The nurse is assessing a client with heart failure. Which finding should the nurse expect to observe in this client?
1. Confusion
2. Weight gain
3. Clear lung sounds
4. Twitching of the arms and legs
Answer: 2
1. Confusion is not usually a sign of fluid volume excess.
2. The client with heart failure experiences fluid volume excess and will gain weight due to retention of water.
3. The client with too much fluid volume is apt to have wet breath sounds.
4. Twitching of the arms and legs can be a sign of a neurological problem or an electrolyte imbalance.
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