During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?
Peripheral vascular disease
Fluid and electrolyte disturbances
Heart failure
Atrial-septal defect
The Correct Answer is C
A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Top-to-bottom comparison is not the best method for auscultation. A more systematic approach is needed.
B. Posterior-to-anterior comparison does not apply to all auscultation areas, and a consistent method across the thorax is preferred.
C. Interspace-by-interspace comparison involves comparing sounds across different intercostal spaces but is not a method for transitioning between sites.
D. Side-to-side comparison ensures the nurse is assessing both sides of the thorax equally and systematically, which is the correct approach.
Correct Answer is C
Explanation
A. Palpation of the thyroid helps assess its size, consistency, and tenderness but does not aid in detecting a bruit.
B. Swallowing helps assess the mobility of the thyroid but does not aid in auscultating for a bruit.
C. The bell of the stethoscope is used to detect low-pitched sounds, such as a bruit, which might be heard if there is increased blood flow through the thyroid gland, as seen in hyperthyroidism or Graves' disease.
D. The diaphragm is used to detect high-pitched sounds, such as lung or heart sounds. The bell is better for detecting a bruit.
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