A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right sided
Which of the following statements best describes the presentation that the nurse should anticipate? The client
A)
has a distended bladder, facial edema, and nighttime difficulty breathing.
B)
complains of dyspnea and has adventitious breath sounds on auscultation (listening).
C)
has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain.
D)
has cyanotic lips and extremities, low urine output, and low blood pressure.
Ans:
C
Feedback:
Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-sided failure when the liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine output, and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs and symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.
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