A nurse is assessing a client with congestive heart failure. Which finding indicates possible fluid accumulation in the lungs, a common symptom of CHF?
Wheezing on auscultation
Hyperactive bowel sounds
Absence of jugular vein distention
Crackles on auscultation
The Correct Answer is D
A) This choice is incorrect because wheezing on auscultation is a characteristic finding in respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not congestive heart failure.
B) This choice is incorrect because hyperactive bowel sounds are not specific to congestive heart failure and are more indicative of gastrointestinal activity.
C) This choice is incorrect because the absence of jugular vein distention is not directly related to fluid accumulation in the lungs. Jugular vein distention is associated with right-sided heart failure.
D) This choice is correct. Crackles, also known as rales, are abnormal lung sounds heard on auscultation and may indicate fluid accumulation in the lungs, a common symptom of congestive heart failure. The presence of crackles suggests pulmonary congestion due to fluid leaking into the alveoli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because clubbing refers to the enlargement of the fingertips and nails due to chronic hypoxia, which is not related to the client's reported symptoms.
B) This choice is correct. Peripheral edema refers to swelling in the legs, ankles, and feet, which is a common symptom of congestive heart failure. The client's symptoms of swollen ankles, legs, and abdomen indicate peripheral edema.
C) This choice is incorrect because pitting edema is a specific type of edema where pressure on the skin leaves an indentation or "pit." While the client's edema may indeed be pitting, the question does not provide enough information to confirm this.
D) This choice is incorrect because ascites is the accumulation of fluid in the abdominal cavity and is not specific to the client's reported symptoms of swollen ankles and legs.
Correct Answer is A
Explanation
A) This choice is correct. Alcohol abuse can lead to dilated cardiomyopathy, a condition in which the heart becomes enlarged and weakened, contributing to congestive heart failure. Chronic alcohol consumption can cause toxic effects on the heart muscle, leading to impaired pumping function.
B) This choice is incorrect because malnutrition, while it can impact overall health, is not a direct precipitating cause of congestive heart failure. However, malnutrition can exacerbate heart failure symptoms and weaken the heart further.
C) This choice is incorrect because a sedentary lifestyle can be a risk factor for heart disease, including congestive heart failure, but it is not a direct precipitating cause of the client's condition in this scenario.
D) This choice is incorrect because occupational exposure to toxins can have health implications, but it is not directly related to the client's signs and symptoms of congestive heart failure in this case.
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