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Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
- A. A loud S1, S2 split, and a mitral opening snap.
- B. A holosystolic murmur heard best at the cardiac apex.
- C. A midsystolic ejection click or murmur heard at the base.
- D. A high-pitched sound heard at the third left intercostal space.
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (B) due to backflow. S1/S2 snap (A) is mitral stenosis, ejection click (C) is aortic/pulmonic, and high-pitched sound (D) is nonspecific.
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The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first?
- A. Notify the health care provider (HCP).
- B. Assess what the client ate at the last meal.
- C. Request a STAT 12 lead electrocardiogram.
- D. Administer furosemide IVP.
Correct Answer: A
Rationale: Edema and crackles post-STEMI suggest heart failure; notifying the HCP (A) ensures timely intervention. Diet (B), ECG (C), and furosemide (D) follow HCP orders.
The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select all that apply.
- A. Obtain a midstream urine specimen.
- B. Attach the telemetry monitor to the client.
- C. Start a saline lock in the right arm.
- D. Draw a basal metabolic panel (BMP).
- E. Request an order for a STAT 12-lead ECG.
Correct Answer: B,C,E
Rationale: Telemetry (B), saline lock (C), and STAT ECG (E) assess cardiac status. Urine specimen (A) and BMP (D) are not priority for suspected cardiac issues.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?
- A. Midepigastric pain and pyrosis.
- B. Diaphoresis and cool, clammy skin.
- C. Intermittent claudication and pallor.
- D. Jugular vein distention and dependent edema.
Correct Answer: B
Rationale: MI causes diaphoresis and cool, clammy skin (B) due to sympathetic activation. Epigastric pain/pyrosis (A) suggest GI issues, claudication/pallor (C) indicate PAD, and JVD/edema (D) suggest heart failure.
Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.