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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. "I can eat frozen juice bars for a snack." Frozen juice bars are generally low in sodium and are a healthy snack option for clients with hypertension. This choice is acceptable as long as they are made from 100% juice and do not contain added sugars or sodium.

B. "I can have a cola drink twice a day." Cola drinks contain caffeine, sugar, and sometimes sodium, which can increase blood pressure. Clients with hypertension should limit their intake of sugary or caffeinated drinks. This statement indicates a need for further teaching.

C. "I will replace table salt with dried herbs." Replacing table salt with dried herbs is a good practice to reduce sodium intake, which can help manage hypertension. This statement does not indicate a need for further teaching.

D. "Fresh fruits are good to include with meals." Fresh fruits are low in sodium and rich in potassium, which can help regulate blood pressure. This is a good dietary choice for clients with hypertension and does not indicate a need for further teaching.

A. Valve disorder B. Asthma C. Pulmonary embolism D. Heart failure

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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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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