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While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.

Pericarditis.

Arterial obstruction or aneurysm.

Forceful atrial contraction to overcome ventricular resistance.

An infectious valvular disorder.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Pericarditis is an inflammation of the pericardium and would not directly cause an S4 heart sound.

Choice B rationale:

Arterial obstruction or aneurysm would cause changes in blood flow, but not specifically an S4 heart sound.

Choice C rationale:

An S4 heart sound is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle, often due to forceful atrial contraction to overcome ventricular resistance.

Choice D rationale:

An infectious valvular disorder could cause a variety of heart sounds, but not specifically an S42.

So, the correct answer is C, after analyzing all choices.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.

Choice B rationale:

Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.

Choice C rationale:

Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.

Choice D rationale:

Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.

Choice E rationale:

Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.

Choice F rationale:

Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.

Choice G rationale:

Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.

Choice H rationale:

A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.

So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .

A. "Do you have a history of a heart attack?". B. "Have you had any recent immunizations?". C. "Do you have a family history of endocarditis?". D. "Have you had dental work done recently?".

Correct Answer is D

Explanation

Choice A rationale:

While a history of heart attack indicates a general risk for heart disease, it is not specifically associated with an increased risk for infective endocarditis.

Choice B rationale:

Immunizations do not typically increase the risk for infective endocarditis.

Choice C rationale:

Family history of endocarditis does not necessarily increase the risk for infective endocarditis.

Choice D rationale:

Dental work can introduce bacteria into the bloodstream, which can lead to infective endocarditis, especially in individuals with prosthetic heart valves.

So, the correct answer is D, after analyzing all choices.

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While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

Correct Answer is D

Explanation

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.

A patient has pain due to acute pericarditis. Which action would the nurse take?.

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective?

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.