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 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 2 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.
Question 3 of 5
The nurse is caring for a client who just received a percutaneous balloon valvuloplasty for the treatment of mitral stenosis. For which finding should the nurse assess?
Correct Answer: B
Rationale: The balloon valvuloplasty stretches the valve and can impair the papillary muscles, resulting in regurgitation of blood back through the mitral valve. A percutaneous balloon valvuloplasty does not have an incision and does not use a porcine graft. The septum is perforated and can allow shunting of blood but the shunting, if occurs, will move from left to right.
Question 4 of 5
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
Correct Answer: A
Rationale: A cough with productive, pink, frothy sputum and crackles in the bases of the lungs are signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive failure, thrombophlebitis, or cardiogenic shock.
Question 5 of 5
The nurse is interviewing a client who is being admitted for possible mitral regurgitation. Which historical fact is of greatest value to the nurse?
Correct Answer: B
Rationale: Rheumatic fever and subsequent heart disease is the prominent cause of valvular insufficiency. Congenital neural tube defect is associated with spina bifida not mitral regurgitation. Smoking and insertion of pacemaker are significant to heart disorders but not of greatest value as rheumatic fever.