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 C
Explanation
Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
Correct Answer is D
Explanation
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
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