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 C
Explanation
Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.
Correct Answer is A
Explanation
Choice A rationale
Acute pancreatitis is characterized by severe epigastric pain and elevated levels of amylase and lipase. These enzymes are released into the bloodstream when the pancreas is inflamed, making acute pancreatitis the most likely diagnosis.
Choice B rationale
Acute hematochezia refers to the passage of fresh blood through the anus, usually in or with stools. It is not associated with elevated amylase and lipase levels or severe epigastric pain.
Choice C rationale
Left heart failure can cause symptoms such as shortness of breath and fluid retention, but it does not typically cause elevated amylase and lipase levels or severe epigastric pain.
Choice D rationale
Chronic hepatic failure involves long-term liver damage and may present with jaundice, ascites, and other symptoms. It is not associated with elevated amylase and lipase levels or severe epigastric pain.