A nurse is caring for a client in the outpatient cardiologist's office. The client is alert and oriented. Lung sounds with crackles are heard bilaterally. Dyspnea is observed on exertion, and heart sounds reveal an S3 gallop. Which of the following findings is the nurse most likely to expect?
Elevated blood pressure
Decreased respiratory rate
Pitting edema
Irregular pulse
The Correct Answer is C
Choice A rationale
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
Choice B rationale
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
Choice C rationale
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
Choice D rationale
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned soup is typically high in sodium, which can worsen fluid volume excess (FVE). Patients with liver failure need to limit sodium intake to reduce fluid retention.
Choice B rationale
Baked chicken breast is a low-sodium and protein-rich option suitable for clients with liver failure. Protein is essential for tissue repair and maintaining fluid balance within the body.
Choice C rationale
A bowl of ice cream is high in sugar and fat, which can be difficult for a liver-compromised patient to process and may contribute to further fluid retention.
Choice D rationale
Spaghetti with commercial red sauce can be high in sodium due to the sauce, which is not recommended for clients with FVE as it may exacerbate their condition.
Correct Answer is A
Explanation
Choice A rationale
Liver cirrhosis is the most common cause of esophageal varices and portal hypertension. Cirrhosis leads to scarring of the liver, which impedes blood flow through the portal vein, causing increased pressure (portal hypertension) and the development of collateral blood vessels (varices) as the body attempts to bypass the blockage.
Choice B rationale
Throat lacerations are not related to the development of esophageal varices or portal hypertension. They are typically acute injuries and do not cause the chronic changes seen in the vasculature associated with these conditions.
Choice C rationale
Kyphosis, a curvature of the spine, does not cause esophageal varices or portal hypertension. It is a structural skeletal condition and does not affect the vasculature of the esophagus or the portal venous system.
Choice D rationale
While squamous cell cancer can occur in the esophagus, it is not a typical cause of portal hypertension or esophageal varices. These varices are usually a result of increased pressure in the portal vein, not directly from a malignancy.
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