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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."

This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.

B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."

This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.

C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."

This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex. B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema. C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue. D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

Correct Answer is D

Explanation

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

Correct Answer is D

Explanation

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