Practice Question
A client is admitted with a history of hypertension and an acute myocardial infarction 2 years ago. The client reports, I weak and tired, so I cannot exercise at all. I feel out of breath when I walk even a short distance. Since I cannot exercise, I gaining weight. My shoes are even getting tight!" The cardiac monitor displays sinus tachycardia. Which cue should lead the nurse to further assess the client for other symptoms of right sided heart failure?
Answer Choices:
Correct Answer:
Report of tight shoes.
Rationale:
🌟 Right-sided heart failure is commonly associated with systemic venous congestion, leading to peripheral edema.
🌟 The client’s statement that their shoes are getting tight suggests swelling in the feet and ankles, a hallmark sign of fluid retention due to right ventricular dysfunction.
🌟 Right-sided failure often presents with jugular venous distention, hepatomegaly, ascites, and peripheral edema, all linked to backup of blood in the systemic circulation.
🌟 While weakness, lack of exercise, and breathlessness are consistent with left-sided heart failure (pulmonary congestion and decreased cardiac output), tight shoes point directly to right-sided involvement.
🌟 Recognizing this cue helps the nurse assess for additional right-sided findings and provide timely management.
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This question is from HESI RN Med-Surg Fall 2024. which contains 40 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi MedSurg
- Answer Choices: 4