A 16-year-old female client presents with complaints of palpitations. While the nurse is auscultating heart sounds, asking the client to get into a seated position and leaning forward, would help the nurse assess the presence of which of the following?

Mitral stenosis

Atrial repolarization

The first heart sound

Aortic murmurs

Answer and Explanation

The Correct Answer is D

A) Mitral stenosis: Mitral stenosis is best assessed in the left lateral decubitus position, not by asking the client to lean forward. This position brings the mitral valve closer to the chest wall, allowing for better auscultation of the mitral valve area.
B) Atrial repolarization: Atrial repolarization, which is not typically auscultated as a distinct sound, occurs during the repolarization phase of the atria and is not specifically assessed by positioning the client in any particular way.
C) The first heart sound: The first heart sound (S1) is best heard over the mitral and tricuspid areas of the heart and does not specifically require the client to lean forward. It is associated with the closure of the atrioventricular valves and can be assessed in various positions.
D) Aortic murmurs: Aortic murmurs, including those associated with aortic stenosis or regurgitation, are often best heard with the client sitting and leaning forward. This position brings the aortic valve closer to the chest wall and can enhance the auscultation of murmurs or abnormal heart sounds associated with the aortic area.

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Correct Answer is ["A","C","D"]

Explanation

A) Cerebrovascular disease: Uncontrolled hypertension can lead to cerebrovascular disease, including stroke. High blood pressure damages the blood vessels in the brain, increasing the risk of both ischemic and hemorrhagic strokes. Chronic hypertension contributes to the development of atherosclerosis and can lead to significant cerebrovascular complications.
B) Venous insufficiency: Venous insufficiency is typically associated with conditions that affect the veins, such as chronic venous disease or deep vein thrombosis, rather than hypertension. While hypertension can impact overall cardiovascular health, it is not a primary cause of venous insufficiency.
C) Transient Ischemic Attack (TIA): A TIA, often referred to as a "mini-stroke," is a temporary period of symptoms similar to those of a stroke. Uncontrolled hypertension is a major risk factor for TIAs, as it can cause temporary disruptions in blood flow to the brain, leading to symptoms that resolve within minutes to hours but indicate a higher risk for a full-blown stroke.
D) Left Ventricular Hypertrophy: Left ventricular hypertrophy (LVH) occurs when the heart's left ventricle becomes thickened due to increased pressure workload, commonly from uncontrolled hypertension. This condition can lead to heart failure, arrhythmias, and other cardiovascular problems.
E) Constipation: Constipation is generally not a direct consequence of uncontrolled hypertension. While lifestyle factors such as diet can affect both hypertension and bowel movements, constipation itself is not directly linked to high blood pressure.
F) Bronchitis: Bronchitis, an inflammation of the bronchial tubes, is not directly related to hypertension. It is more commonly associated with smoking, infections, and chronic lung

A. XI B. VIII C. IX D. X

Correct Answer is B

Explanation

A) XI: Cranial nerve XI, the spinal accessory nerve, is primarily responsible for motor function, particularly in the muscles involved in shoulder elevation and head rotation. It does not play a role in balance, so focusing on this nerve would not be relevant to the client’s complaint of balance issues.
B) VIII: Cranial nerve VIII, the vestibulocochlear nerve, is directly involved in hearing and balance. It transmits information from the inner ear to the brain regarding head position and motion, which are essential for maintaining balance. The client’s report of spontaneous loss of balance strongly suggests involvement of this nerve, making it the most appropriate focus for additional assessment.
C) IX: Cranial nerve IX, the glossopharyngeal nerve, is primarily associated with taste and the gag reflex. While it is important for swallowing and certain aspects of speech, it does not influence balance, so it would not be the primary concern in this situation.
D) X: Cranial nerve X, the vagus nerve, has extensive functions related to autonomic control of the heart, lungs, and digestive tract, as well as motor and sensory functions in the throat. Although it plays a significant role in the body, it does not directly influence balance, making it less relevant in this context.

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A 16-year-old female client presents with complaints of palpitations. While the nurse is auscultating heart sounds, asking the client to get into a seated position and leaning forward, would help the nurse assess the presence of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is doing a community teaching about the consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is B

Explanation

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