A nurse is caring for a client with a diagnosis of left-sided heart failure. The nurse expects what assessment findings associated with left-sided heart failure? (Select All that Apply.)
Ascites
Edema in the legs and feet
Crackles in the lungs
Confusion
Exertional dyspnea
Correct Answer : C,D,E
A. Ascites is more commonly associated with right-sided heart failure. Right-sided failure leads to systemic congestion, causing fluid accumulation in the abdomen.
B. Edema in the legs and feet is a symptom of right-sided heart failure. Left-sided failure primarily affects the lungs, while right-sided failure leads to peripheral edema.
C. Crackles in the lungs are expected in left-sided heart failure. Pulmonary congestion results from blood backing up into the lungs, leading to fluid accumulation in the alveoli.
D. Confusion can occur due to decreased cardiac output and poor oxygenation to the brain. Clients with severe heart failure may experience cognitive changes or altered mental status.
E. Exertional dyspnea is a hallmark of left-sided heart failure. The inability of the left ventricle to pump effectively leads to pulmonary congestion, making breathing difficult during physical activity.
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Related Questions
Correct Answer is D
Explanation
A. Heart failure is associated with central sleep apnea, not obstructive sleep apnea (OSA), which results from airway obstruction.
B. Opioid overdose is linked to central sleep apnea, where the brain fails to send proper signals to the breathing muscles. It does not cause obstruction of the airway.
C. Brainstem injury can affect respiratory drive, but it is not a direct cause of OSA, which is due to mechanical airway obstruction.
D. Enlarged tonsils are correct. In children and adults, enlarged tonsils can block the airway, making them a common cause of OSA.
Correct Answer is A
Explanation
A. Adequate hydration helps thin mucus secretions, making them easier to expectorate. Drinking 2 to 3 L of water daily is recommended unless contraindicated by another condition.
B. Semi-Fowler's position can help with breathing but does not directly aid in thinning secretions.
C. Oxygen therapy helps with oxygenation but does not address thick mucus.
D. A low-salt diet may be beneficial for overall health but does not directly impact mucus consistency.
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