A nurse is collecting data on a patient who has mitral valve stenosis. Which of the following findings should the nurse expect?

Barrel chest

Clubbing of the fingers

Heart murmur

Bradycardia

Answer and Explanation

The Correct Answer is C

Choice A reason: A barrel chest is typically not associated with mitral valve stenosis. It is more commonly seen in chronic obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. Mitral valve stenosis affects the heart and not the lung structure.

Choice B reason: Clubbing of the fingers is a sign that can be associated with chronic hypoxia and certain types of congenital heart disease. While it can be seen in some heart conditions, it is not a specific finding for mitral valve stenosis.

Choice C reason: A heart murmur, specifically a diastolic murmur, is a classic finding in mitral valve stenosis. As the stenotic mitral valve obstructs blood flow from the left atrium to the left ventricle, a pressure gradient is created, which produces a murmur that can be heard upon auscultation.

Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct finding associated with mitral valve stenosis. Mitral valve stenosis may lead to arrhythmias such as atrial fibrillation due to atrial enlargement, but bradycardia is not typically induced by this condition.

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Correct Answer is A

Explanation

Choice A reason : Hepatomegaly, or the enlargement of the liver, is a common finding in right-sided heart failure. This condition occurs because the heart does not pump blood effectively, leading to congestion and increased pressure in the venous system, including the hepatic veins. As a result, the liver becomes engorged with blood, causing it to enlarge. The normal liver span in adults is about 10-12 cm in the midclavicular line, and any measurement above this can indicate hepatomegaly.

Choice B reason : Orthopnea, which is shortness of breath while lying flat, is more commonly associated with left-sided heart failure. In right-sided heart failure, symptoms are more related to systemic congestion, such as swelling in the legs and abdomen, rather than pulmonary symptoms like orthopnea.

Choice C reason : Dyspnea, or difficulty breathing, can be a symptom of both left and right-sided heart failure. However, in the context of right-sided heart failure, dyspnea is usually due to the accumulation of fluid in the abdominal cavity (ascites) and the increased pressure in the abdominal veins, which can compress the diaphragm and make breathing difficult.

Choice D reason : Frothy sputum is typically not a symptom of right-sided heart failure. It is more indicative of pulmonary edema, which is associated with left-sided heart failure. In right-sided heart failure, the primary issues are related to the systemic circulation and venous congestion.

A. Thickened toenails B. Shiny, thin skin on the lower extremities C. Dusky, red color of the feet when dangling D. Pitting edema

Correct Answer is D

Explanation

Choice A reason : Thickened toenails are often associated with fungal infections and are not a direct symptom of venous insufficiency. However, they can appear in patients with chronic venous insufficiency due to poor circulation that affects the health of the toenails.

Choice B reason : Shiny, thin skin on the lower extremities is more characteristic of arterial insufficiency, where there is a reduction in blood flow and oxygen to the tissues. In venous insufficiency, the skin may instead appear thickened and discolored due to stasis and buildup of hemosiderin from the breakdown of red blood cells.

Choice C reason : A dusky, red color of the feet when dangling can be a sign of dependent rubor, which is associated with arterial insufficiency. This occurs when there is a severe decrease in arterial blood flow to the lower extremities. Venous insufficiency may cause a different color change, typically a brownish discoloration due to hemosiderin deposition.

Choice D reason : Pitting edema is a hallmark sign of venous insufficiency. It occurs due to the accumulation of fluid in the tissues, which is a result of increased pressure in the veins. This pressure causes fluid to leak into the surrounding tissues, leading to swelling that retains an indentation when pressed.

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A nurse is collecting data on a patient who has mitral valve stenosis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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