Nokea
You are caring for a patient with mitral valve stenosis. You plan to assess the mitral valve during your initial assessment. Where will you be best able to auscultate the mitral valve?
- A. The right base of the heart
- B. The left base of the heart
- C. The apex of the left ventricle
- D. The left lateral sternal border
Correct Answer: C
Rationale: The mitral valve is best heard at the apex of the left ventricle, typically in the 5th intercostal space, midclavicular line.
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Explain the importance of performing an initial shift assessment within the first hour of your shift.
- A. Ensures early detection of changes in patient condition
- B. Establishes a baseline for comparison
- C. Guides care planning and interventions
- D. All of the above
Correct Answer: D
Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.
What type of assessment is performed on admission?
- A. A focused assessment
- B. An initial head-to-toe shift assessment
- C. A comprehensive health assessment
- D. A brief admission systems assessment
- E. Disease and injury assessment
Correct Answer: B,C
Rationale: A comprehensive health assessment (C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (B) to evaluate all body systems.
Select the symptom(s) from this list of assessment findings.
- A. Flushing
- B. Fever of 102.8°F
- C. Nausea
- D. Vomiting
- E. Light-headedness
- F. Cramping
- G. Guarding
Correct Answer: C,D,E,F
Rationale: Symptoms are subjective complaints reported by the patient (nausea, vomiting, light-headedness, cramping), while others are objective findings.
You have just completed an initial shift assessment of your 72-year-old female patient who has congestive heart failure. Which of the following assessment findings causes you the most concern?
- A. Fine papular rash under both breasts
- B. Reports her last BM was 2 days ago
- C. AP 78 regular and distant
- D. Has not voided in 12 hours
- E. Complaints of fatigue
Correct Answer: D
Rationale: Not voiding in 12 hours is concerning in a patient with congestive heart failure, as it may indicate worsening renal perfusion or fluid retention.
Your instructor has asked you to come to the patient's room to hear a good example of a murmur and a bruit. You know that there are specific instances when you use the bell versus the diaphragm side on your stethoscope and when you use light pressure as opposed to pressing to make a firm seal against the patient's skin. Which of the following correctly describes how to use the bell and diaphragm chest piece of your stethoscope?
- A. Use the flat diaphragm to auscultate lower-pitched sounds
- B. Use the bell to auscultate lower-pitched sounds
- C. When using the bell, press firmly to seal it against the skin
- D. When using the flat diaphragm, press it firmly to seal it against the skin
- E. Murmurs and bruits are considered high-pitched sounds
- F. The S1 and S2 are considered high-pitched sounds
Correct Answer: B,D
Rationale: The bell is used for low-pitched sounds with light pressure, while the diaphragm is pressed firmly for high-pitched sounds like murmurs and bruits.