The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

increased fluid in the pericardial sac.

dysfunction of one or more heart valves.

an aneurysm of the descending aorta.

an occlusion of the right coronary artery.

Answer and Explanation

The Correct Answer is B

A. increased fluid in the pericardial sac: While fluid accumulation can affect heart sounds, it typically leads to muffled heart sounds rather than a loud murmur. Increased fluid in the pericardial sac (pericardial effusion) usually does not produce a classic heart murmur.

B. dysfunction of one or more heart valves: This statement is correct. Heart murmurs are often caused by turbulence in blood flow due to the dysfunction of heart valves, such as stenosis (narrowing) or regurgitation (leaking). A loud murmur suggests significant turbulence, which is often indicative of valvular heart disease.

C. an aneurysm of the descending aorta: While an aortic aneurysm can cause other types of heart sounds or signs of cardiovascular compromise, it is not primarily associated with heart murmurs.

D. an occlusion of the right coronary artery: An occlusion may lead to ischemia or myocardial infarction, which can cause changes in heart sounds, but it does not directly cause a heart murmur. Murmurs are more specifically related to blood flow dynamics, particularly involving valves.

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Correct Answer is D

Explanation

A) Reassuring the client that they will be able to do the exercise program: While reassurance is important for motivation, it does not provide practical support or help the client engage effectively in the program.

B) Explaining the exercise program to the client's spouse: While involving the spouse can be beneficial, the primary focus should be on ensuring the client understands and can engage in the program themselves.

C) Providing the client with specific details of how to perform the exercises: While it's important for the client to understand the exercises, simply giving details may not address the client's personal preferences or limitations, which are crucial for adherence.

D) Adapting the program to the client's needs and abilities: This intervention is the best approach to help the client maintain the exercise program. By tailoring the exercise regimen to fit the client's individual abilities, preferences, and any physical limitations, the client is more likely to feel confident, motivated, and able to stick with the program long-term.

A. Encourage oral fluids. B. Record the client's weight C. Take a pulse oximetry reading D. Place the call bell in reach of the client

Correct Answer is D

Explanation

A. Encourage oral fluids: While hydration is important, it is not the most immediate concern following the administration of prazosin.

B. Record the client's weight: Weight monitoring is not specifically indicated after the initial dose of prazosin and is not a priority action in this context.

C. Take a pulse oximetry reading: While monitoring oxygen saturation is important in many situations, it is not directly related to the administration of prazosin, which primarily affects blood pressure.

D. Place the call bell in reach of the client: This is the most appropriate action. Prazosin can cause orthostatic hypotension, particularly after the first dose, leading to dizziness or fainting. Ensuring that the call bell is within reach allows the client to request help if they feel lightheaded or need assistance.

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The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

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Naxlex Comprehensive Predictor Exams

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