Patho Patho #85

Question

A client has jugular venous distention (JVD), hepatomegaly, and peripheral edema. The client is exhibiting signs of:

Answers

  1. left sided heart failure.
    • Rationale:

      This answer choice is not correct because signs of left sided heart failure indicate that blood is backing up into the lungs such as crackles and dyspnea.

  2. septal failure.
    • Rationale:

      This answer choice is not correct as JVD, hepatomegaly, and peripheral edema indicate that the right side of the heart has lost contractility and indicate right sided heart failure.

  3. biventricular failure.
    • Rationale:

      This answer choice is not correct because JVD, hepatomegaly, and peripheral edema indicate only that a client is experiencing right sided heart failure. If the left side of the heart were also involved, the client would display signs of blood backing up into the lungs such as dyspnea or crackles.

  4. right-sided heart failure.
    • Rationale:

      This answer is correct because JVD, peripheral edema, and hepatomegaly are indications of right sided heart failure.

Overview

The focus of this question is asking the nurse to identify signs of right sided heart failure. When the right side of the heart fails, blood backs up into the periphery or systemic circulation. JVD, hepatomegaly, and peripheral edema are manifestations associated with right sided heart failure.

Explanation

Learning Outcomes

Right sided heart failure usually occurs in clients with prolonged pulmonary disease. Thje right side of the heart pumps blood to the lungs and when pressures within the lungs are elevated, such as in COPD, the right side of the heart enlarges to compensate. When this occurs, the right side of the heart loses contractility and blood begins to back up into peripheral circulation. Signs of right sided heart failure include peripheral edema, hepatomegaly, and JVD.

Test Taking Tip

Left= lungs; Right= systemic

Video Rationale