The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:
An occlusion of the right coronary artery
An aneurysm of the descending aorta
Decreased fluid in the pericardial sac
Distortion of one or more heart valves
The Correct Answer is D
Choice A reason: This is not a correct interpretation. An occlusion of the right coronary artery is a blockage of the blood flow to the right side of the heart, which can cause a heart attack or ischemia. This condition does not produce a systolic murmur, but rather chest pain, shortness of breath, sweating, or nausea. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice B reason: This is not a correct interpretation. An aneurysm of the descending aorta is a bulging or weakening of the wall of the large artery that carries blood from the heart to the lower body. This condition does not produce a systolic murmur, but rather a pulsating mass in the abdomen, back pain, or abdominal pain. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice C reason: This is not a correct interpretation. Decreased fluid in the pericardial sac is a condition where the amount of fluid that surrounds and cushions the heart is reduced. This can be caused by dehydration, infection, or inflammation. This condition does not produce a systolic murmur, but rather a pericardial friction rub, which is a scratching or grating sound that occurs when the layers of the pericardium rub against each other. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice D reason: This is the correct interpretation. Distortion of one or more heart valves is a condition where the shape or function of the valves that regulate the blood flow through the heart is altered. This can be caused by congenital defects, rheumatic fever, endocarditis, or aging. This condition can produce a systolic murmur, which is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve. The location and the intensity of the murmur can help identify which valve is affected. A systolic murmur in the second intercostal space to the right of the sternum can indicate a problem with the aortic valve.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Stopping the medication if the client develops a change in vision is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Change in vision is not a common or serious side effect of rosuvastatin, and it may be caused by other factors, such as eye strain, infection, or disease. The nurse should not advise the client to stop the medication without consulting the healthcare provider, as this may increase the risk of adverse outcomes, such as heart attack or stroke.
Choice B reason: Monitoring body weight weekly is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Body weight is not a direct indicator of the effectiveness or safety of rosuvastatin, and it may fluctuate due to various factors, such as diet, exercise, or fluid retention. The nurse should encourage the client to maintain a healthy weight and lifestyle, but not to focus on the weekly changes in body weight.
Choice C reason: Reporting muscle weakness or pain is the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. However, statins can also cause muscle damage, which can manifest as weakness, pain, tenderness, or cramps. This can be a sign of a serious condition called rhabdomyolysis, which is the breakdown of muscle tissue that can lead to kidney failure or death. The nurse should instruct the client to report any muscle symptoms to the healthcare provider as soon as possible, and to avoid taking any other drugs or supplements that may interact with rosuvastatin and increase the risk of muscle damage.
Choice D reason: Having biannual renal function studies is not the information that the nurse should provide in the teaching about rosuvastatin. Rosuvastatin is a drug that lowers the cholesterol and prevents the complications of cardiovascular disease. It belongs to a class of drugs called statins, which work by inhibiting an enzyme that produces cholesterol in the liver. Renal function studies are tests that measure the health and function of the kidneys, which are responsible for filtering the blood and removing waste and excess fluid. Rosuvastatin is not known to cause significant kidney damage, and it is excreted mainly by the liver. The nurse should not recommend the client to have biannual renal function studies, as this may be unnecessary and costly. The nurse should advise the client to follow the healthcare provider's orders regarding the frequency and type of laboratory tests that are needed to monitor the effects of rosuvastatin.
Correct Answer is A
Explanation
Choice A reason: Having analgesic properties without sedation is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that prevent blood clots from forming in the arteries that supply the heart. They do not have significant analgesic or sedative effects.
Choice B reason: Triggering vasodilation and improving blood flow is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not directly cause vasodilation or increase blood flow. They work by reducing the stickiness of platelets and preventing them from clumping together and blocking the arteries.
Choice C reason: Improving contractility and decreasing afterload is not the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel do not affect the contractility or the afterload of the heart. They act on the blood vessels and the blood cells, not on the heart muscle. Contractility and afterload are influenced by other drugs such as beta-blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors.
Choice D reason: This is the correct answer. Inhibiting platelet aggregation and clot formation is the rationale for prescribing aspirin and clopidogrel for coronary artery disease. Aspirin and clopidogrel are antiplatelet drugs that interfere with the function of platelets, which are blood cells that help with clotting. By inhibiting platelet aggregation and clot formation, aspirin and clopidogrel reduce the risk of heart attack and stroke in people with coronary artery disease.
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