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

Answer and Explanation

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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Correct Answer is C

Explanation

This is because peritonitis is an infection of the peritoneal cavity that can occur as a complication of peritoneal dialysis. Peritonitis can cause inflammation and irritation of the peritoneum, which can lead to cloudy or milky appearance of the dialysate fluid that drains out of the abdomen (also known as effluent). Cloudy effluent is often the first and most reliable sign of peritonitis in peritoneal dialysis patients. Other signs and symptoms of peritonitis may include increased heart rate, generalized abdominal pain, fever, nausea, vomiting, loss of appetite, and malaise.

The nurse should instruct the client and his partner to inspect the effluent for clarity every time they perform an exchange and to report any changes to their health care provider immediately. The nurse should also teach them how to prevent peritonitis by following strict aseptic technique when handlingcatheters and supplies, washing hands before and after each exchange, wearing a mask during exchanges, and storing supplies in a clean and dry place.

A. Pupillary dilation B. Decorticate posturing C. Altered level of consciousness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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