Which statement made by a patient indicates a possible exacerbation of heart failure (HF)?
"I have gained 8 pounds this week."
"I am able to breathe easier today."
"I cooked dinner last night."
"There is no swelling in my feet."
The Correct Answer is A
Choice A reason: A rapid weight gain is a common sign of fluid retention, which can indicate an exacerbation of heart failure.
Choice B reason: Being able to breathe easier would typically indicate an improvement in heart failure symptoms, not an exacerbation.
Choice C reason: Cooking dinner suggests a level of activity that is not indicative of an exacerbation of heart failure.
Choice D reason: The absence of swelling in the feet would generally be a positive sign, not indicative of an exacerbation of heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
Correct Answer is A
Explanation
Choice A reason: The myocardium requires a constant supply of oxygen to function properly. Coronary artery disease (CAD) causes a reduction in blood flow due to narrowed or blocked coronary arteries, leading to a lack of oxygen in the heart muscle, which can result in angina or chest pain.
Choice B reason: While increased cardiac workload can exacerbate chest pain, it is not the primary cause of pain in CAD. The pain is primarily due to ischemia, which is the lack of oxygen and nutrients to the heart tissue due to reduced blood flow.
Choice C reason: Interrupted electrical activity can lead to arrhythmias or heart attack, but it is not the direct cause of pain in CAD. The pain is related to ischemia, not electrical disturbances.
Choice D reason: A lack of nutrients, including oxygen, to the heart does contribute to the pain experienced in CAD; however, the primary factor is the insufficient oxygen supply, which is explicitly stated in choice A.
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