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[nclex-expert]

A home care nurse visits an elderly man who is diagnosed with heart failure. Which of the following statements if made by the patient need immediate follow up.

1. “My feet are swollen by the end of the day”
2. “I did not eat lunch today because I feel nauseous.”
3. “I urinate frequently at night and can not sleep”
4. “I could not button up my pants this morning”


Answer 3.

Rational

1. Dependent edema is a sign of right side heart failure
2. Nausea is a symptom of right side failure
3. Nocturia is a sign of left side heart failure which is more serious than right side failure.
4. Acites is a sign of right side failure



Reference.
Smeltzer,S, Bare, B.
Medical/Surgical Nursing 10th Ed (2004)

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