A client is being seen in the clinic to rule out mitral valve stenosis. Which assessment data would be an early indication of this condition?
The client's blood pressure has decreased since the last visit
The client's liver is enlarged and the abdomen is edematous
The client has jugular vein distention and 3+ pedal edema
The client complains of shortness of breath when walking
The Correct Answer is D
A. The client's blood pressure has decreased since the last visit. Decreased blood pressure is not a typical early sign of mitral valve stenosis.
B. The client's liver is enlarged and the abdomen is edematous. These are signs of more advanced heart failure, which can result from mitral valve stenosis but are not early indicators.
C. The client has jugular vein distention and 3+ pedal edema. Jugular vein distention and pedal edema are later signs of heart failure caused by mitral valve stenosis, not early signs.
D. The client complains of shortness of breath when walking. Shortness of breath on exertion is an early sign of mitral valve stenosis as the left atrium is unable to effectively pump blood into the left ventricle, leading to pulmonary congestion and difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Urine glucose, high: High urine glucose would suggest hyperglycemia, typically seen in diabetes mellitus, not diabetes insipidus.
B. Urine specific gravity, 1.001: Diabetes insipidus results in excessive urine output with a low specific gravity (dilute urine), reflecting the inability to concentrate urine.
C. Urine output, 50 ml/hr: This is a relatively low urine output, which does not indicate diabetes insipidus. Diabetes insipidus is characterized by very high urine output, often greater than 3 liters per day.
D. Urine protein, high: High urine protein could suggest kidney disease or glomerular injury, not diabetes insipidus.
Correct Answer is A
Explanation
A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.
B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.
C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.
D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.
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