A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

The client reports increased shortness of breath.

The client has a temperature of 37°C (98.6°F).

The client has a blood pressure of 120/80 mmHg.

The client reports occasional dizziness.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.
Choice B rationale
A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.
Choice C rationale
A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.
Choice D rationale
Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.

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Correct Answer is A

Explanation

Choice A rationale
A temperature of 38°C (100.4°F) and a stiff neck are classic signs of meningitis, indicating inflammation of the meninges.
Choice B rationale
Myocardial infarction typically presents with chest pain, not a stiff neck.
Choice C rationale
Appendicitis presents with abdominal pain, not a stiff neck.
Choice D rationale
Pneumonia presents with respiratory symptoms, not a stiff neck.

A. The client has a respiratory rate of 28 breaths per minute. B. The client has a temperature of 38°C (100.4°F). C. The client has a blood pressure of 140/90 mmHg. D. The client has a heart rate of 90 beats per minute.

Correct Answer is A

Explanation

Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.

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A nurse is caring for a client with congestive heart failure (CHF). Which of the following symptoms would indicate worsening of the condition?

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Naxlex Comprehensive Predictor Exams

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