A nurse is caring for a client with right sided heart failure. Which of the following symptoms should the nurse include in teaching the client about signs of worsening heart failure? (SELECT ALL THAT APPLY)
Unable to lie flat
Feeling fatigued
Distended neck veins
Increased appetite
Weight gain 2 in 24hours
Worsening Lower extremity edema
Correct Answer : A,B,C,E,F
Rationale:
A. Unable to lie flat due to orthopnea is a sign of worsening heart failure.
B. Feeling fatigued is a general symptom of heart failure but can worsen as heart failure progresses.
C. Distended neck veins indicate increased central venous pressure, which is a sign of worsening right-sided heart failure.
D. Increased appetite is not typically associated with worsening heart failure.
E. Weight gain of 2 pounds in 24 hours indicates fluid retention and worsening heart failure.
F. Worsening lower extremity edema is a sign of worsening heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Alteplase (fibrinolytics) is used to dissolve clots in coronary arteries during an acute myocardial infarction (AMI).
B. IV Nitroglycerine is a vasodilator that dilates coronary blood vessels, increasing blood flow to the myocardium.
C. Metoprolol (beta blockers) are used to decrease heart rate, blood pressure, and myocardial oxygen demand.
D. IV Heparin is used to prevent further clot formation in coronary arteries during an acute myocardial infarction (AMI).
Correct Answer is C
Explanation
Rationale:
A. This is wrong because the ECG leads show ST segment elevation.
B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.
C. This is correct because of the ST segment elevation.
D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.
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