Cardiac Question #11

Question

The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5 pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition?

Answers

  1. Acute pericarditis
    • Rationale:
  2. Myocardial infarction
    • Rationale:
  3. Left-sided heart failure
    • Rationale:
  4. Right-sided heart failure
    • Rationale:

Overview

Explanation

The client exhibits signs of right-sided heart failure because fluid is being retained (weight gain), and is backing up systemically. The patient is fatigued due to diminished cardiac output and reduced oxygenation, and has jugular venous distention. Acute pericarditis often presents with pain that may be intense on inspiration, low-grade fever, heart palpitations, and although pericarditis may result in fluid collection around the heart, the answer does not fit the complaints and findings of the client. Left-sided heart failure may present with pulmonary congestion, dry cough, and orthopnea, but differs from right sided HF. Myocardial infarction does not fit the signs and symptoms or assessment findings.

Learning Outcomes

Test Taking Tip

Video Rationale