A nurse is caring for a client diagnosed with heart failure and atrial fibrillation. The client reports feeling palpitations and shortness of breath. The nurse is aware that clients with atrial fibrillation are at risk for which complication?
Hypertensive crisis
Cardiogenic shock
Embolic cerebral vascular accident
Flash pulmonary edema
The Correct Answer is C
A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.
Correct Answer is D
Explanation
A. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.
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