Author Question: The nurse is obtaining the health history of a patient who is being assessed for possible heart ... (Read 103 times)

Pea0909berry · **on:** Jun 25, 2018

The nurse is obtaining the health history of a patient who is being assessed for possible heart failure (HF). Which patient statement should the nurse identify as being associated with this condition?

1. I break out in a cold sweat when I eat a large meal.
2. I am sleepy after I eat lunch every day.
3. I have to prop myself up on three pillows to sleep at night. Otherwise I can't breathe.
4. I feel better with my legs down when I sit in my favorite chair.

Question 2

The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient?

1. S1, S2, and flat neck veins
2. S3 and distended neck veins
3. S2 heard the loudest and followed by S1
4. S4 and flat neck veins

kingdude89 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3
Needing to prop oneself up with pillows at night to breathe describes orthopnea, which is consistent with heart failure (HF). HF produces a volume excess, congestion in the lungs, and dyspnea when the patient attempts to lie down. Diaphoresis and sleepiness after meals as well as the effects of leg position are not related to a diagnosis of HF.

Answer to Question 2

Correct Answer: 2
The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle, and the neck veins distend because of the increased venous pressure. Most patients have elements of both right- and left-sided heart failure. S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding. The S1 and S2 sounds may be diminished in the heart failure patient and do not vary in intensity. S4 (gallop) may be present, but neck veins would be distended.