# A nurse is assessing a 68-year-old patient with chronic heart failure who was admitted for acute exacerbation. Which assessment finding would be the MOST concerning and require immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540267  
> language: ko  
> subject: Adult Health

## 문제

A nurse is assessing a 68-year-old patient with chronic heart failure who was admitted for acute exacerbation. Which assessment finding would be the MOST concerning and require immediate intervention?

## 보기

1. Bilateral lower extremity edema with 2+ pitting and mild discomfort
2. Crackles in bilateral lung bases on auscultation with mild dyspnea
3. Jugular venous distension visible at 45-degree elevation with hepatojugular reflux **✔ 정답**
4. S3 gallop heart sound audible at the apex with mild fatigue

**정답: 3**

## 해설

Jugular venous distension with hepatojugular reflux indicates severe right heart failure and elevated central venous pressure, requiring immediate intervention. Other findings like crackles, edema, and S3 gallop are concerning but less urgent.

## 심화 해설

Understanding the Clinical Scenario

In a patient admitted with acute decompensated heart failure (ADHF), the nurse's assessment must differentiate between findings that represent chronic compensated congestion and those indicating acute hemodynamic decompensation requiring urgent intervention. All four options describe classic signs of heart failure, but they carry different prognostic weights and urgency levels.

The key pathophysiological concept here is the distinction between right ventricular (RV) dysfunction with systemic venous congestion and left ventricular (LV) dysfunction with pulmonary congestion. While both can coexist, certain signs reflect more severe hemodynamic derangement and predict poorer outcomes, as demonstrated in the ESCAPE trial analysis [4].

Analysis of Each Option

**Option 1: Bilateral lower extremity edema with 2+ pitting and mild discomfort**

This represents chronic venous congestion from right heart failure. While uncomfortable, peripheral edema develops gradually and does not typically indicate an immediate life-threatening change. It reflects elevated right atrial pressure transmitted backward through the venous system, but the body has compensatory mechanisms (lymphatic drainage, tissue compliance) that accommodate this over time. This finding warrants continued diuretic therapy but is not the most urgent concern in the acute setting.

**Option 2: Crackles in bilateral lung bases with mild dyspnea**

Bibasilar crackles indicate pulmonary congestion from elevated left ventricular filling pressures. This is a hallmark of left-sided heart failure and does require intervention. However, in the 2016 and 2021 ESC Guidelines, isolated mild pulmonary crackles in a patient with known chronic heart failure may represent a manageable degree of volume overload . The presence of "mild" dyspnea suggests the patient is not in severe respiratory distress, giving the nurse some time to escalate care systematically.

**Option 3: Jugular venous distension visible at 45-degree elevation with hepatojugular reflux**

Jugular venous distension (JVD) visible at 45 degrees indicates a markedly elevated central venous pressure (CVP), typically exceeding 10-12 cm H₂O. The presence of a positive hepatojugular reflux (HJR) — sustained rise in JVP with abdominal compression — is particularly ominous. The ESCAPE trial data revealed that a positive HJR at discharge was independently associated with significantly higher 6-month mortality and the composite endpoint of death, rehospitalization, and cardiac transplant [4]. This sign reflects severe RV dysfunction and an inability of the right ventricle to handle increased venous return, indicating profound hemodynamic compromise. The combination of JVD at 45 degrees plus positive HJR signals that the patient is in a hypervolemic state that the failing right ventricle cannot compensate for, placing them at high risk for cardiogenic shock, hepatic congestion, and end-organ hypoperfusion. This finding demands immediate escalation to the healthcare provider for aggressive diuresis or hemodynamic monitoring.

**Option 4: S3 gallop heart sound audible at the apex with mild fatigue**

An S3 gallop is a classic sign of LV systolic dysfunction and elevated left ventricular end-diastolic pressure. It occurs during rapid ventricular filling when a stiff, noncompliant ventricle resists inflow. While an S3 is a valuable diagnostic and prognostic marker in heart failure, it is often a chronic finding in patients with established cardiomyopathy. In the context of an acute exacerbation, its presence confirms significant LV dysfunction but does not, by itself, indicate an acute, immediately life-threatening change that requires instantaneous intervention over the other findings. Mild fatigue accompanying the S3 is a nonspecific symptom of low cardiac output.

