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. Hemoptysis (coughing up blood) is a known symptom of a pulmonary embolism (PE). It results from lung tissue damage due to obstructed blood flow.
B. Petechiae are not typically associated with a PE. They are more commonly linked to conditions such as thrombocytopenia or fat embolism syndrome.
C. Tachycardia is a common manifestation of a PE. The heart rate increases as a compensatory mechanism due to decreased oxygenation.
D. Facial weakness is not a typical sign of PE. It is more commonly associated with conditions like stroke or Bell's palsy.
Correct Answer is D
Explanation
A. Intermittent claudication with pallor is typically associated with peripheral artery disease (PAD) rather than myocardial infarction.
B. Jugular vein distention and dependent edema are signs of right-sided heart failure, which may develop after an MI but are not classic acute MI symptoms.
C. Mid-epigastric pain and heartburn can sometimes be confused with MI symptoms, but heartburn alone is not diagnostic of an MI.
D. Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock.
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