A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make?
"A heart murmur is a high-pitched sound due to a narrow valve."
"A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber."
"This means that there is some inflammation around your heart."
"This indicates turbulent (chaotic, random fluctuations) blood flow through a valve."
The Correct Answer is D
A. "A heart murmur is a high-pitched sound due to a narrow valve." While some murmurs may be caused by a narrow valve (stenosis), not all murmurs are high-pitched. Murmurs vary in pitch depending on the cause, so this is not a comprehensive explanation.
B. "A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber." This describes an S3 or S4 sound rather than a murmur. A heart murmur is typically related to turbulent blood flow through valves, not just an inflexible heart chamber.
C. "This means that there is some inflammation around your heart." This statement incorrectly links a murmur to pericarditis or myocarditis, which involve inflammation. A murmur is associated with abnormal blood flow, not inflammation.
D. "This indicates turbulent (chaotic, random fluctuations) blood flow through a valve." A heart murmur is caused by turbulent blood flow, which can occur when blood moves through a valve that is narrow or has regurgitation. This is the correct explanation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client's blood pressure. While it is important to monitor vital signs after surgery, checking blood pressure is not the first action unless the client is showing signs of instability.
B. Check the client's IV catheter insertion site. Assessing the IV site is important for identifying complications such as infiltration or phlebitis, but this is not the priority.
C. Check the level of the client's pain. Pain assessment is the priority because unmanaged pain can affect recovery and indicate complications such as bleeding or infection. Managing pain is crucial in the postoperative period.
D. Check the client's bowel sounds. Assessing bowel sounds is important following abdominal surgery, but it is not the first priority compared to pain assessment.
Correct Answer is D
Explanation
A. Valve disorder: While valve disorders can cause fatigue and dyspnea, the client’s history of hypertension, tachycardia, hypercholesteremia, and medication noncompliance are more suggestive of heart failure rather than a valve disorder.
B. Asthma: Asthma typically presents with wheezing, shortness of breath, and chest tightness. It is less likely to be the cause of symptoms in this scenario, where cardiac conditions and medication noncompliance are noted.
C. Pulmonary embolism: While pulmonary embolism can cause dyspnea and tachycardia, the client's chronic cardiovascular history and edema are more consistent with heart failure than an acute pulmonary embolism.
D. Heart failure: The client has a history of hypertension, tachycardia, and hypercholesteremia, along with medication noncompliance, tachycardia, and edema. These are classic signs of heart failure, making this the most likely diagnosis
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