A client reports episode of dyspnea and chest pain unrelated to activity. Which valve disorder does the nurse suspect may be causing these symptoms?

Aortic regurgitation

Mitral valve prolapse

Mitral stenosis

Aortic stenosis

Answer and Explanation

The Correct Answer is D

a. Aortic regurgitation: Aortic regurgitation involves the backflow of blood from the aorta into the left ventricle during diastole due to a dysfunctional aortic valve. While aortic regurgitation can cause symptoms such as dyspnea and chest pain, they are typically associated with exertion rather than occurring at rest or unrelated to activity.

b. Mitral valve prolapse: Mitral valve prolapse is characterized by the abnormal movement of the mitral valve leaflets into the left atrium during systole. While mitral valve prolapse can lead to symptoms such as palpitations, chest discomfort, and dyspnea, these symptoms are usually not unrelated to activity. They are often precipitated or exacerbated by physical exertion or stress.

c. Mitral stenosis: Mitral stenosis involves narrowing of the mitral valve opening, which obstructs blood flow from the left atrium to the left ventricle. Symptoms of mitral stenosis, such as dyspnea and chest discomfort, typically occur with exertion or during periods of increased cardiac demand rather than being unrelated to activity.

d. Aortic stenosis: Aortic stenosis is characterized by narrowing of the aortic valve opening, which obstructs blood flow from the left ventricle to the aorta. This obstruction leads to increased pressure in the left ventricle and can cause symptoms such as dyspnea (due to pulmonary congestion) and chest pain (angina) even at rest. These symptoms are often exacerbated during physical activity but can occur spontaneously as well.

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Correct Answer is C

Explanation

a. Check current WBC count: While an elevated white blood cell (WBC) count may indicate inflammation, it is not specific to the assessment of cardiac tamponade. WBC count may be elevated in pericarditis due to the inflammatory process, but it does not directly assess for the potential complication of cardiac tamponade.

b. Assess for hypertension: Hypertension is not typically associated with cardiac tamponade. Instead, cardiac tamponade is characterized by hemodynamic compromise, which may manifest as hypotension rather than hypertension. While assessing blood pressure is important in overall cardiovascular assessment, it is not specific to detecting cardiac tamponade.

c. Auscultate heart sounds: Auscultating heart sounds, specifically for the presence of muffled heart sounds (reduced intensity of heart sounds) and distant heart sounds, is a key assessment for detecting cardiac tamponade, a potential complication of pericarditis. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. This can lead to hemodynamic compromise and potentially life-threatening consequences. Muffled or distant heart sounds are classic signs of cardiac tamponade and indicate the need for immediate intervention.

d. Measure blood glucose: Blood glucose measurement is not directly related to the assessment of cardiac tamponade. While monitoring blood glucose levels may be important in clients with diabetes or those at risk of hyperglycemia, it does not provide information specific to the detection of cardiac tamponade.

A. Check MAR for antianxiety medication B. Ask when the dyspnea started C. Notify the provider D. Increase oxygen from 3L/minute to 5L/minute

Correct Answer is D

Explanation

In this scenario, the client is exhibiting signs of severe respiratory distress, which could indicate worsening acute heart failure and potential respiratory failure.

a. Check MAR for antianxiety medication: While anxiety may exacerbate the client's symptoms, the priority at this moment is to address the acute respiratory distress and ensure adequate oxygenation. Checking the medication administration record (MAR) for antianxiety medication can be done later but is not the immediate priority.

b. Ask when the dyspnea started: While obtaining a thorough history is important for understanding the onset and progression of the client's symptoms, it is not the first action to take in this critical situation. The client's current condition requires immediate intervention to ensure adequate oxygenation and stabilization.

c. Notify the provider: Notifying the provider is important, especially in a situation where the client's condition is deteriorating rapidly. However, this action may take some time, and the priority is to address the client's immediate needs first.

d. Increase oxygen from 3L/minute to 5L/minute: This is the most appropriate action to take first. The client is showing signs of severe respiratory distress with cyanosis and increased work of breathing. Increasing the oxygen flow rate from 3L/minute to 5L/minute can help improve oxygenation and alleviate hypoxemia, which is crucial in the management of acute heart failure exacerbation.

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A client reports episode of dyspnea and chest pain unrelated to activity. Which valve disorder does the nurse suspect may be causing these symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

Correct Answer is C

Explanation

A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

Correct Answer is D

Explanation

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