The client is admitted with right-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
A. Feet
B. Neck
C. Hands
D. Sacrum
Correct Answer: B. Neck
The jugular veins in the neck should be assessed for distension. Increased blood volume, which can occur with right-sided heart failure, or anything that interferes with filling of the right atrium or movement of the blood into the right ventricle, can increase the central venous pressure and the amount of jugular vein distention.
Option A: Jugular vein distention is affected by the position of your body. If the height is greater than 3 to 4 centimeters when measured while you are in bed with your head elevated 45 degrees, this may signal vascular or heart disease. Smaller amounts of jugular vein distention can occur in people without heart or vascular disease.
Option C: For example, jugular vein distention may be raised by a narrowing or blockage of the superior vena cava, which can interfere with blood return to the heart.
Option D: It can also be caused by constrictive pericarditis (infection of the lining that surrounds the heart) and cardiac tamponade (filling of the sac around the heart with blood or other fluid), both of which restrict the volume of the heart. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided.