Upon admission to the ICU, a client with a history of cor pulmonale will likely be exhibiting which clinical manifestations of right-sided heart failure? Select all that apply. (Select All that Apply.)
Expectorating copious amounts of frothy, pink sputum
Fine crackles throughout both lung fields
+pitting edema in lower extremities
Altered level of consciousness
Jugular vein distention
Correct Answer : C,D,E
A. Expecting copious amounts of frothy, pink sputum: This symptom is typically associated with left-sided heart failure or pulmonary edema, where fluid accumulates in the lungs, leading to the production of frothy, pink sputum. It is not a classic manifestation of right-sided heart failure.
B. Fine crackles throughout both lung fields: Fine crackles are more indicative of left-sided heart failure due to fluid accumulation in the lungs (pulmonary congestion). In right-sided heart failure, the primary issues relate more to systemic congestion rather than pulmonary congestion.
C. +pitting edema in lower extremities: Right-sided heart failure often leads to fluid retention and peripheral edema due to increased venous pressure. Pitting edema in the lower extremities is a common clinical manifestation in patients with cor pulmonale and right-sided heart failure.
D. Altered level of consciousness: This can occur due to decreased cardiac output and resulting reduced cerebral perfusion. In right-sided heart failure, especially in advanced stages, fluid overload can lead to increased intracranial pressure, contributing to altered mental status.
E. Jugular vein distention: Jugular vein distention is a classic sign of right-sided heart failure. Increased pressure in the right atrium due to fluid overload results in distended neck veins, indicating elevated venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Carotid wall thinness: Carotid wall thinness is not considered a nontraditional risk factor for coronary artery disease (CAD). Traditional risk factors for CAD include age, gender, hypertension, hyperlipidemia, and smoking, while carotid wall thickness (rather than thinness) is often used as a marker for atherosclerosis and cardiovascular risk.
B. Chronic kidney disease: Chronic kidney disease (CKD) is recognized as a nontraditional risk factor for coronary artery disease. It is associated with increased cardiovascular risk due to factors like inflammation, mineral metabolism disorders, and increased vascular stiffness.
C. Coronary artery calcification: Coronary artery calcification is considered a nontraditional risk factor for CAD. It reflects the presence of atherosclerosis and is associated with an increased risk of cardiovascular events.
D. Markers of inflammation, ischemia, and thrombosis: Markers of inflammation (such as C-reactive protein), ischemia, and thrombosis (such as fibrinogen and D-dimer) are nontraditional risk factors for coronary artery disease. Elevated levels of these markers indicate increased cardiovascular risk and are used in risk stratification.
Correct Answer is B
Explanation
A. Chest pain: While chest pain can occur in various pulmonary diseases, it is not as universally common or characteristic as cough. Chest pain may be more indicative of specific conditions rather than a broad symptom associated with pulmonary disease.
B. Cough: Cough is one of the most common symptoms associated with pulmonary disease, often occurring in conditions such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and bronchitis. It serves as a protective reflex to clear airways and is frequently reported by patients with pulmonary issues.
C. Hemoptysis: Hemoptysis, or coughing up blood, can be a significant symptom in certain pulmonary conditions (e.g., lung cancer, pulmonary embolism), but it is not as common across all pulmonary diseases. It is typically more specific to particular conditions.
D. Digit clubbing: Digit clubbing is a physical finding associated with chronic pulmonary diseases, particularly those that cause long-term hypoxia (e.g., cystic fibrosis, interstitial lung disease). However, it is less common than cough and typically develops over time rather than being a frequent presenting symptom.
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