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?
Crepitus
Elevated pulmonary artery pressure
Hepatosplenomegaly
Confusion
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.
Correct Answer is B
Explanation
A. A flexible activity schedule may increase overstimulation; structured activities with set limits are more appropriate for clients in acute mania.
B. Clients experiencing acute mania often have increased energy expenditure and may neglect meals; providing high-calorie nutritional supplements helps prevent weight loss and maintains adequate nutrition.
C. Eating alone may increase the risk of inadequate intake due to distraction or hyperactivity; supervised or structured meal times are safer.
D. Allowing unrestricted choice of clothing may lead to inappropriate or disorganized attire; guidance is needed to maintain safety and appropriate appearance.
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