A nurse is assessing a patient who has right-sided heart failure. What findings should the nurse anticipate?

Orthopnea.

Pink frothy sputum.

Lower extremity edema.

Damp skin.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Orthopnea, or difficulty breathing when lying flat, is a common symptom of left-sided heart failure. It occurs due to fluid accumulation in the lungs, which makes it hard for the person to breathe when lying down.

Choice B rationale

Pink frothy sputum is a sign of pulmonary edema, a condition often associated with left-sided heart failure. It happens when fluid backs up into the lungs, causing shortness of breath and coughing up blood-tinged, frothy sputum.

Choice C rationale

Lower extremity edema is a common symptom of right-sided heart failure. It occurs due to fluid accumulation in the peripheral tissues, especially the legs and ankles, as a result of the heart’s inability to pump blood effectively.

Choice D rationale

Damp skin, or diaphoresis, is not specifically associated with right-sided heart failure. It can be a symptom of many conditions, including left-sided heart failure, where it is caused by the body’s increased effort to compensate for the heart’s decreased pumping ability.

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Correct Answer is A

Explanation

Choice A rationale

Marking the edges of steps can help a visually impaired person navigate their home more safely. This can be done with contrasting colors or textures to make the steps more visible.

Choice B rationale

Using low-wattage light bulbs is not recommended for visually impaired individuals. Instead, they may benefit from brighter lighting to enhance visibility.

Choice C rationale

Placing throw rugs over electrical cords is not safe as it can create a tripping hazard. It’s better to secure cords out of walkways.

Choice D rationale

Leaving doors slightly ajar can be dangerous for visually impaired individuals as they may walk into them. It’s safer to keep doors fully open or fully closed.

A. Accepts that sexual activity will decrease. B. Denies feelings of sadness about the ostomy. C. Participates in performing ostomy care. D. Prefers not to look at the stoma site.

Correct Answer is C

Explanation

Choice A rationale

Accepting that sexual activity will decrease does not necessarily indicate acceptance of a new altered body image. It may reflect a misunderstanding or fear about the impact of the colostomy.

Choice B rationale

Denying feelings of sadness about the ostomy does not necessarily indicate acceptance of a new altered body image. It may suggest that the patient is not fully acknowledging the emotional impact of the change.

Choice C rationale

Participating in performing ostomy care is a positive sign that the patient has accepted their new altered body image. It shows that the patient is taking an active role in their care and adapting to the change.

Choice D rationale

Preferring not to look at the stoma site does not indicate acceptance of a new altered body image. It may suggest avoidance or denial.

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A nurse is assessing a patient who has right-sided heart failure. What findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting data from a patient who has a newly placed colostomy.Which of the following findings would indicate to the nurse that the patient has accepted their new altered body image?

Correct Answer is C

Explanation

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