The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?
Left-sided HF
Right-sided HF
Chronic heart failure (HF)
Acute decompensated heart failure (ADHF)
The Correct Answer is B
The assessment findings of jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute are consistent with right-sided heart failure (HF). Right-sided HF occurs when the right ventricle of the heart is unable to pump effectively, leading to congestion in the venous circulation. This can result in jugular venous distention (JVD) due to increased pressure in the jugular veins, peripheral edema due to fluid retention, and weight gain due to fluid accumulation.
Option A (Left-sided HF) may also present with similar symptoms like jugular venous distention, weight gain, and peripheral edema. However, in left-sided HF, there would typically be signs of pulmonary congestion, such as crackles in the lungs and shortness of breath.
Option C (Chronic heart failure) is a general term used for heart failure that has been present for an extended period, and it does not specify whether it is left-sided or right-sided heart failure.
Option D (Acute decompensated heart failure - ADHF) is a form of heart failure that presents with severe symptoms and requires urgent treatment. It is more of a clinical classification rather than a specific complication related to the symptoms mentioned in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement indicates effective learning because serum cardiac markers are indeed proteins that are released from necrotic (damaged) heart muscle cells when there is myocardial injury, such as in acute coronary syndrome (ACS). These markers are measured in blood tests and help in the diagnosis and assessment of ACS, particularly myocardial infarction (heart attack).
Option A is incorrect because a nitroprusside stress echocardiogram is not used for acute pericarditis. It is a diagnostic test used for evaluating coronary artery disease and ischemia.
Option B is incorrect because a pathologic Q wave is not always present in the electrocardiogram (ECG) of patients with unstable angina. It is a characteristic finding in the ECG of patients with a previous myocardial infarction (heart attack) but may not be present in unstable angina.
Option D is incorrect because coronary angiography is not the only way to confirm the diagnosis of unstable angina. Unstable angina is primarily diagnosed based on the clinical presentation, symptoms, and changes in the ECG. Coronary angiography is an invasive procedure used to visualize the coronary arteries directly and is typically reserved for cases where further assessment and intervention are needed, such as in cases of suspected coronary artery disease.
Correct Answer is A
Explanation
Diuretics are the primary class of drugs used to treat volume overload in patients with acute decompensated heart failure (ADHF). These medications help to increase urine output, reducing the overall fluid volume in the body and relieving congestion in the lungs and other tissues.
The goal of using diuretics in ADHF is to alleviate symptoms such as shortness of breath, edema (swelling), and fluid retention by promoting the elimination of excess fluid. The most commonly used diuretics in this setting are loop diuretics (e.g., furosemide, bumetanide), which have a potent diuretic effect and can rapidly reduce fluid overload.
While narcotics, vasodilators, and positive inotropes may have roles in specific cases of ADHF, they are not the primary drugs used to treat volume overload. Narcotics may be used for pain management, vasodilators to reduce afterload (the resistance the heart has to pump against), and positive inotropes to increase the heart's contractility in certain situations. However, the first-line treatment for volume overload in ADHF is diuretic therapy.
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