A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?
Jugular vein distention
Weight gain
Peripheral edema
Bilateral lung crackles
The Correct Answer is D
A. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure due to increased venous pressure. While important to note, it is not a primary sign of left-sided heart failure.
B. Weight gain: Weight gain can occur in both right- and left-sided heart failure due to fluid retention. However, it is a nonspecific finding and does not localize the dysfunction to the left side of the heart.
C. Peripheral edema: Peripheral edema is commonly associated with right-sided heart failure, where fluid backs up into the extremities. It is not the earliest or most specific sign of left-sided heart failure.
D. Bilateral lung crackles: Crackles on auscultation of the lungs indicate pulmonary congestion or fluid accumulation, a hallmark of left-sided heart failure. This finding reflects impaired left ventricular function and should be reported promptly to the provider for evaluation and management.
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Related Questions
Correct Answer is D
Explanation
A. Herpes simplex virus 2: HSV-2 is a common sexually transmitted infection, but it is not universally reportable to the CDC in all states. While some jurisdictions may require reporting, it is not consistently a nationally notifiable infection.
B. Candida albicans: Candida infections are common opportunistic infections and are not considered reportable to the CDC because they occur frequently and do not typically pose a public health threat. Routine cases are managed at the clinical level.
C. Staphylococcus aureus: Although S. aureus infections, including MRSA, are clinically significant, they are generally not reportable to the CDC unless part of a specific outbreak or public health investigation. Routine cases are not mandatory to report.
D. Lyme disease: Lyme disease is a nationally notifiable infection that must be reported to the CDC. Reporting is essential for surveillance, tracking trends, and implementing public health interventions to reduce disease transmission and prevent outbreaks.
Correct Answer is A
Explanation
A. Tetany: Calcium is essential for proper neuromuscular function. A deficiency can lead to increased neuromuscular excitability, resulting in muscle spasms, cramps, and tetany, which are hallmark signs of hypocalcemia.
B. Anemia: Anemia is typically related to deficiencies in iron, vitamin B12, or folate, not calcium. While calcium plays roles in other body functions, it is not a direct factor in hemoglobin synthesis or red blood cell production.
C. Kidney stones: Kidney stones are more commonly associated with hypercalcemia or high calcium excretion rather than calcium deficiency. Low calcium intake may actually increase oxalate absorption, but it is not a direct cause of stones.
D. Osteoarthritis: Osteoarthritis is a degenerative joint disease influenced by age, joint stress, and cartilage wear. Calcium deficiency affects bone density (leading to osteoporosis) rather than the cartilage degeneration seen in osteoarthritis.
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