A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?
Heart murmur
Bradycardia
Clubbing of the fingers
Barrel chest
The Correct Answer is A
Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.
Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.
Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.
Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Tachycardia is not an adverse effect of oxygen therapy. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Tachycardia can be caused by various factors, such as fever, infection, pain, or anxiety. Tachycardia can also be a sign of hypoxemia, which is a low level of oxygen in the blood, and may indicate the need for oxygen therapy.
Choice B reason: Cracks in oral mucous membranes are an adverse effect of oxygen therapy. Cracks in oral mucous membranes are a sign of dryness and irritation caused by the oxygen flow. Oxygen therapy can reduce the natural moisture and lubrication of the mouth and nose, leading to discomfort and increased risk of infection. To prevent or treat this problem, the nurse should provide the client with humidified oxygen, oral care, and hydration.
Choice C reason: Excessive pulmonary secretions are not an adverse effect of oxygen therapy. Excessive pulmonary secretions are a sign of inflammation and infection in the lungs, which can impair gas exchange and cause coughing, wheezing, and dyspnea. Excessive pulmonary secretions can be a symptom of pneumonia, which is a common cause of respiratory failure and may require oxygen therapy.
Choice D reason: Poor skin turgor is not an adverse effect of oxygen therapy. Poor skin turgor is a sign of dehydration, which is a loss of fluid from the body. Dehydration can be caused by various factors, such as vomiting, diarrhea, fever, or inadequate intake. Dehydration can affect the blood volume and pressure, and may worsen the oxygen delivery to the tissues. To prevent or treat this problem, the nurse should monitor the client's fluid balance and provide adequate hydration.
Correct Answer is D
Explanation
Choice A reason: Dry skin is not a sign of respiratory alkalosis. Respiratory alkalosis is a condition where the blood pH is too high due to excessive loss of carbon dioxide through rapid breathing. Dry skin can be caused by dehydration, cold weather, or skin conditions.
Choice B reason: Diarrhea is not a sign of respiratory alkalosis. Diarrhea is a condition where the stool is loose and watery due to increased intestinal motility or infection. Diarrhea can cause metabolic acidosis, which is a condition where the blood pH is too low due to excessive loss of bicarbonate.
Choice C reason: Abdominal pain is not a sign of respiratory alkalosis. Abdominal pain is a symptom that can have many causes, such as gastritis, appendicitis, or irritable bowel syndrome. Abdominal pain can also cause hyperventilation due to anxiety or discomfort, but it is not a direct result of respiratory alkalosis.
Choice D reason: Hyperventilation is a sign of respiratory alkalosis. Hyperventilation is a condition where the breathing rate is faster than normal, causing excess carbon dioxide to be expelled from the lungs. This lowers the partial pressure of carbon dioxide in the blood, which increases the blood pH and causes alkalosis. Hyperventilation can be caused by anxiety, fever, pain, or lung diseases.
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