Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?
Enlarged liver and peripheral edema.
Crackles in the lungs.
Dry hacking cough.
Altered mentation with pinpoint pupils.
The Correct Answer is A
Choice A rationale
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypocortisolism, also known as Addison’s disease, is characterized by insufficient production of cortisol by the adrenal glands. It does not typically cause goiter, which is an enlargement of the thyroid gland due to various causes such as iodine deficiency, autoimmune diseases, or nodules.
Choice B rationale
Hyperinsulinemia refers to an excess level of insulin in the blood, often associated with insulin resistance and type 2 diabetes. It is not related to the development of goiter.
Choice C rationale
Iodide deficiency is a common cause of goiter. The thyroid gland requires iodine to produce thyroid hormones. When there is a deficiency, the gland enlarges in an attempt to capture more iodine from the bloodstream.
Choice D rationale
Azotemia is an elevation of blood urea nitrogen (BUN) and serum creatinine levels, typically due to kidney dysfunction. It is not associated with the development of goiter.
Correct Answer is A
Explanation
Choice A rationale
Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
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