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 A
Explanation
Choice A rationale
The absence of burning epigastric pain after eating indicates that the treatment for peptic ulcer disease (PUD) secondary to H. pylori has been effective. This suggests that the ulcer has healed and the inflammation has subsided.
Choice B rationale
Coffee-ground emesis indicates the presence of blood in the vomit, which suggests ongoing bleeding and is not a sign of effective treatment for PUD.
Choice C rationale
A decrease in alcohol intake is beneficial for overall health but does not directly indicate the effectiveness of treatment for PUD secondary to H. pylori.
Choice D rationale
Normalization of hemoglobin levels is important but does not specifically indicate the effectiveness of treatment for PUD secondary to H. pylori. The primary indicator would be the resolution of symptoms such as burning epigastric pain.
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.