ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 24 : Caring for Clients With Valvular Disorders of the Heart Questions
Question 1 of 5
The client has been diagnosed with aortic regurgitation. Which nursing data is most significant in identifying the cause for this disorder?
Correct Answer: C
Rationale: The incidence of mitral and aortic regurgitation increased by as much as 36% in 1997, due to the use of fenfluramine with phentermine (Fen-Phen) for weight loss. Obesity, tobacco use, and lack of exercise have been identified as risk factors for heart disease but not a significant identified cause for aortic regurgitation.
Question 2 of 5
Which symptom is most important in determining the diagnosis and nursing care for a client experiencing pulmonary hypertension?
Correct Answer: C
Rationale: Tachycardia, low systolic pressure, and decreased stroke volume are symptoms associated with pulmonary hypertension. A productive cough with pink-tinged frothy sputum can indicate progression of the disorder and need for treatment.
Question 3 of 5
A client is being evaluated for mitral stenosis versus mitral insufficiency. Which of the following symptoms would the nurse find in either condition?
Correct Answer: C
Rationale: Mitral stenosis and mitral insufficiency both create regurgitation of blood back through the mitral valve which can be heard as a murmur. Angina and syncope are not common and would only be exhibited if decrease nourishment of the cardiac muscle and organs occur. Hypertension may be an underlying condition but not necessarily associated with both disorders.
Question 4 of 5
The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?
Correct Answer: C
Rationale: Changes in heart sounds may be the earliest indication of mitral valve stenosis. S1 may be extremely loud if the cusps are fused or muffled or absent if the cusps have calcified and are immobile. A murmur, described as sounding like a rumbling underground train, can be heard at the heart's apex, especially when the client assumes a left lateral position. The other positions are not supported by evidence-based practice guidelines as appropriate positions in which to place the client to monitor a murmur.
Question 5 of 5
The nurse is caring for a client diagnosed with mitral stenosis. Which client symptom change would most likely indicate to the nurse, a progression of this condition?
Correct Answer: A
Rationale: As mitral stenosis progresses, the systolic blood pressure will decrease due to the reduction of the cardiac output. Widening pulse pressure with normal diastolic pressure is associated more with aortic regurgitation.