While assessing a 68-year-old with ascites, the nurse also notes ...

[cartlidgeashley]

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
 
  a. decreased fluid volume.
  b. jugular vein atherosclerosis.
  c. increased right atrial pressure.
  d. incompetent jugular vein valves.

Question 2

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider?
 
  a. Q waves on ECG
  b. Elevated troponin levels
  c. Fever and hyperglycemia
  d. Tachypnea and crackles in lungs

[voltaire123]

Answer to Question 1

ANS: C
The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

Answer to Question 2

ANS: D
Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

[cartlidgeashley]

Excellent

[marict]

TYSM