A nurse is preparing to administer digoxin to a client who has left-sided heart failure.
Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).
Gastrointestinal bloating.
Jugular vein distention.
Tachycardia.
Orthopnea.
Dyspnea.
Correct Answer : C,D,E
Choice A rationale:
Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.
Choice B rationale:
Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.
Choice C rationale:
Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.
Choice D rationale:
Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.
Choice E rationale:
Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.
Choice B rationale:
"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.
Choice C rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.
Choice D rationale:
Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.
Correct Answer is D
Explanation
Choice A rationale:
Cool, clammy skin is not a typical manifestation of hypernatremia (high sodium levels). Hypernatremia is characterized by an excess of sodium in the blood, which typically leads to symptoms such as thirst, dry mucous membranes, and decreased skin turgor. Cool, clammy skin is more often associated with conditions like shock or hypoglycemia.
Choice B rationale:
Increased salivation is not a common manifestation of hypernatremia. Instead, hypernatremia often leads to signs of dehydration, including dry mouth and decreased salivation.
Choice C rationale:
Hypertension is not a direct manifestation of hypernatremia. Hypernatremia can cause increased blood pressure, but it is not one of the typical clinical signs of hypernatremia. Hypertension is more commonly associated with conditions like high sodium intake, kidney disease, or primary hypertension.
Choice D rationale:
A decreased level of consciousness is a significant manifestation of hypernatremia. Elevated sodium levels in the blood can lead to cellular dehydration, affecting brain cells and resulting in neurological symptoms such as confusion, lethargy, and decreased consciousness. Severe hypernatremia can even lead to seizures and coma. .
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