The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF)
The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?
A) The woman is demonstrating the early signs of cardiogenic shock.
B) The woman has left-sided heart failure.
C) The woman is also likely to experience shortness of breath.
D) The woman may be experiencing an exacerbation of right-sided HF.
D
You might also like to view...
Which of these communication techniques BEST illustrates how a nurse can assess a client's orientation status?
a. "Tell me what month and day of the week it is." b. "Did you know you were in the hospital?" c. "Hello, Mrs. Smith. I am Emily, your nurse today. Can you tell me your name?" d. "My, what a pretty gown. Where did you get it?"
Ms. M is being seen in the well-baby clinic with Tamara, who is 21 months old. Ms. M says Tamara is eating well, mainly pureed junior foods. The nurse will base her teaching on which of the following concepts?
1. Attempting to feed herself is too difficult at this age for Tamara. 2. Giving Tamara table foods would be much less expensive for Ms. M. 3. Processing removes much of the iron in canned foods, so this meal pattern puts Tamara at risk of anemia. 4. Varying textures is believed to aid speech development.
When working with a client, you notice that he always tends to stand within 10 to 18 inches of others. The client's peers and the staff complain that this closeness is uncomfortable. The client follows you around the unit
After assessing this client, your MOST likely conclusion will be that this client: a. has developed a bad habit b. is lonely and needs friends c. needs to work on boundary issues d. would benefit from behavior modification
An older adult with a diagnosis of heart failure has been admitted to the hospital with an exacerbation of this condition. Which of the following are consequences of heart failure for which the nurse must monitor? (Select all that apply.)
A) Arrhythmias B) Autoimmune disorders C) Drug interactions D) Hypotension E) Sleep disorders