Nokea
When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?
- A. S1 heart sound
- B. S3 heart sound
- C. Heart murmur
- D. Crackles
Correct Answer: B
Rationale: An S3 heart sound, if heard, is an early sign of impending heart failure. The S1 heart sound is normal. Heart murmur is not a sign of impending heart failure. Moist lung sounds could be indicative of either heart failure or pneumonia.
You may also like to solve these questions
What disease process is mitral regurgitation associated with?
- A. Aortic stenosis
- B. Cellulitis
- C. Pulmonary fibrosis
- D. Rheumatic carditis
Correct Answer: D
Rationale: Mitral regurgitation is associated with rheumatic carditis and mitral valve prolapse. It is not associated with aortic stenosis, cellulitis, or pulmonary fibrosis. Aortic stenosis is a narrowing of the aortic valve, not related to the mitral valve. Cellulitis is inflammation in tissue, and pulmonary fibrosis is a scarring in the tissue of the lung.
The client has been diagnosed with aortic regurgitation. Which nursing data is most significant in identifying the cause for this disorder?
- A. Obesity
- B. Tobacco use
- C. Fen-Phen
- D. Lack of exercise
Correct Answer: C
Rationale: The incidence of mitral and aortic regurgitation increased by as much as 36% in 1997, due to the use of fenfluramine with phentermine (Fen-Phen) for weight loss. Obesity, tobacco use, and lack of exercise have been identified as risk factors for heart disease but not a significant identified cause for aortic regurgitation.
A client reports a family history of aortic stenosis. Which assessment finding would the nurse identify as a likely contributing factor?
- A. High blood pressure
- B. Missing aortic cusp
- C. Unidirectional blood flow
- D. Chest pain
Correct Answer: B
Rationale: In young adults, aortic stenosis usually is a consequence of a congenital defect in which the valve has two instead of three cusps. High blood pressure and chest pain are symptoms that can be exhibited in aortic stenosis. Unidirectional blood flow is the normal flow of blood through the heart.
The nurse provides care for an older adult client who is diagnosed with valvular heart disease. On auscultation of the client's heart sounds, the nurse notes an erratic heart rhythm. Which age-related change is the most likely cause for this finding?
- A. A stiffening of the aorta
- B. A decrease in metabolism
- C. An increase in thirst sensation
- D. A thinning of the mitral valve
Correct Answer: A
Rationale: Age-related effects, such as stiffening of the aorta, calcification, and fibrotic thickening (not thinning) of the mitral and aortic valves, contribute to development of symptoms (e.g., increased systolic blood pressure [BP], dangerous arrhythmias [erratic heart rhythms or rates that are too fast or slow] sometimes referred to as dysrhythmias) and complications (e.g., increased myocardial oxygen demand, heart failure, and alterations in cardiac output) in the older adult with valvular heart disease. A decrease in metabolism is an age-related effect for clients with valvular heart disease; however, this affects the dosage of prescribed medication and is not the cause of the client's dysrhythmia. A decrease, not increase, in thirst sensation is an age-related change that could lead to dehydration, and, thus, changes in the client's heart rhythm.
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
- A. Pulmonary edema
- B. Congestive failure
- C. Thrombophlebitis
- D. Cardiogenic shock
Correct Answer: A
Rationale: A cough with productive, pink, frothy sputum and crackles in the bases of the lungs are signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive failure, thrombophlebitis, or cardiogenic shock.