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 C

Explanation

A) Depending on the client's age, the findings may be normal: While changes in hair growth and nail texture can occur with aging, the specific combination of hair loss on the legs and thick toenails in a client with peripheral vascular disease is indicative of underlying circulatory issues rather than simply a normal aging process.

B) A blood clot may be forming and the client needs immediate intervention: While peripheral vascular disease does increase the risk of blood clots, the presence of no hair on the legs and thick toenails is more directly related to chronic insufficient blood flow rather than an acute clotting situation requiring immediate intervention.

C) Decreased oxygen to the tissues causes changes in hair growth and nail texture: This statement accurately describes the physiological changes occurring in peripheral vascular disease. Reduced blood flow and oxygen delivery to the lower extremities result in hair loss and thickened nails, as hair follicles and nail growth depend on adequate perfusion.

D) Decreased hair is most likely a hereditary condition and nail changes are related to fungus: While hereditary factors can influence hair loss and fungal infections can affect nails, in the context of peripheral vascular disease, the findings are primarily due to inadequate blood supply rather than hereditary issues or fungal infections.

A. Bone marrow aspiration study B. Vitamin B2 level C. Stool for occult blood D. Schelling's test

Correct Answer is C

Explanation

A. Bone marrow aspiration study: While this test can provide information about the bone marrow's ability to produce red blood cells, it is not typically the first diagnostic test used to detect the cause of chronic iron deficiency anemia.

B. Vitamin B2 level: This test measures riboflavin levels, which are not related to iron deficiency anemia. Vitamin B12 or folate levels are more relevant in differentiating types of anemia.

C. Stool for occult blood: This test is commonly used to detect hidden blood in the stool, which can indicate gastrointestinal bleeding—a frequent cause of chronic iron deficiency anemia. Identifying blood loss in the GI tract is crucial for diagnosing the underlying issue.

D. Schelling's test: This test is used to determine the absorption of vitamin B12 and is not
applicable to iron deficiency anemia.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement best describes the cause of this finding?

Correct Answer is C

Explanation

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?

Correct Answer is C

Explanation

The nurse, who is caring for a client diagnosed with coronary artery disease, prioritizes the problem of impaired Tissue Perfusion into the plan of care. Which expected outcome would be most appropriate? The client will:

The client with coronary artery disease asks the nurse. "Why do I get this chest pain?" Which would be the most appropriate response?

A 10-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. After 5 weeks of methylphenidate, the nurse should monitor for which desired outcome? (SELECT ALL THAT APPLY)

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

In preparation for a client having a Schilling test the nurse should explain that the test:

The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

The nurse is teaching a client with hypertension about the prescribed bumetanide, a loop diuretic, 1 mg PO daily. Which statement, made by the client would indicate that the teaching has been effective?

The client diagnosed with Vitamin B12 deficiency presents to the outpatient department for the follow up evaluation. Which nursing assessment finding indicates that the treatment has been effective? The client: