A client who has a history of angina and hypertension now complains of fatigue, shortness of breath, and cough. Based on this assessment finding, what does the nurse suspect that the client might be developing?
1. Peripheral edema
2. Left-sided heart failure
3. Hypokalemia
4. Right-sided heart failure
Correct Answer: 2
Rationale 1: Peripheral edema is caused by right-sided heart failure.
Rationale 2: The left ventricle has limits to its ability to compensate. Blood "backs up" into the lungs, resulting in the classic symptoms of cough and shortness of breath, particularly when the patient is lying down with left-sided heart failure.
Rationale 3: Hypokalemia does not cause fatigue, shortness of breath, and cough.
Rationale 4: Right-sided heart failure causes peripheral edema.
Global Rationale: The left ventricle has limits to its ability to compensate. Blood "backs up" into the lungs, resulting in the classic symptoms of cough and shortness of breath, particularly when the patient is lying down with left-sided heart failure. Peripheral edema is caused by right sided heart failure. Hypokalemia does not cause fatigue, shortness of breath, and cough. Right-sided heart failure causes peripheral edema.
You might also like to view...
A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?
a. Client who has been diagnosed with meningitis with a fever of 101 ° F (38.3 ° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed
A male elementary school student has a severe allergy to peanuts and is displaying the signs of anaphylactic shock after inadvertently eating a peanut-containing candy bar
Which of the following statements best captures the boy's current status and preferred treatment? A) He is experiencing shortness of breath caused by potent vasoconstriction that can be relieved by epinephrine injection. B) He is approaching vascular shock and developing edema due to actions of IgE antibodies, situations that can be reversed by administration of epinephrine. C) His mast cells and basophils have been sensitized, but systemic effects can be mitigated by administration of bronchodilators. D) He is likely in a primary- or initial-stage allergic response that can be relieved by antihistamine administration.
The nurse delegates bathing an older adult client diagnosed with Alzheimer's disease to an experienced certified nursing assistant. The assistant accidentally nicks the client while shaving his chin. Who is legally liable for this error?
a. The nurse who delegated the activity b. The certified nursing assistant c. Both the nurse and the certified nursing assistant d. Both the nurse and the nurse's supervisor
The nurse notes that a patient has astigmatism. What should the nurse expect when collecting data from this patient?
a. Blind spots b. Blurred vision c. Distorted near vision d. Distorted distance vision