While Assessing a Patient with Heart Failure, the Nurse Notes

question 20

Multiple Choice

While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to

• A) have the patient perform the Valsalva maneuver and observe the jugular veins.
• B) palpate the jugular veins and compare the volume and pressure on the both sides.
• C) use a centimeter ruler to measure and document accurately the level of the JVD.
• D) elevate the patient gradually to an upright position and examine for continued JVD.

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Definitions:

Jean-Paul Sartre

A French philosopher, playwright, novelist, and political activist from the 20th century, recognized for his work in existentialism and phenomenology.

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A struggle or clash between opposing forces, ideas, or interests, either internally within a person or externally between individuals, groups, or nations.

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An American philosopher known for his contributions to philosophy of mind, political philosophy, and ethics, particularly famous for the essay "What Is It Like to Be a Bat?".