After teaching a nursing student about mitral valve stenosis and mitral valve regurgitation, the nurse identifies effective learning when the student identifies which common feature of both disorders?

Hemoptysis

High-pitched holosystolic murmur

Hepatomegaly

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.

Choice B Reason:

A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.

Choice C Reason:

Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.

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Correct Answer is D

Explanation

Choice A Reason:

A decreased thyroxine (T4) level is not expected in a client with Graves’ disease. Graves’ disease is an autoimmune disorder that leads to hyperthyroidism, where the thyroid gland produces excessive amounts of thyroid hormones, including T4. Therefore, the T4 level is typically elevated, not decreased.

Choice B Reason:

Similarly, a decreased triiodothyronine (T3) level is not expected in Graves’ disease. Like T4, T3 levels are usually elevated due to the overactive thyroid gland. T3 is the active form of thyroid hormone and is often increased in hyperthyroid conditions.

Choice C Reason:

Decreased thyroid-stimulating immunoglobulins (TSI) percentage is incorrect. In Graves’ disease, TSI levels are elevated because these antibodies stimulate the thyroid gland to produce more thyroid hormones. TSI mimics the action of TSH, leading to increased production of T3 and T4.

Choice D Reason:

Decreased thyroid-stimulating hormone (TSH) level is the correct answer. In Graves’ disease, the excessive thyroid hormones (T3 and T4) exert negative feedback on the pituitary gland, leading to suppressed TSH production. Therefore, TSH levels are typically low in patients with Graves’ disease.

A. Strict monitoring of hourly intake and output B. Managing pain through drug and non-drug methods C. Assessing neurological status at least every 2 to 4 hours D. Decreasing environmental stimuli

Correct Answer is C

Explanation

Choice A reason:

Strict monitoring of hourly intake and output is important for managing fluid balance and detecting potential complications such as dehydration or fluid overload1. However, it is not the highest priority in the acute phase of bacterial meningitis. The primary concern is to monitor for signs of increased intracranial pressure (ICP) and neurological deterioration.

Choice B reason:

Managing pain through drug and non-drug methods is essential for patient comfort and overall well-being. Pain management can help reduce stress and improve the patient’s ability to rest and recover. However, it is not the highest priority compared to monitoring neurological status, which can provide early indications of complications such as increased ICP or seizures.

Choice C reason:

Assessing neurological status at least every 2 to 4 hours is the highest priority for a client with bacterial meningitis. This frequent assessment helps detect early signs of neurological deterioration, increased ICP, and other complications. Early detection and intervention are crucial in preventing severe outcomes and improving the patient’s prognosis.

Choice D reason:

Decreasing environmental stimuli is important to reduce stress and prevent exacerbation of symptoms such as headache and photophobia. While this intervention is beneficial, it is not as critical as frequent neurological assessments in the acute management of bacterial meningitis.

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After teaching a nursing student about mitral valve stenosis and mitral valve regurgitation, the nurse identifies effective learning when the student identifies which common feature of both disorders?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Graves’ disease. The nurse should expect which of the following laboratory results?

Correct Answer is D

Explanation

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?

Correct Answer is C

Explanation

The provider writes an order for a client to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube? Select all that apply.

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?

An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

A client with type II diabetes is scheduled to have a computed tomography (CT) scan with IV contrast of the brain to rule out a brain tumor. What health teaching would the nurse include?Your provider will obtain a signed consent from you prior to the completion of the CT scan.

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?