Why Option 3 Takes Priority

The ESC Guidelines emphasize that clinical congestion — particularly signs of elevated right-sided filling pressures — is a powerful predictor of adverse outcomes in acute heart failure . The hepatojugular reflux test is a bedside maneuver that unmasks occult RV dysfunction and preload intolerance. When positive, it reveals that the right ventricle is operating on the steep portion of the Frank-Starling curve, where additional volume does not augment stroke volume but instead worsens congestion and reduces coronary perfusion pressure [4].

This finding is more concerning than isolated pulmonary crackles or peripheral edema because it signifies biventricular failure with systemic venous hypertension severe enough to cause hepatic congestion, which can rapidly progress to impaired hepatic function, coagulopathy, and cardiorenal syndrome. The immediate intervention required includes notifying the provider, preparing for intravenous diuretic administration, strict intake and output monitoring, and potentially preparing for advanced hemodynamic monitoring or inotropic support .

References (research sources)

- [4]Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE TrialResearch articleHesham R. Omar, Maya Guglin (2017) · DOI: 10.1155/2017/5734749

## 임상 시나리오

Assessing JVD & HJR in ADHFA Bedside Guide to Identifying Acute Hemodynamic Compromise
In acute decompensated heart failure, jugular venous distension (JVD) with a positive hepatojugular reflux (HJR) is a critical finding. It directly reflects severely elevated central venous pressure (CVP), often exceeding 15 mmHg, and signals acute right ventricular failure.

To assess, position the patient at a 45-degree angle. Identify the top of the venous pulsation in the neck. A column height greater than 3 cm above the sternal angle is abnormal. For HJR, apply firm, sustained pressure to the right upper quadrant for 10-30 seconds; a sustained rise in JVP of >3 cm during compression is a positive sign.

CautionJVD with HJR indicates a preload-dependent state on the verge of decompensation. This finding takes priority over chronic signs like peripheral edema or bibasilar crackles. Immediate intervention, such as intravenous diuresis or vasodilator therapy, is often required to reduce preload and prevent cardiogenic shock.

## 핵심 개념

- **Jugular Venous Distension (JVD)** — Visible distension of the jugular veins reflecting elevated right atrial pressure, best assessed with the patient at a 45-degree angle.
- **Hepatojugular Reflux (HJR)** — A sustained rise in jugular venous pressure by more than 3 cm during firm abdominal compression, indicating right ventricular inability to handle increased venous return.
- **S3 Gallop** — A low-frequency diastolic heart sound heard at the apex, indicative of volume overload and left ventricular dysfunction.
- **Right Ventricular Failure** — The inability of the right ventricle to effectively pump blood into the pulmonary circulation, leading to systemic venous congestion.
- **Pulmonary Crackles** — Discontinuous adventitious lung sounds produced by fluid in the alveoli, commonly associated with left-sided heart failure.

## 같은 주제 문제

- [A nurse is caring for a patient with acute exacerbation of heart failure. Which nursing in…](https://mymerci.kr/pages/nclex_q.php?qn_id=540268)
- [A nurse is caring for a patient with chronic heart failure who has been receiving IV furos…](https://mymerci.kr/pages/nclex_q.php?qn_id=540269)
- [A nurse is caring for a patient with acute exacerbation of heart failure who presents with…](https://mymerci.kr/pages/nclex_q.php?qn_id=540270)
- [A nurse is caring for a patient with acute heart failure who has been receiving IV furosem…](https://mymerci.kr/pages/nclex_q.php?qn_id=540271)
- [A nurse is caring for a patient with acute heart failure who has been receiving IV furosem…](https://mymerci.kr/pages/nclex_q.php?qn_id=540272)
- [A nurse is caring for a patient with hypertension who has been receiving oral hydrochlorot…](https://mymerci.kr/pages/nclex_q.php?qn_id=540273)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._