Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

"I will use the nitroglycerin patch whenever I have chest pain."

"I will take furosemide (Lasix) every day just before bedtime."

"I will call the clinic if my weight goes up 3 pounds in a week."

"I will use an additional pillow if I am short of breath at night.”

Answer and Explanation

The Correct Answer is C

The statement "I will call the clinic if my weight goes up 3 pounds in a week" indicates that the teaching about heart failure was effective. Monitoring weight is an essential self-care measure for patients with heart failure to manage fluid retention effectively. A sudden weight gain of 2-3 pounds in a week can indicate fluid retention and worsening heart failure. It is crucial for the patient to report such weight changes promptly to the healthcare provider or clinic to adjust medication doses or treatment plans as needed.

The other statements are incorrect:

A) "I will use the nitroglycerin patch whenever I have chest pain." Nitroglycerin is not typically used to manage heart failure. It is used for angina, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed coronary arteries.

B) "I will take furosemide (Lasix) every day just before bedtime." While furosemide is a diuretic commonly prescribed for heart failure to reduce fluid retention, it is not usually taken just before bedtime. Taking furosemide in the evening may lead to frequent nighttime urination and disrupt sleep.

D) "I will use an additional pillow if I am short of breath at night." Using an extra pillow may provide temporary relief for positional dyspnea (shortness of breath when lying flat) but is not an appropriate long-term strategy for managing heart failure. Elevated pillows may not effectively improve breathing and can lead to neck strain. Instead, patients with heart failure should be encouraged to sleep with their head slightly elevated on a regular basis, using a wedge pillow or adjustable bed if needed. Managing fluid retention and adhering to prescribed medications are essential for improving heart failure symptoms and preventing complications.

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Correct Answer is D

Explanation

ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment

elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.

ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.

The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.

A. Jugular vein atherosclerosis B. Increased fluid volume C. Decreased fluid volume D. Incompetent jugular vein valves

Correct Answer is B

Explanation

Jugular venous distention (JVD) is a clinical sign that indicates increased fluid volume or fluid overload in the cardiovascular system. When the head of the client's bed is elevated at 45 degrees, the jugular veins should normally be flat or slightly distended. However, if the jugular veins appear engorged and bulging, it suggests that there is an increased amount of blood returning to the right side of the heart and is unable to be efficiently pumped forward, leading to jugular venous distention.

JVD is commonly seen in conditions such as heart failure, where the heart's ability to pump blood efficiently is compromised, leading to fluid accumulation in the veins and eventually causing jugular venous distention.

Option A, jugular vein atherosclerosis, is not a common cause of JVD. Atherosclerosis refers to the build-up of plaque within arteries, not veins.

Option C, decreased fluid volume, would lead to dehydration and decreased venous filling, which would not cause jugular venous distention. It would lead to flat or sunken jugular veins.

Option D, incompetent jugular vein valves, would not cause jugular venous distention with the head of the bed elevated. Incompetent valves may lead to venous reflux or backward flow of blood, but it would not lead to the distention of the jugular veins in this position.

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Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

Correct Answer is D

Explanation

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Correct Answer is B

Explanation

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