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
Hypercalcemia is characterized by increased calcium levels in the blood, often due to increased absorption of calcium from the gut. However, in chronic kidney disease (CKD), the kidneys’ ability to activate vitamin D is impaired, leading to decreased calcium absorption from the gut, not increased. Therefore, hypercalcemia is not a typical sign of CKD.
Choice B rationale
A positive Chvostek’s sign is indicative of hypocalcemia, which is a common symptom in CKD. The kidneys’ reduced ability to activate vitamin D leads to decreased calcium absorption from the gut, resulting in low calcium levels in the blood. This hypocalcemia can cause neuromuscular irritability, leading to a positive Chvostek’s sign.
Choice C rationale
Tetany is a condition characterized by muscle cramps and spasms, often due to hypocalcemia. In CKD, hypocalcemia occurs due to the kidneys’ inability to activate vitamin D, leading to decreased calcium absorption from the gut. This hypocalcemia can cause hyperexcitability of nerves and muscles, resulting in tetany.
Choice D rationale
Hyperphosphatemia is characterized by high phosphate levels in the blood. In CKD, the kidneys’ ability to excrete phosphate is impaired, leading to its accumulation in the blood. However, this is not directly related to the inability to absorb phosphate from the gut but rather the kidneys’ reduced excretion capacity.
Correct Answer is A
Explanation
Choice A rationale
It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.
Choice B rationale
The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.
Choice C rationale
It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.
Choice D rationale
After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.