A client comes to the emergency department complaining of coughing and difficulty breathing. The diagnosis is heart failure

Question

The client asks the nurse how difficulty breathing could be a heart problem. Which response by the nurse is the most appropriate?
Standard Text: Select all that apply.
1. "The right side of your heart has enlarged, and cannot effectively pump blood."
2. "What you have is called congestive heart failure."
3. "The left side of your heart is weak, and pumps blood too quickly."
4. "The right side of your heart has weakened and blood has entered your lungs."
5. "The left side of your heart has weakened and blood has entered your lungs."

Answer 1

Correct Answer: 2,5
Rationale 1: Right-sided heart failure results in peripheral edema, not pulmonary congestion.
Rationale 2: Left-sided heart failure is sometimes called congestive heart failure, because it causes pulmonary edema (congestion).
Rationale 3: Some heart failure is the result of the heart pumping so quickly that it is not able to fully relax and fill up with blood (reducing preload), but there is no indication in the question that this client's heart failure has this particular pathophysiology.
Rationale 4: Left-sided, not right-sided, heart failure is associated with pulmonary edema (congestion). Right-sided heart failure results in peripheral edema.
Rationale 5: When the left ventricle cannot compensate for increased preload, blood backs up into the lungs, resulting in cough and shortness of breath.
Global Rationale: Left-sided heart failure is sometimes called congestive heart failure, because it causes pulmonary edema (congestion). When the left ventricle cannot compensate for increased preload, blood backs up into the lungs, resulting in cough and shortness of breath. Right-sided heart failure results in peripheral edema, not pulmonary congestion. Some heart failure is the result of the heart pumping so quickly that it is not able to fully relax and fill up with blood (reducing preload), but there is no indication in the question that this client's heart failure has this particular pathophysiology.