A nurse is assessing a patient who has mitral valve stenosis.
What symptoms should the nurse expect?

Heart murmur

Bradycardia

Clubbing of the fingers

Barrel chest

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Mitral valve stenosis is a condition characterized by a narrowing of the mitral valve in the heart, which can lead to a variety of symptoms. One of the most common symptoms of mitral valve stenosis is a heart murmur. This is due to the turbulent flow of blood caused by the narrowed valve. The murmur is typically heard during a physical examination when a healthcare provider listens to the heart with a stethoscope.

Choice B rationale:

Bradycardia, or a slower than normal heart rate, is not typically associated with mitral valve stenosis. While mitral valve stenosis can cause irregular heart rhythms, it does not typically cause the heart rate to slow down.

Choice C rationale:

Clubbing of the fingers is a physical symptom that involves changes in the areas under and around the nails and is typically associated with conditions that cause chronic low blood oxygen levels. While mitral valve stenosis can lead to shortness of breath and fatigue, it does not typically cause clubbing of the fingers.

Choice D rationale:

A barrel chest, characterized by an increased chest diameter, is typically associated with conditions that cause chronic overinflation of the lungs, such as chronic obstructive pulmonary disease (COPD). It is not a typical symptom of mitral valve stenosis.

In conclusion, while mitral valve stenosis can lead to a variety of symptoms, the most relevant to this question is a heart murmur. Other symptoms such as bradycardia, clubbing of the fingers, and a barrel chest are not typically associated with this condition.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.

Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.

Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.

A. The nurse applies the sterile drape after cleaning the perineal area. B. The nurse lubricates the indwelling urinary catheter. C. The nurse separates the patient’s labia with her dominant hand. D. The nurse provides perineal care prior to inserting the urinary catheter.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

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A nurse is assessing a patient who has mitral valve stenosis. What symptoms should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing a bladder-training program for a patient. Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?

Correct Answer is A

Explanation

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient. Which action by the nurse should prompt the charge nurse to intervene?

Correct Answer is C

Explanation

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A nurse is assessing a patient who has mitral valve stenosis.
What symptoms should the nurse expect?