Nokea
Which of the following heart sounds would the nurse expect to auscultate in a client with systolic heart failure? Select all that apply.
- A. S1
- B. S2
- C. S3
- D. S4
- E. Pleural friction rub
Correct Answer: C
Rationale: S1 is a normal heart sound. B: Incorrect - S2 is a normal heart sound. C: Correct - S3 is associated with systolic heart failure due to rapid ventricular filling. D: Incorrect - S4 is linked to diastolic dysfunction, not systolic failure. E: Incorrect - Pleural friction rub indicates pleural inflammation, not heart failure.
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The emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below.
- A. Pulmonary embolism
- B. Hypovolemic shock
- C. Disseminated intravascular coagulation (DIC)
- D. Pulmonary edema
Correct Answer: D
Rationale: Dyspnea and persistent cough in CHF suggest pulmonary edema due to fluid backup in the lungs.
The nurse performs a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are
- A. Heberden's nodes
- B. Janeway lesions
- C. Tophi
- D. Bouchard's nodes
Correct Answer: B
Rationale: Janeway lesions are non-tender, erythematous maculae on the palms and soles, characteristic of infective endocarditis.
The nurse is caring for a client diagnosed with acute pericarditis. Which complication is the client at risk for developing?
- A. cardiac tamponade
- B. hemothorax
- C. pulmonary embolism
- D. tension pneumothorax
Correct Answer: A
Rationale: Acute pericarditis can lead to pericardial effusion, which may progress to cardiac tamponade, compressing the heart.
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The nurse is caring for a client who is reporting pain in their left lower leg. How should the nurse assess for the presence of thrombophlebitis?
- A. By palpating the skin over the tibia and fibula
- B. By documenting daily calf circumference measurements
- C. By recording vital signs obtained four times a day
- D. By noting difficulty with ambulation
Correct Answer: B
Rationale: Measuring calf circumference detects swelling, a key sign of thrombophlebitis, indicating possible deep vein thrombosis.