The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

S4 heart sound

Harsh holosystolic murmur at the apex

S3 heart sound

Carotid bruits

Answer and Explanation

The Correct Answer is C

A. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.

B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.

C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.

D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.

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Correct Answer is D

Explanation

A. Stasis ulceration: While stasis ulcers can occur in the context of venous insufficiency, the description of warm skin and brown pigmentation more directly suggests venous insufficiency.

B. Arterial occlusion: This condition typically presents with cold, pale skin and possible pain or cramping, rather than warm skin and pigmentation.

C. Dependent edema: Dependent edema involves swelling due to fluid accumulation but does not necessarily cause pigmentation changes around the ankles.

D. Venous insufficiency: Warm skin and brown pigmentation around the ankles are indicative of venous insufficiency, a condition where blood flow in the veins is impaired, leading to these symptoms.

A. Stage III B. Stage II C. Stage I D. Stage IV

Correct Answer is D

Explanation

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

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The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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