The nurse is concerned that a patient is developing right heart failure. What did the nurse assess in this patient?
1. Ankle edema
2. Enlarged liver
3. Displaced apical heart rate
4. Shortness of breath
5. Cough
1,2,3
Rationale 1: In right heart failure, the blood backs up into veins, resulting in peripheral edema.
Rationale 2: In right heart failure, the blood backs up into veins, resulting in engorgement of organs such as the liver.
Rationale 3: A displaced apical heart rate would indicate cardiac hypertrophy, which is associated with right heart failure.
Rationale 4: Shortness of breath is a manifestation of left heart failure.
Rationale 5: A cough is a manifestation of left heart failure.
Global Rationale: In right heart failure, the blood backs up into veins, resulting in peripheral edema and engorgement of organs such as the liver. A displaced apical heart rate would indicate cardiac hypertrophy, which is associated with right heart failure. Shortness of breath is a manifestation of left heart failure. A cough is a manifestation of left heart failure.
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