A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed?
Muted systolic murmur.
Dyspnea on exertion.
Upper extremity weakness.
Oxygen saturation of 93%.
The Correct Answer is B
A. Muted systolic murmur: Mitral valve stenosis typically produces a diastolic murmur, not a systolic one. A muted systolic murmur does not specifically indicate progression of mitral stenosis.
B. Dyspnea on exertion: As mitral stenosis progresses, the narrowed valve obstructs blood flow from the left atrium to the left ventricle. This increases left atrial pressure and leads to pulmonary congestion. Dyspnea on exertion is a classic early sign of worsening mitral stenosis and indicates disease progression.
C. Upper extremity weakness: Weakness of the upper extremities is not a typical manifestation of mitral valve stenosis progression. It may suggest a neurologic or musculoskeletal issue instead.
D. Oxygen saturation of 93%: Although slightly decreased, an oxygen saturation of 93% is only mildly low and not specific for progression of mitral stenosis. Dyspnea related to pulmonary congestion is a more significant and classic indicator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tell me more about your concerns about the surgery: This response uses therapeutic communication by encouraging the client to express feelings and fears. It is open-ended, acknowledges the client’s anxiety, and allows the nurse to assess specific concerns.
B. Would you like to speak with a chaplain prior to surgery: While spiritual support may be helpful, this option changes the focus away from exploring the client’s expressed fear. The nurse should first assess the client’s concerns before offering additional resources.
C. What support systems do you have to assist you: This question may be appropriate later, but it does not directly address the client’s immediate fear of dying. The priority is to explore the expressed anxiety.
D. This is a routine surgery and the risk of death is very low: Providing false reassurance dismisses the client’s feelings and may undermine trust. Emergent aortic aneurysm repair is a high-risk surgery, so minimizing the risk is inappropriate and nontherapeutic.
Correct Answer is D
Explanation
A. EKG showing sinus tachycardia, rate 112: After a heart transplant, the heart is denervated, and mild resting tachycardia (90–110 bpm) is common. A rate of 112 can occur and, by itself, does not specifically indicate rejection.
B. Blood pressure 154/90: Mild hypertension is common in transplant recipients due to immunosuppressive therapy (such as corticosteroids or calcineurin inhibitors). This finding alone does not strongly suggest rejection.
C. White blood cell count 11,000: A WBC count of 11,000 is only slightly elevated and may reflect stress or mild infection. It is not a specific indicator of transplant rejection.
D. Ejection fraction of 20%: A significantly decreased ejection fraction indicates poor ventricular function. In a client 6 months post–heart transplant, a marked drop in ejection fraction strongly suggests acute or chronic rejection and requires immediate evaluation and intervention.
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