After receiving report on the following clients, which client should the nurse assess first?
Client with infective endocarditis who has a murmur and splinter hemorrhages
Client with rheumatic fever who has sharp chest pain with a deep breath
Client with dilated cardiomyopathy who has bilateral crackles at the lung bases
Client with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
The Correct Answer is D
A. A murmur and splinter hemorrhages are expected findings in infective endocarditis and do not indicate an immediate life-threatening condition.
B. Sharp chest pain with inspiration in rheumatic fever may indicate pericarditis, which needs monitoring but is not immediately unstable.
C. Bilateral crackles suggest fluid overload in dilated cardiomyopathy, requiring attention, but not as urgent as hypotension in acute valve failure.
D. Acute aortic regurgitation with hypotension (BP 86/54 mm Hg) indicates a possible hemodynamic collapse and cardiogenic shock, making this client the highest priority for immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Blood flowing back from the left atrium to the left ventricle describes mitral regurgitation, not aortic regurgitation.
B. Aortic regurgitation involves the backflow of blood from the aorta into the left ventricle during diastole due to an incompetent aortic valve. This leads to volume overload in the left ventricle.
C. Obstruction of blood from the left atrium to the left ventricle occurs in mitral stenosis, not aortic regurgitation.
D. Obstruction of blood flow from the left ventricle is characteristic of aortic stenosis, not aortic regurgitation.
Correct Answer is A
Explanation
A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.
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