A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?
S3 heart sound
Dyspnea on exertion
Cyanosis
S4 Heart Sound
The Correct Answer is B
A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.
B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.
C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.
D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.
B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.
C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.
D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.
Correct Answer is C
Explanation
A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.
B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.
C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.
D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.
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