Which physical assessment finding does the nurse would expect in a client with left-sided heart failure?
1. Enlarged liver
2. Lung congestion
3. Jugular vein distension
4. Peripheral edema
Correct Answer: 2
Rationale 1: Right-sided failure causes blood to back up to the large veins, which can cause hepatomegaly.
Rationale 2: Left-sided heart failure results in blood backing up into the lungs, causing pulmonary edema.
Rationale 3: Right-sided failure causes blood to back up to the large veins, resulting in jugular venous distension.
Rationale 4: Right-sided failure causes blood to back up to the large veins. Gravity pulls backed-up blood toward the feet, resulting in pedal edema.
Global Rationale: Left-sided heart failure results in blood backing up into the lungs, causing pulmonary edema. Right-sided failure causes blood to back up to the large veins, which can cause hepatomegaly, jugular venous distention, and pedal edema caused by gravity pulling back-up blood toward the feet.
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