Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?
Enlarged liver and peripheral edema.
Crackles in the lungs.
Dry hacking cough.
Altered mentation with pinpoint pupils.
The Correct Answer is A
Choice A rationale
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.
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Correct Answer is D
Explanation
Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A rationale
The tripod position helps to improve breathing by allowing the diaphragm to expand more effectively. This position reduces the work of breathing and helps to increase lung capacity, which is beneficial for patients with emphysema.
Choice B rationale
Pursed lip breathing is a technique that helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing. This method helps to improve ventilation and oxygenation in patients with emphysema.
Choice C rationale
Staying current with yearly vaccinations is important for overall health, but it is not a specific strategy for better breathing in emphysema patients. Vaccinations help prevent respiratory infections, which can exacerbate emphysema symptoms.
Choice D rationale
Taking an antihistamine every day is not a recommended strategy for better breathing in emphysema patients. Antihistamines are typically used to treat allergies and may have side effects that could worsen breathing difficulties.
Choice E rationale
Inhaling slowly and deeply helps to maximize lung expansion and improve oxygenation. This technique can help to reduce shortness of breath and improve overall breathing efficiency in patients with emphysema.
Choice F rationale
Sleeping with 2 pillows to prop oneself up helps to reduce the work of breathing by preventing the diaphragm from being compressed. This position can help to improve breathing and reduce shortness of breath during sleep.
Choice G rationale
Measuring peak flow is a useful tool for monitoring lung function, but it is not a specific strategy for better breathing in emphysema patients. Peak flow measurements can help to track the progression of the disease and adjust treatment plans accordingly.
Choice H rationale
Taking a leukotriene inhibitor every day is not a recommended strategy for better breathing in emphysema patients. Leukotriene inhibitors are typically used to treat asthma and may not be effective for emphysema.