal sinus rhythm that becomes sinus tachycardia

Sinus tachycardia can be an indication of increased sympathetic activity in response to decreased cardiac output. It may suggest the heart's compensatory response to maintain adequate perfusion.

B. Onset of a cough with pink, frothy sputum

Pink, frothy sputum is a classic sign of pulmonary edema, which can occur in the setting of worsening heart failure. It indicates the presence of blood-tinged fluid in the alveoli.

C. Presence of dyspnea at rest

Dyspnea at rest suggests that the client is experiencing difficulty breathing even without physical exertion. This can be indicative of more severe heart failure.

D. Falls asleep when not disturbed

Falling asleep when not disturbed may indicate fatigue or exhaustion, which is common in individuals with heart failure. However, it is not a direct indicator of worsening heart failure and can be influenced by various factors.

E. Urine drainage is increased in amount

Increased urine output can be a sign of diuretic therapy or an attempt by the body to compensate for fluid overload. However, it is essential to consider other factors such as renal function and medication effects.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Shortness of breath

Shortness of breath can be a symptom of a myocardial infarction in both men and women.

B. Anxiety

Anxiety can be a symptom in some cases, as individuals may feel a sense of impending doom or anxiety during an MI.

C. Unusual fatigue

Unusual fatigue, especially if it is severe or occurs with exertion, can be a symptom of a myocardial infarction.

D. Back pain

Back pain, particularly between the shoulder blades, can be a symptom of a myocardial infarction in women.

E. Chest pain

Chest pain or discomfort is a classic symptom of a myocardial infarction. While women may experience chest pain, they are also more likely than men to have atypical symptoms.

A. The development of chronic obstructive pulmonary disease (COPD) B. The development of left sided heart failure C. The development of right-sided heart failure D. The development of cor pulmonale

Correct Answer is B

Explanation

A. The development of chronic obstructive pulmonary disease (COPD)

Explanation: The signs and symptoms described, including crackles, orthopnea, S3 heart sound, cough with pink, frothy sputum, and low pulse oximetry, are more indicative of heart failure than COPD.

B. The development of left-sided heart failure

Explanation: This is the correct answer. The signs and symptoms, such as crackles, orthopnea, and cough with pink, frothy sputum, are characteristic of left-sided heart failure. The S3 heart sound is often associated with increased ventricular filling pressures.

C. The development of right-sided heart failure

Explanation: The presented signs and symptoms are more consistent with left-sided heart failure. Right-sided heart failure is often associated with peripheral edema, hepatomegaly, and jugular venous distension.

D. The development of cor pulmonale

Explanation: Cor pulmonale is typically associated with right-sided heart failure due to chronic lung disease. The signs and symptoms described are more indicative of left-sided heart failure.

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The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally: 3 pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

Correct Answer is B

Explanation

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