The nurse is caring for a client who was diagnosed with left-sided heart failure and states, "I do not understand why I have so much trouble breathing if I have heart failure.”. Which of the following responses should the nurse make?
"I am going to notify the healthcare provider because you should not have trouble breathing with left-sided heart failure.”.
"The right side of your heart fails first and causes a back-up of blood in the left side of the heart and then the lungs.”.
"When the left side of your heart does not pump enough blood out, it gets backed up in your lungs and causes shortness of breath.”.
"Typically, clients with left-sided heart failure have difficulty breathing with exertion, but not when resting.”.
The Correct Answer is C
Choice A rationale
Trouble breathing is a hallmark symptom of left-sided heart failure. Suggesting that it should not occur would be inaccurate. The failure of the left ventricle leads to blood accumulation in the pulmonary vessels, creating pulmonary congestion and shortness of breath. Prompt provider notification may be necessary but does not address the underlying pathophysiology. Pulmonary symptoms are expected in this type of heart failure.
Choice B rationale
While left-sided heart failure can eventually lead to right-sided heart failure, the initial problem is with left ventricular dysfunction. This causes reduced forward blood flow and pulmonary congestion due to backflow of blood into the lungs. Right-sided heart failure is not the primary event leading to pulmonary symptoms in left-sided heart failure.
Choice C rationale
The left ventricle's inability to pump effectively results in blood backing up into the pulmonary circulation, causing pulmonary congestion and symptoms like shortness of breath. This is consistent with the hemodynamics of left-sided heart failure. Pulmonary capillary pressure increases, leading to fluid leakage and impaired gas exchange, explaining the client's breathing difficulty.
Choice D rationale
Although difficulty breathing with exertion (dyspnea on exertion) is common, resting symptoms, including orthopnea and paroxysmal nocturnal dyspnea, can also occur in left-sided heart failure due to fluid redistribution. Limiting symptoms to exertion inaccurately portrays the clinical presentation and disregards other significant pulmonary signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Amlodipine, a calcium channel blocker, primarily acts on vascular smooth muscles to reduce blood pressure. It does not directly affect renal function or significantly increase urine output. This statement reflects a misunderstanding of the drug's mechanism of action.
Choice B rationale
Edema, a common side effect of amlodipine, is due to vasodilation and capillary leakage, particularly in lower extremities. However, sudden discontinuation of the medication may lead to rebound hypertension and should be avoided. Reporting side effects is crucial for alternative management.
Choice C rationale
Amlodipine does not necessitate routine potassium monitoring as it does not significantly affect potassium homeostasis. This requirement is more commonly associated with potassium-wasting diuretics or renin-angiotensin-aldosterone system modulators.
Choice D rationale
Constipation and abdominal pain, although less common, may occur due to gastrointestinal motility changes caused by smooth muscle relaxation. Prompt reporting ensures timely assessment and potential treatment modifications to enhance adherence.
Correct Answer is D
Explanation
Choice A rationale
A low sodium, high-calorie diet does not directly address severe pain caused by renal colic. Dietary interventions are long-term strategies for kidney health but are not immediate priorities for acute pain relief. Renal colic pain requires prompt management with pharmacological interventions to alleviate severe discomfort. Adjusting dietary intake may support prevention but would not resolve the acute symptoms, emphasizing that this is not the first-line measure for this clinical situation.
Choice B rationale
Increasing fluid intake to 3–4 L/day is beneficial for flushing out kidney stones and preventing further stone formation. However, this intervention does not directly alleviate severe pain experienced during an episode of renal colic. While adequate hydration is crucial for long-term management, acute pain demands immediate pharmacological relief. Therefore, fluid intake implementation is secondary when compared to pain management priorities.
Choice C rationale
Tamsulosin (Flomax) is an alpha-blocker that promotes the passage of kidney stones by relaxing the smooth muscles of the ureter. Although effective in expediting stone passage, it does not provide immediate pain relief for severe renal colic. Its role is valuable for the resolution of the obstruction but does not address acute symptoms. Administering pain medication remains a priority to manage distress caused by colic episodes.
Choice D rationale
Morphine sulfate is an opioid analgesic that directly targets severe pain associated with renal colic. It binds to mu-opioid receptors in the central nervous system, producing analgesia and a calming effect. Its rapid onset and effectiveness in severe pain management make it the first prescription to implement. Pain relief improves the client's comfort and allows for addressing underlying causes of colic after stabilizing acute distress.
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