A heart murmur should be assessed for which of the following? Select all that apply.

Timing

Radiation

Fremitus

Egophony

Location

Answer and Explanation

Correct Answer : A,B,E

A.   The timing of the murmur (systolic or diastolic) is an essential component of murmur assessment. It
helps in determining the cause of the murmur, whether it’s related to heart valves or flow.
B.   Radiation refers to where the murmur can be heard best, or if it radiates to other parts of the chest or neck, helping to indicate the origin of the murmur.
C.   Fremitus is a term used to describe the vibrations felt on the chest wall when a person speaks, which is unrelated to heart murmurs.
D.   Egophony refers to an abnormal lung sound heard during auscultation and is not relevant to the assessment of a heart murmur.
E.   The location where the murmur is heard best on the chest wall is crucial in determining its origin, such as whether it is coming from the aortic or mitral valve.

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Correct Answer is A

Explanation

A. Smoking, hypertension, obesity, diabetes, and high cholesterol: These are all well-established major risk factors for heart disease and should be included in the patient's history.
B. Personality type, high cholesterol, diabetes, and smoking: While personality type may contribute to stress, the other factors listed are more directly linked to heart disease.
C. Alcohol consumption, obesity, diabetes, stress, and high cholesterol: Alcohol consumption may be a risk factor, but smoking and hypertension are more significant.
D. Family history, hypertension, stress, and age: While family history, age, and hypertension are important, this option misses key factors like obesity, smoking, and diabetes.

A. Pneumococcal vaccine B. Level of consciousness C. Influenza vaccine D. Health history E. Fluid intake F. Age G. Smoking history

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

Explanation

A. The client has not received the pneumococcal vaccine, but pneumococcal vaccination would help prevent pneumonia, particularly from Streptococcus pneumoniae. However, because the client has nothad the vaccine, this option would be a risk factor for pneumonia, but it is not an immediate concern in terms of assessing the current risks in their medical record.
B. The client appears lethargic and has difficulty answering questions due to shortness of breath, which suggests a decrease in the level of consciousness. Decreased mental status or level of consciousness increases the risk of aspiration, which can lead to pneumonia. For example, an altered level of consciousness makes it harder for patients to protect their airways (e.g., coughing or swallowing properly), which may increase the risk of aspiration and subsequent infection.
C. The client has not received the influenza vaccine, which does increase the risk of contracting
pneumonia, especially if the person develops influenza. However, the patient’s primary issue is likely already in progress, so this is another unvaccinated status contributing to risk rather than an immediate finding.
D. The client’s medical history is notable for no significant conditions other than the acute issue at hand. However, the lack of a pneumococcal vaccine (despite being at higher risk due to age) and not receiving the annual influenza vaccination can contribute to the development of pneumonia. Pneumonia is more common in individuals who do not receive these vaccines, as they provide protection against common respiratory pathogens, including Streptococcus pneumoniae and influenza viruses.
E. The client reports decreased fluid intake over the past 24 hours due to a sore throat, which increases the risk of dehydration. Dehydration can lead to thicker mucus, making it more difficult to clear respiratory secretions. This increases the likelihood of bacterial growth and the development of pneumonia.
F. The client is 70 years old, which places them at higher risk for pneumonia. Older adults have a weakened immune system, and their respiratory function may not be as effective as in younger individuals, making it easier for infections such as pneumonia to take hold. Age is a significant risk factor for more severe respiratory infections.
G. There is no mention of smoking history in the social history provided, so it cannot be included as a risk factor for pneumonia in this case. Smoking is a known risk factor for respiratory infections, but since it isn’t specified here, we cannot assume it is relevant.

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A heart murmur should be assessed for which of the following? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Correct Answer is A

Explanation

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

Explanation

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