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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.

B. A repeat ECG is not necessary for pulseless ventricular tachycardia.

C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.

D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.

A. Murmur B. S3 and S4 C. Click D. Friction rub

Correct Answer is A

Explanation

Rationale:

A. Mitral valve regurgitation typically presents with a murmur, which is a characteristic sound associated with the backflow of blood into the left atrium during systole.

B. S3 and S4 are not typical heart sounds and do not relate to mitral valve regurgitation.

C. A click is typically associated with mitral valve prolapse, not mitral valve regurgitation.

D. A friction rub is typically associated with pericarditis, not mitral valve regurgitation.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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