A patient newly diagnosed with left-sided heart failure is admitted to the hospital. The nurse will observe this patient closely for:
Jugular vein distension.
Increased blood pressure.
Hepatomegaly.
Decreased urine output.
The Correct Answer is D
Choice A reason: This is not a sign of left-sided heart failure. Jugular vein distension is a sign of right-sided heart failure, which occurs when the right ventricle fails to pump blood effectively to the lungs.
Choice B reason: This is not a sign of left-sided heart failure. Increased blood pressure is a risk factor for developing heart failure, but it does not indicate the severity or location of the heart failure.
Choice C reason: This is not a sign of left-sided heart failure. Hepatomegaly is a sign of right-sided heart failure, which occurs when the right ventricle fails to pump blood effectively to the systemic circulation.
Choice D reason: This is a sign of left-sided heart failure. Decreased urine output is a result of reduced renal perfusion, which occurs when the left ventricle fails to pump blood effectively to the aorta and the rest of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the action that the nurse should take. Instructing the patient to monitor weight daily is not relevant to the patient's dizziness. Weight monitoring is more useful for patients with fluid retention or heart failure, which are not caused by calcium channel blockers.
Choice B reason: This is not the action that the nurse should take. Informing the patient to discontinue the medication is not appropriate, as this can cause rebound hypertension and other complications. The patient should not stop taking the medication without consulting their health care provider.
Choice C reason: This is not the action that the nurse should take. Advising the patient to increase dietary sodium is not helpful, as this can worsen the hypertension and increase the risk of cardiovascular events. The patient should follow a low-sodium diet and avoid salt substitutes that contain potassium.
Choice D reason: This is the action that the nurse should take. Encouraging the patient to sit down if feeling faint is a simple and effective way to prevent falls and injuries. Dizziness is a common side effect of calcium channel blockers, especially when the patient changes position or stands up quickly. This is due to the orthostatic hypotension (a drop in blood pressure when standing up) caused by the vasodilation effect of the medication. However, this side effect is usually mild and transient, and can be prevented by rising slowly from a sitting or lying position, drinking plenty of fluids, and avoiding alcohol.
Correct Answer is B
Explanation
Choice A reason: The cells of the myocardium become hypertrophic in response to increased workload or pressure, not as a result of myocardial infarction. Hypertrophy is an adaptive mechanism that can lead to impaired ventricular function over time.
Choice B reason: The resulting hypoxia leads to ischemic injury and myocardial cell death. This is the main cause of impaired ventricular function after a myocardial infarction. The loss of viable myocardial tissue reduces the contractility and pumping ability of the heart.
Choice C reason: There is a temporary alteration in electrolyte balance that can be corrected. This is not the primary cause of impaired ventricular function after a myocardial infarction. Electrolyte imbalance can occur due to fluid loss, renal impairment, or medication side effects, but it can be managed with appropriate interventions.
Choice D reason: There is too much pressure on the heart and the ventricles begin to dysfunction. This is not the direct cause of impaired ventricular function after a myocardial infarction. Increased pressure on the heart can result from hypertension, valvular disease, or pulmonary embolism, but it is not related to myocardial ischemia or necrosis.
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