NURSING 100/ NURS 100/ NUSING100/ NURS100: HEART FAILURE: University Of Massachusetts (GRADE A)
Heart Failure
A client is diagnosed with myocardial
... [Show More] infarction. Which data collection findings indicate that the
client has developed left-sided heart failure?
Orthopnea
Cough
Crackles
RATIONALES: Left-sided heart failure produces primarily pulmonary signs and symptoms, such as
orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and
symptoms, such as ascites, jugular vein distention, and hepatomegaly.
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system
stimulation.
RATIONALES: In the early stage of heart failure, low blood pressure triggers baroreceptors in the
carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster
heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow
causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and
antidiuretic hormone, in turn causing sodium and water retention and arterial vasoconstriction.
When assessing a client with left-sided heart failure, the nurse expects to note:
air hunger.
RATIONALES: With left-sided heart failure, the client typically has air hunger and other signs of
pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of rightsided heart failure.
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients
with heart failure are:
fine crackles.
RATIONALES: Fine crackles are caused by fluid in the alveoli and commonly occur in clientswith
heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are causedby
secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
Crackles: Short, explosive or popping sounds usually heard during inspiration. They may be coarse
(loud and low in pitch) or fine (less intense and high in pitch) and resemble the sounds heard when
rolling hair between the fingers near the ear.
After an anterior wall myocardial infarction, which of the following problems is indicated by
auscultation of crackles in the lungs?
Left-sided heart failure
The left ventricle is responsible for the most of the cardiac output. An anterior wall MI may result in a
decrease in left ventricular function. When the left ventricle doesn’t function properly, resulting in leftsided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes
crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.
1
In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
Right-sided heart failure
The most accurate area on the body to assessed dependent edema in a bedridden client is the sacral area.
Sacral, or dependent, edema is secondary to right-sided heart failure. Diabetes mellitus, pulmonary
emboli, and renal disease aren’t directly linked to sacral edema.
Which of the following symptoms might a client with right-sided heart failure exhibit?
Oliguria
Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid
retention, which causes oliguria (??). Adequate urine output, polyuria, and polydipsia aren’t
associated with right-sided heart failure.
Which of the following classes of medications maximizes cardiac performance in clients with heat
failure by increasing ventricular contractility?
Inotropic agents
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium
channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics
are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease
in urine output?
Right-sided heart failure
Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure.
Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure
causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn’t cause weight
gain, nausea, or a decrease in urine output.
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure.
Which assessment component would elicit specific in [Show Less]