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?
The development of chronic obstructive pulmonary disease (COPD)
The development of left sided heart failure
The development of right-sided heart failure
The development of cor pulmonale
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Limit physical activity
Limiting physical activity is not a primary goal in heart failure care. In fact, promoting appropriate and monitored physical activity is often part of the overall management plan. Exercise, when tailored to the client's condition, can improve functional status and quality of life.
B. Prevent endocarditis
While preventing endocarditis is important for individuals with certain cardiac conditions, it is not a primary goal in the care of heart failure. The focus is typically on optimizing cardiac function and managing heart failure symptoms.
C. Relieve the patient’s symptoms
Managing and relieving symptoms, such as dyspnea, fatigue, and fluid retention, are crucial goals in heart failure care. This includes optimizing medication management and other therapeutic interventions.
D. Extend survival
While heart failure is a chronic condition, the goal is to optimize treatment to improve the client's prognosis and overall survival. This involves the use of evidence-based therapies to address the underlying causes and contributing factors.
E. Improve functional status
Enhancing the client's ability to perform activities of daily living and improving functional capacity are important goals. This can involve a combination of medications, lifestyle modifications, and rehabilitation.
Correct Answer is D
Explanation
A. The client now has developed a myocardial infarction:
A myocardial infarction (heart attack) is characterized by prolonged ischemia leading to damage or death of heart muscle cells. While the symptoms described could be concerning for a heart attack, the term "myocardial infarction" would typically imply a more sustained and severe ischemic event.
B. The client has developed Prinzmetal's angina:
Prinzmetal's angina, also known as variant angina, is characterized by chest pain that usually occurs at rest and is caused by vasospasm of the coronary arteries. The given scenario does not specifically describe the typical characteristics of Prinzmetal's angina.
C. The client now has stable angina:
Stable angina typically follows a predictable pattern and is relieved with rest and/or nitroglycerin. However, the scenario describes a change in the usual pattern of chest pain.
D. The client now has unstable angina:
Unstable angina is characterized by a change in the usual pattern of stable angina, often occurring at rest or with minimal exertion and not relieved by usual measures. This option seems to align with the information provided.
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