The intensive care nurse is performing a cardiac assessment on a newly admitted older adult client and notes the following findings:
peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45-degree angle, and an enlarged liver. Based on this data, which diagnosis does the nurse suspect?
1. Pulmonary edema.
2. Left-sided heart failure.
3. Myocardial infarction.
4. Right-sided heart failure.
Correct Answer: 4
With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement. Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction.
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A patient, age 63, has cancer of the left breast. After a modified radical mastectomy, she has been receiving chemotherapy. Her grandson, who visited a few days ago, now has varicella (chickenpox)
The nurse should observe her carefully for signs of a. herpes zoster. b. herpes simplex type I. c. herpes simplex type II. d. impetigo.
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following?
A) Drink a glass of water every time nausea occurs. B) Take a multivitamin without iron each day. C) Take over-the-counter Benadryl for the nausea. D) Take a multivitamin with iron each day.
Nursing interventions may be categorized based upon the degree of nursing autonomy. An ex-ample of a nurse-initiated intervention is:
1. Providing client teaching 2. Administering medication 3. Ordering a liver CAT scan 4. Referring a client to physical therapy
Calculate the amount to administer: ________. Ordered: Acyclovir 170 mg IVPB q8hOn hand: Acyclovir sodium injection 1,000 mg/20 mL single-dose vial
Fill in the blank(s) with the appropriate word(s).