The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
Heart failure
Pulmonary embolism
Tension pneumothorax
Cardiac tamponade
The Correct Answer is A
A. Heart failure often presents with dyspnea, crackles (from pulmonary congestion), jugular vein distention, dependent edema, and hepatomegaly due to fluid overload and impaired cardiac output—these are classic signs.
B. Pulmonary embolism typically causes sudden dyspnea, chest pain, and tachypnea but not hepatomegaly or dependent edema.
C. Tension pneumothorax presents with tracheal deviation, absent breath sounds on one side, and hypotension—different from the systemic fluid overload signs described.
D. Cardiac tamponade presents with muffled heart sounds, hypotension, and jugular vein distention (Beck's triad), but it does not cause crackles, hepatomegaly, or peripheral edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The view of the electrical current changes in relation to the lead placement – Each ECG lead offers a different angle or view of the heart's electrical activity, so the waveforms in leads I, II, and III naturally look different. This variation helps clinicians assess different parts of the heart.
B. Conduction of the heart differs with lead placement – The heart's electrical conduction system functions independently of lead placement; only the view of the conduction changes.
C. Electrocardiogram (ECG) equipment has malfunctioned – Lead differences are expected and normal; this is not a sign of malfunction.
D. The circadian rhythm has changed – Circadian rhythms affect general physiological patterns but do not cause variation in ECG lead appearance.
Correct Answer is A
Explanation
A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.
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