What is the best indication if the client with congestive heart failure is holding excess fluid?
Intake and output
Pitting pedal edema
Crackles in the bases of the lungs
Daily weights
The Correct Answer is D
A. Intake and output:
Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.
B. Pitting pedal edema:
Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.
C. Crackles in the bases of the lungs:
Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.
D. Daily weights:
Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Intermittent claudication:
Intermittent claudication is more commonly associated with peripheral arterial insufficiency rather than venous insufficiency. It is caused by inadequate blood flow to the muscles during activity, resulting in cramping or pain that typically resolves with rest.
B. Brownish discoloration to the legs:
Brownish discoloration to the legs, often referred to as hemosiderin staining, is a common finding in peripheral venous insufficiency. It occurs due to the breakdown of red blood cells and the deposition of hemosiderin in the tissues, especially around the ankles.
C. Weak or absent pedal pulses:
Weak or absent pedal pulses are more indicative of peripheral arterial insufficiency rather than venous insufficiency. Peripheral arterial disease can result in decreased blood flow to the extremities, leading to diminished pulses.
D. Unequal peripheral pulses between extremities:
Unequal peripheral pulses between extremities are also more suggestive of arterial insufficiency. Conditions such as atherosclerosis or arterial embolism can cause variations in pulses between different limbs.
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