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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should instruct the client to adjust the thermostat so that the environment is warm because cold temperatures can cause vasoconstriction and worsen the symptoms of PAD, such as pain, numbness, and poor wound healing. The client should also avoid exposure to cold weather and wear warm clothing.
- Apply a heating pad on a low setting to help relieve leg pain is wrong because it can cause burns, vasodilation, and increased blood flow to the legs, which can increase the risk of bleeding and edema in PAD.
- Wear antiembolic stockings during the day is wrong because they can impair arterial circulation and cause ischemia and tissue damage in PAD. Antiembolic stockings are used to prevent venous thromboembolism, not arterial disease.
Rest with the legs above heart level is wrong because it can decrease arterial blood flow to the legs and worsen ischemia and pain in PAD. The client should rest with the legs at or below heart level to promote arterial circulation.
Correct Answer is C
Explanation
A. Asthma typically presents with wheezing, shortness of breath, and chest tightness. While dyspnea is a symptom, tachycardia and weak peripheral pulses are not characteristic findings associated with asthma.
B. Aortic valve regurgitation may cause dyspnea and fatigue, but it is more commonly associated with bounding pulses and diastolic murmur rather than weak peripheral pulses.
C. Heart failure is characterized by symptoms such as dyspnea, fatigue, tachycardia, and weak peripheral pulses due to reduced cardiac output and poor perfusion to the extremities. The nurse should recognize these signs as indicative of heart failure.
D. Aortic stenosis can lead to symptoms like dyspnea and fatigue; however, it typically presents with a triad of symptoms including exertional dyspnea, angina, and syncope, rather than weak peripheral pulses.
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