The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?
Jugular vein distention.
Bilateral basilar crackles.
3+ pitting enema in the ankles.
Hepatomegaly with right upper quadrant (RUQ) tenderness.
The Correct Answer is B
Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.
Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.
Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.
Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.
Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.
Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.
Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.
Correct Answer is A
Explanation
Choice A reason: Joining a group weight loss program is important for the client's overall health, particularly due to obesity being a significant risk factor for gallbladder disease. Weight loss can help decrease the likelihood of gallstone formation and other gallbladder-related issues. Participation in a weight loss program can also provide support and structured guidance for achieving a healthier weight.
Choice B reason: Beginning a smoking cessation class is beneficial for the client's health, as smoking is a risk factor for many diseases, including gallbladder issues. However, in the context of reducing gallbladder disease risk, weight loss would have a more direct and immediate impact, making it the primary focus for intervention.
Choice C reason: Considering hormone replacement therapy may be relevant for managing symptoms associated with menopause. However, it is not directly related to the risk reduction for gallbladder disease. Hormone replacement therapy should be discussed with a healthcare provider to weigh the benefits and risks.
Choice D reason: Scheduling rest periods after eating is generally helpful for digestion and comfort, but it does not directly address the key risk factors for gallbladder disease in this client, such as obesity and diet. Addressing these primary risk factors through weight loss would be more effective in reducing the client's risk.
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