Question

The RN on a Medical Surgical Unit is doing her admission assessment on a new patient Mr. A.W. A.W. was admitted for SOB and CHF exacerbation. He has a medical history of CHF, DM, arthritis, HTN, and hyperlipidemia. (#1-10)

7. A.W. tells the RN that he has not been taking his Lasix at home, he has gained 7 lbs over the

past week, and gets tired when walking short distances. The RN suspects that this is due to...?

a.Diabetes

b. Hypertension

c.Elevated cholesterol

d. Congestive Heart Failure

8. What type of lung sounds can the RN expect to hear on A.W.?

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9. Mr. A.W. tells the RN that he thinks all of his problems are just because he is “getting old.” List

three normal changes that occur during the aging process.

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10. The RN is assessing A.W. for left-sided and right-sided heart failure. List at least three signs of

each left and right-sided heart failure.

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Answer 1

Answer : d) congestive heart failure .

Patient with congestive heart failure weight gain is first sign that the disease is getting worse .

Patient may gain 3 pounds per day and 5-10 pounds in one week .

8) fine crackles ( rales) lung sounds will be heared in patient with CHF .mostly heared in posterior lung bases .

9) normal changes during aging process :

Integumentary system : skin may lose elasticity , scales may form ,skin will be thinned.

Reduces sensation

Hearing impairment common

Lose of sense of smell ,sight.

Respiratory system : decreases respiratory function

Circulatory system : blood vessels lose elasticity and may rigid .

High blood pressure may occur due to inelasticity of blood vessels .

Cardiac output decreased

Gastrointestinal system : gastric motility slows and causes constipation

There will be decreased absorption rate .

CNS : loss of neuron ,so may get loss of sensation and other neurological diseases such as dementia , delirium and algiemers disease.

10) signs and symptoms of left sided heart failure :

Cyanosis

Paraxysmal nocturnal dyspnea

Orthopnea

Fatigue

Restlessness

Pulmonary congestion - cough , crackles ,wheezes , blood tinged sputum , tachypnea .

Elevated pulmonary pressure

Signs and symptoms of right sided heart failure :

Dependent edema

Swelling of hands and fingers

Distended jugular veins

Elevated peripheral venous pressure.

Enlarged liver and spleen

Fatigue

Ascitis