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
A: Vertigo is a common finding in clients with essential hypertension due to changes in blood flow and possible impacts on the inner ear, which can affect balance.
B: Blurred vision, while it can be associated with hypertension, is not as directly related to essential hypertension as vertigo is. It is more commonly a sign of complications from prolonged uncontrolled hypertension.
C: Dyspnea or difficulty breathing is not typically a direct symptom of essential hypertension, though it can be a symptom of complications such as heart failure, which can be a result of long-standing, uncontrolled hypertension.
D: Uremia, which is an elevated level of waste products in the blood, is not a symptom of essential hypertension but rather a sign of kidney failure, which can be a secondary complication of chronic hypertension. Essential hypertension itself does not directly cause uremia.
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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