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A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?



A.

Crepitus

B.

Elevated pulmonary artery pressure

C.

Hepatosplenomegaly

D.

Confusion

Answer and Explanation

The Correct Answer is B

A. Crepitus is a finding associated with subcutaneous emphysema or gas accumulation under the skin, typically not directly related to right ventricular heart failure.

B. Right ventricular heart failure can lead to increased pressure in the pulmonary artery, resulting in symptoms such as dyspnea, fatigue, and possibly right-sided heart murmurs.

C. Hepatosplenomegaly (enlargement of the liver and spleen) is more commonly associated with conditions such as liver cirrhosis, not specifically right ventricular heart failure.

D. Confusion is not typically associated with right ventricular heart failure unless there are complications such as hypoxemia or impaired cerebral perfusion.


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Related Questions

Correct Answer is ["92"]

Explanation

  • Pulse pressure is the difference between systolic and diastolic blood pressure.
  • The client's pulse pressure is 132 - 40 = 92 mm Hg.

Correct Answer is D

Explanation

A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.

B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.

C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.

D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.

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