Nokea
The nurse is told in report the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal notch.
- B. Erb's point.
- C. Second intercostal space, left sternal notch.
- D. Fourth intercostal space, left sternal border.
Correct Answer: A
Rationale: Aortic stenosis murmur is best heard at the second intercostal space, right sternal notch (A), where the aortic root is closest. Erb’s point (B), left sternal notch (C), and fourth space (D) are for other murmurs.
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Which nursing diagnosis would be priority for the client diagnosed with myocarditis?
- A. Anxiety related to possible long-term complications.
- B. High risk for injury related to antibiotic therapy.
- C. Increased cardiac output related to valve regurgitation.
- D. Activity intolerance related to impaired cardiac muscle function.
Correct Answer: D
Rationale: Myocarditis impairs cardiac function, making activity intolerance (D) the priority due to reduced cardiac output. Anxiety (A), injury (B), and increased output (C) are less immediate or incorrect.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?
- A. Put a nitroglycerin tablet under the tongue.
- B. Stop the activity immediately and rest.
- C. Document when and what activity caused angina.
- D. Notify the health-care provider immediately.
Correct Answer: B
Rationale: Stopping activity and resting (B) reduces oxygen demand, the first step in angina. Nitroglycerin (A) follows, documenting (C) is later, and notifying HCP (D) is for persistent pain.
Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.
- A. Paroxysmal nocturnal dyspnea.
- B. Orthopnea.
- C. Cough.
- D. Pericardial friction rub.
- E. Pulsus paradoxus.
Correct Answer: A,B,C
Rationale: Valvular disease causes fluid overload, leading to PND (A), orthopnea (B), and cough (C). Pericardial rub (D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.