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

Answer and Explanation

The Correct Answer is B

A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.

B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.

C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.

D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.

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Correct Answer is A

Explanation

A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.

A. "Try to suppress your grief when your child is present." B. "Avoid discussing the funeral when your child is around." C. "Bring the child to the funeral service before visitors arrive." D. "School-age children tend to view death as a temporary form of sleep."

Correct Answer is C

Explanation

A. Encouraging the parents to suppress their grief can be detrimental to their emotional well- being and may inhibit healthy grieving processes.
B. Avoiding discussing the funeral when the child is around may create confusion and anxiety for the child, who may sense that something significant is happening but is excluded from the discussion.
C. Including the child in the funeral service before visitors arrive allows the child to be part of the grieving process and provides an opportunity for closure and understanding of the sibling's death in a supportive environment.
D. While it is important for parents to understand how school-age children perceive death, this statement does not offer guidance on how to support the child during the grieving process.

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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?

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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?