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 A
Explanation
A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.
B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.
C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.
D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.
Correct Answer is A
Explanation
A. Bradycardia: Atenolol can slow the heart rate as it reduces the workload of the heart. Bradycardia (a heart rate below 60 beats per minute) is a potential adverse effect and should be monitored.
B. Dry Cough: A dry cough is a common side effect of ACE inhibitors, not beta-blockers like atenolol. This statement is incorrect.
C. Migraine Headache: Atenolol is sometimes used to prevent migraines, not cause them. Therefore, migraines are not an expected adverse effect of atenolol. This statement is incorrect.
D. Insomnia or Hyperactivity: Atenolol can cause fatigue or lethargy, but insomnia or hyperactivity is not a typical side effect. This statement is incorrect.
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