Difficulty: Medium
Average Score: 91%
Simulated
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?
Correct answer
A
Rationale
CHF exacerbation causes fluid overload, leading to tachycardia (apical pulse 110) and severe edema (4+ pitting, A). Thick sputum/crackles (B) suggest pneumonia, sleeping flat with eupnea (C) is unlikely, and normal CRT (D) doesnÔÇÖt reflect CHF severity.