The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?

Correct Answer: C

Rationale: During pregnancy, it is not uncommon for women to have an extra heart sound known as a gallop rhythm. This is often referred to as a ventricular gallop, which is the presence of an S3 heart sound. In pregnant women, the increased blood volume and changes in heart dynamics can lead to the development of this extra sound. It is considered a normal finding during the third trimester of pregnancy and is usually not a cause for concern. It is important for healthcare providers to differentiate between normal physiological changes associated with pregnancy and potential heart abnormalities, which is why a ventricular gallop in this context is typically considered a benign finding.

Correct Answer: C

Rationale: In the case of a client diagnosed with cardiomyopathy and experiencing tachycardia, a beta blocker is the anticipated medication. Beta blockers work by blocking the effects of adrenaline on the heart, reducing heart rate, blood pressure, and myocardial oxygen demand. This can help manage symptoms of tachycardia in cardiomyopathy by slowing down the heart rate and improving its overall function. Other medications like ACE inhibitors and angiotensin II receptor blockers may be used to manage specific aspects of cardiomyopathy such as hypertension or heart failure, but in the context of tachycardia, a beta blocker is the preferred choice. Cardiac glycosides, like Digoxin, are used for heart failure but not primarily for managing tachycardia in cardiomyopathy.

Correct Answer: A

Rationale: The best response is "Your risk of continued coronary artery disease will decrease by half when you stop." This response provides a specific and concrete benefit of quitting smoking for the client with a history of myocardial infarction. By explaining that quitting smoking can reduce the risk of continued coronary artery disease by half, the nurse is providing motivation and encouragement for the client to make a positive change in their lifestyle. This information is factual and can help the client understand the immediate benefits of quitting smoking in relation to their current health condition.

Correct Answer: C

Rationale: The client who is excited to learn ambulation techniques (Option C) is exhibiting the highest motivation to learn. This client's enthusiasm for learning new skills related to ambulation indicates a strong willingness to actively engage in their rehabilitation process. Learning ambulation techniques is a crucial aspect of recovery following a total hip replacement, as it helps improve mobility and independence. The excitement to learn demonstrates that this client is eager to participate in their rehabilitation and is likely to be more proactive in achieving their recovery goals.

Correct Answer: A

Rationale: Arteriosclerosis is a form of peripheral vascular disease characterized by the thickening, loss of elasticity, and calcification of arterial walls. This results in the narrowing and hardening of the arteries, leading to reduced blood flow to tissues and organs. Atherosclerosis, on the other hand, specifically refers to the buildup of plaque (composed of fat, cholesterol, calcium, and other substances) on the inner walls of arteries, which contributes to arteriosclerosis. Chronic venous insufficiency is a condition involving poor blood flow from the legs back to the heart, often causing swelling and skin changes. Deep venous thrombosis is the formation of a blood clot in a deep vein, commonly in the legs.

Correct Answer: A

Rationale: As individuals age, there is a natural increase in systolic blood pressure (the top number in a blood pressure reading). This rise is attributed to factors such as arterial stiffness, reduced compliance of blood vessels, and decreased elasticity of the arteries. This increase in systolic blood pressure with age is considered a significant risk factor for hypertension in older adults. Hypertension is commonly defined as having a systolic blood pressure of 140 mmHg or higher and/or a diastolic blood pressure of 90 mmHg or higher. Therefore, the age-related increase in systolic blood pressure contributes to the overall risk of developing hypertension in the elderly population.

Correct Answer: B

Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.

Correct Answer: B

Rationale: - **Bedrest as ordered (B):** Bedrest is essential for managing deep venous thrombosis to prevent clot dislodgment and further complications. It helps reduce excessive movement, which can increase the risk of clots breaking loose and traveling to the lungs, causing a pulmonary embolism.

Correct Answer: C

Rationale: Lyme disease is primarily spread through the bite of an infected black-legged tick, also known as a deer tick. The tick must be infected with the bacterium Borrelia burgdorferi in order to transmit the disease. Contrary to popular belief, the tick doesn't transmit the infection immediately upon biting. Borrelia burgdorferi is typically transmitted after the tick has been attached to the host for at least 24 hours. This gives individuals a window of time to remove attached ticks before transmission occurs. Therefore, the most accurate statement regarding the spread of the organism for Lyme disease is through an infected tick that has been embedded for more than 24 hours.