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. Ventricular tachycardia is characterized by a ventricular rate >100 bpm, regular rhythm, no visible P waves, and wide QRS complexes (>0.12 seconds). The findings described—ventricular rate of 162, regular R-R intervals, no visible P waves, and a QRS duration of 0.18 seconds—are consistent with ventricular tachycardia.
B. Ventricular fibrillation shows a chaotic, irregular rhythm with no identifiable QRS complexes, which is not the case here.
C. Sinus tachycardia would have visible P waves and a normal QRS duration.
D. Atrial flutter typically has "sawtooth" flutter waves and a more organized atrial rhythm with a distinct P wave pattern, which is absent in this scenario.
Correct Answer is C
Explanation
A. A client showing signs of shock (e.g., cold, clammy skin, decreased bowel sounds, tachycardia) is not likely to stabilize and be released by the next day without intensive treatment.
B. The irreversible stage of shock is marked by profound hypotension, multi-organ failure, and unresponsiveness—more severe than this client’s current status.
C. The progressive stage of shock is characterized by impaired tissue perfusion, cold and clammy skin, tachycardia, hypoactive bowel sounds, and early signs of organ dysfunction. Even though the blood pressure is currently normal, perfusion is inadequate.
D. The compensatory stage is earlier and includes signs like tachycardia and restlessness, but perfusion to vital organs is still maintained, and skin may remain warm. This client’s cold skin and decreased bowel sounds suggest progression beyond this stage.
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