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 B
Explanation
Choice A rationale
Decreasing the secretion of thyroid stimulating hormone (TSH) by the pituitary gland is not a compensatory response to fluid volume deficit. TSH primarily regulates thyroid function and metabolism, and its secretion is not directly related to fluid balance or osmolality.
Choice B rationale
Increasing renin-angiotensin-aldosterone system (RAAS) activity by the kidneys is the body’s primary compensatory response to fluid volume deficit. When there is a decrease in blood volume or blood pressure, the kidneys release renin, which activates the RAAS. This system increases the reabsorption of sodium and water in the kidneys, leading to an increase in blood volume and blood pressure.
Choice C rationale
Decreasing the secretion of cortisol by the adrenal gland is not a compensatory response to fluid volume deficit. Cortisol is a stress hormone that helps regulate metabolism, immune response, and other functions, but it is not directly involved in fluid balance.
Choice D rationale
Increasing the secretion of natriuretic peptides by the heart is a response to fluid overload, not fluid deficit. Natriuretic peptides promote the excretion of sodium and water by the kidneys, which helps reduce blood volume and pressure. This response is opposite to what is needed in a fluid volume deficit situation.
Correct Answer is B
Explanation
Choice A rationale
Decreased breath sounds in the lower lobes can indicate areas of the lung that are not ventilating well, but this finding alone does not specifically indicate an exacerbation of COPD. It could be due to other conditions such as pleural effusion or atelectasis.
Choice B rationale
Increased respiratory rate and use of accessory muscles are signs of respiratory distress and indicate that the patient is working harder to breathe. These findings are consistent with an exacerbation of COPD, where the airways are more obstructed, and the patient has difficulty maintaining adequate ventilation.
Choice C rationale
Elevated blood pressure and heart rate can occur in many conditions and are not specific indicators of a COPD exacerbation. These vital sign changes can be due to pain, anxiety, or other stressors.
Choice D rationale
Presence of wheezing and cyanosis are also indicators of a COPD exacerbation. Wheezing indicates airway obstruction, and cyanosis indicates hypoxemia, both of which are common during an exacerbation.