A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

Barrel chest

Clubbing of the fingers

Bradycardia

A heart murmur

Answer and Explanation

The Correct Answer is D

Rationale:

A. A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) due to chronic hyperinflation of the lungs, not mitral valve stenosis.

B. Clubbing occurs in chronic hypoxia conditions such as congenital heart defects or long-term lung disease. It is not a primary feature of mitral stenosis.

C. Mitral stenosis does not typically cause bradycardia. Some clients may develop atrial fibrillation, which usually causes irregularly rapid heart rates, not slowed heart rate.

D. Mitral valve stenosis narrows the mitral valve, causing turbulent blood flow from the left atrium to the left ventricle during diastole. This produces a diastolic murmur, often heard best at the apex with the client in the left lateral position.

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Correct Answer is ["C","E"]

Explanation

Rationale:
A. A thready, weak pulse is typically associated with fluid volume deficit, not excess. Clients with FVE often have bounding pulses due to increased intravascular volume.

B. Dizziness is more commonly a sign of hypovolemia or hypotension, rather than fluid overload.

C. Edema occurs when excess fluid accumulates in the interstitial spaces, commonly in the lower extremities in clients with heart failure, making it a classic manifestation of FVE.

D. FVE usually causes distended (full) neck veins due to increased central venous pressure. Flat neck veins are associated with hypovolemia.

E. Rapid or unexplained weight gain in a client with HF is an early sign of fluid retention and is commonly used to monitor FVE.

A. Orthopnea B. Chest pain C. Tachycardia D. Headache E. Diaphoresis

Correct Answer is ["B","C","E"]

Explanation

Rationale:
A. Orthopnea (difficulty breathing when lying flat) is more characteristic of heart failure, not the acute presentation of MI.

B. Chest pain is the hallmark symptom of an acute MI, often described as pressure, squeezing, or heaviness in the chest.

C. The sympathetic nervous system often responds to myocardial ischemia with increased heart rate, making tachycardia a common finding.

D. Headache is not a typical manifestation of MI and is not used in diagnostic assessment for acute coronary events.

E. Excessive sweating is a common autonomic response during an acute MI due to sympathetic activation and pain.

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A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has fluid volume excess (FVE) due to heart failure (HF). Which of the following manifestations should the nurse associate with FVE? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

A 22-year-old patient presents with fatigue, chest discomfort, and palpitations. Vital signs show HR 112 bpm. BP 98/5, and low-grade fever. The nurse notes irregular heart sounds and severe pedal edema. Which condition should the nurse suspect? (Select All that Apply.)

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

A nurse is reviewing laboratory results for a client who has pericarditis. Which of the following blood test results should the nurse anticipate? (Select All that Apply.)

A 65-year-old patient with congestive heart failure has been on diuretic therapy for the past two weeks. During a follow-up appointment, which of the following findings would indicate that the diuretic therapy is effective?

A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?