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 ["B","C","D"]
Explanation
A. Massaging the calves is incorrect. This action can dislodge a deep vein thrombus (DVT), increasing the risk of a pulmonary embolism.
B. Applying elastic compression stockings is correct. These help promote venous return, reducing the risk of blood stasis and clot formation.
C. Performing passive range of motion exercises is correct. These exercises prevent venous stasis, which is a major risk factor for DVT and PE.
D. Assessing legs for redness is correct. Redness, swelling, and warmth can indicate DVT formation, allowing for early intervention before it leads to PE.
E. Placing pillows under the client's knees is incorrect. This can impair circulation and increase the risk of clot formation by promoting venous stasis.
Correct Answer is A
Explanation
A. Orthopnea is correct. Left-sided heart failure causes pulmonary congestion, making it difficult for the client to breathe when lying flat. This results in orthopnea, where the client must sit up or use multiple pillows to breathe comfortably.
B. Bradycardia is incorrect. Heart failure typically leads to tachycardia due to the heart compensating for decreased cardiac output.
C. Diaphoresis is incorrect. While excessive sweating can occur in acute decompensated heart failure, it is not a hallmark symptom of left-sided heart failure.
D. Frequent coughing with yellow sputum is incorrect. A client with left-sided heart failure may have a dry or frothy, pink-tinged cough, but yellow sputum suggests infection rather than heart failure.
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