A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Shortness of breath while lying down
Jugular venous distention
Right upper quadrant pain
Pitting edema of the lower legs
The Correct Answer is A
A. Shortness of breath while lying down. Shortness of breath when lying down, or orthopnea, is common in left-sided heart failure due to fluid backing up into the lungs, causing pulmonary congestion.
B. Jugular venous distention. Jugular venous distention is more commonly associated with right-sided heart failure due to systemic venous congestion.
C. Right upper quadrant pain. Right upper quadrant pain is associated with liver congestion due to right-sided heart failure, not left-sided heart failure.
D. Pitting edema of the lower legs. Pitting edema is a symptom of right-sided heart failure, as fluid backs up into the peripheral circulation.
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Correct Answer is B
Explanation
A. "I am constipated." Constipation is not a common indicator of digoxin toxicity; it may be more related to diet or other medications.
B. "My vision seems yellow." Yellow or blurred vision, also called xanthopsia, is a classic sign of digoxin toxicity and should be reported immediately.
C. "My tongue is red and beefy." A red and beefy tongue may indicate vitamin B12 deficiency, not digoxin toxicity.
D. "I am gaining weight." Weight gain is usually a sign of fluid retention or worsening heart failure, not specifically digoxin toxicity.
Correct Answer is B
Explanation
A. Bounding peripheral pulses: Hypokalemia typically causes weak, thready pulses rather than bounding ones.
B. Decreased deep-tendon reflexes: Hypokalemia can cause muscle weakness and decreased deep-tendon reflexes due to impaired neuromuscular function.
C. Hyperactive bowel sounds: Hypokalemia generally causes decreased or hypoactive bowel sounds due to slowed smooth muscle contraction.
D. Restlessness: Restlessness is not a typical sign of hypokalemia; hypokalemia more commonly causes weakness, lethargy, or fatigue.