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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Asthma exacerbation typically causes wheezing or bronchospasm and would not usually cause decreased breath sounds in one lung.
B. Pulmonary embolism may cause breathlessness or decreased oxygen levels, but it wouldn't typically cause unilateral decreased breath sounds.
C. Pneumothorax is the most likely cause, as air in the pleural space can collapse the lung, leading to decreased or absent breath sounds on the affected side.
D. Pulmonary edema typically causes bilateral crackles and would not cause unilateral decreased breath sounds.

A. Assess the forearm and hand for infection B. Assess the lower extremities C. Assess the dorsalis pedis pulses D. None of the above

Correct Answer is B

Explanation

A. Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B. Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C. Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D. None of the above is incorrect because assessing the lower extremities is the next logical step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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