The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Murmurs.

Absent sounds.

No adventious sounds.

Adventious sounds.

Answer and Explanation

The Correct Answer is A

A. Murmurs can be a normal finding in older adults due to age-related changes in the heart valves or blood flow. They are not necessarily indicative of pathology if they are not associated with symptoms or changes in the client's condition.

B. Absent heart sounds would be abnormal and could indicate severe underlying issues such as cardiac arrest or severe hypovolemia.

C. While no adventitious sounds are generally expected, the presence of murmurs is considered normal in this age group.

D. Adventitious sounds (such as crackles or wheezes) are not normal in heart auscultation and would suggest potential pathologies.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Muscle pain can be a sign of rhabdomyolysis, a serious side effect of lovastatin that requires immediate evaluation and intervention.

B. Altered taste is a less serious side effect and does not require urgent follow-up.

C. Diarrhea and flatulence are common and less urgent side effects of lovastatin.

D. Abdominal cramps are uncomfortable but less critical compared to muscle pain associated with potential rhabdomyolysis.

A. Restless B. Awake and alert C. Anxious D. Respiratory rate 28 breaths/minute E. Oxygen Saturation 90% on room air F. Productive cough G. Heart rate 101 beats/minute H. Capillary refill 4 seconds I. Blood pressure 145/89 mm Hg

Correct Answer is ["A","C","D","E","G"]

Explanation

Neurological: Restlessness and anxiety can both be symptoms of hypoxia due to the brain's sensitivity to changes in oxygen levels.

Respiratory: Low oxygen saturation directly indicates hypoxia, and an increased respiratory rate can be a compensatory response to low oxygen levels.

Cardiovascular: Elevated heart rate can be a compensatory mechanism for hypoxia, and delayed capillary refill may indicate poor perfusion related to low oxygen levels.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is A

Explanation

Correct Answer is ["A","C","D","E","G"]

Explanation

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