The nurse is caring for a patient with a history of left-sided congestive heart failure (CHF). Which finding leads the nurse to suspect that the patient could be experiencing an acute exacer-bation of this condition?
a. The abdomen is tight and shiny.
b. Wheezes are present during lung ausculta-tion.
c. The pupils react sluggishly to light.
d. The heart rate is irregularly irregular.
B
Left-sided heart failure causes increased pressure on the lungs and may manifest in wheezing. A tight and shiny abdomen is consistent with ascites, a manifestation of right-sided CHF. Sluggish pupillary reaction is consistent with a neurologic problem, and an irregularly irregular heart rate is consistent with a cardiac arrhythmia like atrial fibrillation.
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