Question

The nurse is assessing a patient with heart failure. which of the following manifestations would require...

The nurse is assessing a patient with heart failure. which of the following manifestations would require the nurse to take immediate action. The patient

A. is anxious, pale, and coughing blood tinged sputum

B. has distention of the jugular vein at 45 degrees

C has 4+ pitting edema in bilateral lower extremities

D. has liver enlargement with right upper quadrant pain

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Answer #1

The nurse is assessing a patient with heart failure. The patient has distention of the jugular vein at 45 degrees require the nurse to take immediate action.

Answer - B. has distention of the jugular vein at 45 degrees

Distention of the jugular vein is a sign of increase of preload of Heart most commonly due to Heart failure. It requires immediate treatment otherwise it can lead to Hypotension and shock.

Others signs like sputum production and 4+ pitting edema is also a sign of Heart failure but distention of the jugular vein at 45 degrees is a potent sign.

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