Question

The nurse is concerned that a patient is developing right heart failure. What did the nurse assess in this patient?

Select all that apply.
1. Ankle edema
2. Enlarged liver
3. Displaced apical heart rate
4. Shortness of breath
5. Cough

Answer 1

The nurse assessed ankle edema, enlarged liver, and shortness of breath in the patient, which may indicate the development of right heart failure.

Step-by-step explanation:

Right-sided heart failure occurs when the right ventricle of the heart is unable to pump blood effectively. The nurse assessed several signs and symptoms in this patient that may indicate the development of right heart failure, including:

1. Ankle edema: Swelling in the ankles can occur when fluid builds up in the body due to right heart failure.
2. Enlarged liver: When the heart is unable to pump blood efficiently, it can back up into the liver, causing it to become enlarged.
3. Shortness of breath: Difficulty breathing can be a result of fluid accumulation in the lungs due to right heart failure.
4. The nurse would need to further assess the patient to confirm a diagnosis of right heart failure and implement appropriate interventions.