A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Dependent edema

Frothy sputum

Nocturnal polyuria

Jugular distention

Answer and Explanation

The Correct Answer is B

Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.

a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and ﬂuid retention. The edema is usually symmetrical and aﬀects the lower extremities, abdomen, and sometimes the face.

c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.

d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward ﬂow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.

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Correct Answer is D

Explanation

Cytotoxic hypersensitivity is a type of hypersensitivity that involves the production of IgG or IgM antibodies that bind to antigens on the surface of cells, leading to cell destruction by complement activation or antibody-dependent cellular cytotoxicity. Myasthenia gravis is an example of a cytotoxic hypersensitivity, as it is caused by autoantibodies that target the acetylcholine receptors on the muscle cells, impairing neuromuscular transmission and causing muscle weakness.

Delayed hypersensitivity is a type of hypersensitivity that involves the activation of T cells and macrophages, leading to inﬂammation and tissue damage after several hours or days of exposure to an antigen. Examples of delayed hypersensitivity include contact dermatitis, tuberculin skin test, and transplant rejection.

Immediate hypersensitivity is a type of hypersensitivity that involves the production of IgE antibodies that bind to mast cells or basophils, leading to degranulation and release of histamine and other mediators, causing anaphylaxis, urticaria, or allergic rhinitis within minutes of exposure to an antigen.

Immune complex-mediated hypersensitivity is a type of hypersensitivity that involves the formation of antigen- antibody complexes that deposit in tissues or blood vessels, leading to complement activation and inﬂammation, causing vasculitis, glomerulonephritis, or serum sickness within hours or days of exposure to an antigen.

A. Exercise at least three times per week. B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. C. Take diuretics early in the morning and before bedtime. D. Take naproxen for generalized discomfort.

Correct Answer is A

Explanation

a.This is appropriate as regular, moderate exercise can help improve cardiovascular health and functional capacity in clients with heart failure. It is essential to discuss appropriate types and levels of exercise based on the individual’s condition.

b.This is incorrect because clients should be instructed to notify the provider if they gain 1 kg (2.2 lbs) in one day or 2 kg (4.4 lbs) in one week. A weight gain of 0.5 kg is not typically a threshold for concern.

c. Take diuretics early in the morning and before bedtime is wrong because it may disrupt the client's sleep patern and cause nocturia. The nurse should advise the client to take diuretics early in the morning and avoid taking them in the evening or at night, unless prescribed otherwise.

d. Take naproxen for generalized discomfort is wrong because naproxen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can worsen heart failure by causing sodium and water retention, increasing blood pressure, and reducing the eﬀectiveness of diuretics and other heart failure medications. The nurse should advise the client to avoid NSAIDs and use acetaminophen or other alternatives for pain relief, as prescribed by the provider.

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A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

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