ATI TEAS (Test of Essential Academic Skills) Version 7ReadingHard
A nurse is reviewing a patient's electronic health record (EHR) and sees a physician's note stating: 'Patient presents with S3 heart sound, JVD, and bilateral pitting edema 3+ in lower extremities.' Based on these clinical indicators, which condition is the patient most likely experiencing?
- ACongestive Heart Failure (CHF)
- BDeep Vein Thrombosis (DVT)
- CPneumonia
- DMyocardial Infarction
Show answer & explanationAnswer & explanation
Correct answer: A. Congestive Heart Failure (CHF)
The combination of an S3 heart sound (gallop rhythm), JVD (Jugular Venous Distension), and bilateral pitting edema are classic clinical signs of fluid overload and ventricular dysfunction, which are hallmarks of Congestive Heart Failure (CHF).
Why the other options are wrong
- B. DVT typically involves unilateral leg swelling, pain, and redness, not bilateral edema with S3 and JVD.
- C. Pneumonia typically presents with respiratory symptoms like cough, fever, and crackles, not this specific triad.
- D. Myocardial Infarction (heart attack) is characterized by chest pain, EKG changes, and elevated cardiac enzymes, not primarily by these fluid overload signs.
Clinical Indicators of Congestive Heart Failure (CHF)
A collection of signs and symptoms that indicate the heart's inability to pump enough blood to meet the body's needs, leading to fluid accumulation.
- S3 heart sound (ventricular gallop).
- Jugular Venous Distension (JVD).
- Peripheral edema (often bilateral and pitting).
- Dyspnea, orthopnea, paroxysmal nocturnal dyspnea.
Memory trick: CHF: S3, JVD, Edema—FLUID OVERLOAD from a WEAK HEART.