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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decrease allergic reactions: Nitrate-free periods are not primarily designed to address allergic reactions.
B. Decrease tolerance to effects: Nitrates, including isosorbide mononitrate, can lead to the development of tolerance when used continuously. The nitrate-free period helps to minimize this tolerance, allowing the medication to remain effective over time.
C. Prevent reflex tachycardia: While nitrate use can sometimes cause reflex tachycardia, the nitrate-free interval is not specifically aimed at preventing this.
D. Increase absorption: The nitrate-free period does not influence the absorption of the medication itself.
Correct Answer is ["A","D","E"]
Explanation
A) Working on an arithmetic quiz for 20 minutes without getting out of their seat: This outcome indicates improved focus and attention span, which are desired effects of methylphenidate in managing ADHD symptoms. The ability to stay seated and concentrate on a task for an extended period is a positive sign of the medication’s effectiveness.
B) Family members report no episodes of pica: Pica, the consumption of non-food items, is not typically associated with ADHD. Therefore, the absence of pica episodes is not a relevant outcome for evaluating the effectiveness of methylphenidate in this context.
C) Does not tell untrue information: While honesty is important, it is not a primary focus of ADHD treatment. Methylphenidate aims to improve attention, focus, and reduce hyperactivity, rather than directly addressing truthfulness.
D) Completing a jigsaw puzzle with a friend: Successfully completing a jigsaw puzzle with a friend demonstrates improved attention, focus, and social interaction skills. These are positive outcomes of methylphenidate treatment for ADHD, indicating better management of hyperactivity and distractibility.
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