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Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?

A.

Enlarged liver and peripheral edema.

B.

Crackles in the lungs.

C.

Dry hacking cough.

D.

Altered mentation with pinpoint pupils.

Answer and Explanation

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

Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.

Choice B rationale

Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.

Choice C rationale

Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.

Choice D rationale

Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

Correct Answer is B

Explanation

Choice A rationale

Nausea and vomiting can be caused by various conditions, including gastrointestinal issues and brain injuries, but they are not specifically indicative of a diffuse brain stem injury.

Choice B rationale

Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation, often due to meningeal edema in conditions like meningitis.

Choice C rationale

Bilateral fixed and dilated pupils are more commonly associated with severe brain injury or increased intracranial pressure, not specifically a cerebellar brain attack.

Choice D rationale

Brudzinski’s sign is a physical exam finding indicative of meningeal irritation, commonly seen in bacterial meningitis, not specifically viral meningitis.

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