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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Hypersplenism is a condition often associated with cirrhosis, where the spleen becomes overactive. This leads to the destruction of blood cells, causing anemia (low red blood cells), leukopenia (low white blood cells), and thrombocytopenia (low platelets).
Choice B rationale
Peptic ulcer disease primarily affects the stomach and duodenum, leading to ulcers and bleeding. It does not typically cause anemia, leukopenia, and thrombocytopenia in the context of cirrhosis.
Choice C rationale
Cholecystitis is the inflammation of the gallbladder, usually due to gallstones. It does not cause the blood cell abnormalities seen in cirrhosis.
Choice D rationale
Esophageal varices are swollen veins in the esophagus that develop due to portal hypertension in cirrhosis. While they can cause bleeding, they do not directly cause anemia, leukopenia, and thrombocytopenia.
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.