A nurse is providing teaching to a client who has left-sided heart failure. Which of the following manifestations should the nurse include in the teaching?
Neck-vein distention
Ankle edema
Anorexia
Hacking cough
The Correct Answer is D
A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
TPN is a form of intravenous nutrition that provides glucose, amino acids, lipids, vitamins, minerals, and electrolytes to clients who cannot eat or absorb nutrients through their gastrointestinal tract. Discontinuing TPN abruptly can cause a sudden drop in blood glucose levels, leading to hypoglycemia .
Hyperglycemia can occur during TPN administration if the glucose infusion rate is too high or if the client has insulin resistance . Diarrhea can occur as a result of infection, bowel ischemia, or intolerance to enteral feeding . Hypertension can occur due to fluid overload, electrolyte imbalance, or vascular complications .
Correct Answer is A
Explanation
The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.
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