The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-old 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

Question

degree angle, and an enlarged liver. These findings are most consistent with which of the following disorders? 1. Pulmonary edema
2. Left-sided heart failure
3. Myocardial infarction
4. Right-sided heart failure

Answer 1

4
Rationale 1: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system.
Rationale 2: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system.
Rationale 3: 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.
Rationale 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.