Practice Question
An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirms to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.
Answer Choices:
Correct Answer:
Dyspnea.
Rationale:
🟦 Dyspnea is one of the earliest and most reliable indicators of heart failure (HF) exacerbation. When the heart cannot pump effectively, fluid backs up into the pulmonary vasculature, causing pulmonary congestion and difficulty breathing.
🟦 Clients often report shortness of breath during exertion, at rest, or at night (orthopnea or paroxysmal nocturnal dyspnea).
🟦 This occurs because excess fluid in the lungs decreases gas exchange, forcing the client to work harder to breathe.
🟦 Dyspnea is therefore a hallmark symptom of worsening HF and requires immediate assessment and intervention.
✔ Peripheral edema
🟦 Peripheral edema occurs when ineffective cardiac output leads to accumulation of fluid in dependent areas such as the legs, ankles, and feet.
🟦 This is caused by the kidneys retaining sodium and water due to low perfusion from the failing heart.
🟦 The presence of edema indicates volume overload, a classic sign of HF decompensation.
🟦 Progressive swelling signals worsening right-sided HF and often accompanies weight gain, fatigue, and reduced mobility.
❌ Incorrect Answers
Intercostal retractions
— This finding is typically associated with respiratory distress, especially in children, or conditions like airway obstruction—not heart failure exacerbation in adults.
— HF clients show labored breathing but do not normally exhibit retractions.
Headaches
— Headaches are not a characteristic sign of HF worsening.
— They may be linked to hypertension or other neurological issues but are not used to confirm HF exacerbation.
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This question is from Fall 2025-BSN -246 RN Health Assessment which contains 59 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: Health Assessment
- Answer Choices: 4