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. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.

A. Work with the client to create a flexible daily schedule. B. Gradually decrease the time allowed for ritualistic behavior. C. Offer solutions to assist in problem-solving. D. Teach the client to meditate about obsessive thoughts.

Correct Answer is B

Explanation

A. While creating a flexible daily schedule may be helpful, it does not directly address the core symptoms of OCD.

B. Gradually decreasing the time allowed for ritualistic behavior is a common technique used in exposure and response prevention therapy, which is an evidence-based treatment for OCD.

C. Offering solutions for problem-solving may be helpful in general, but it may not directly address the specific symptoms of OCD.

D. While meditation can be beneficial for managing stress and anxiety, it may not specifically address the compulsive thoughts and behaviors characteristic of OCD.

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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?