Question

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening?

A. ADHF
B. Chronic HF
C. Left-sided HF
D. Right-sided HF

Answer 1

The nurse should suspect that the patient is experiencing right-sided heart failure (HF), which is characterized by symptoms such as jugular venous distention, weight gain, peripheral edema, and an increased heart rate.

Step-by-step explanation:

The nurse should suspect that the patient is experiencing right-sided heart failure (HF). Right-sided heart failure occurs when the right ventricle is unable to pump blood effectively, leading to a build-up of fluid in the systemic circulation. This can result in symptoms such as jugular venous distention, weight gain, peripheral edema, and an increased heart rate. In this case, the patient's symptoms suggest that the right side of the heart is not effectively pumping blood to the lungs, causing fluid to back up into the systemic circulation.