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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Fried fish sandwich and potato salad: Fried foods are high in unhealthy fats, which can increase cholesterol levels and are not recommended for clients after a myocardial infarction.

B. Baked turkey and salad: This is a healthy choice, as baked turkey is low in fat, and a salad provides nutrients without excessive fat or cholesterol, supporting heart health.

C. Biscuits with sausage gravy and sliced tomatoes: Biscuits and sausage gravy are high in saturated fats, which are not appropriate for a heart-healthy diet.

D. Barbecued ribs and canned baked beans: Barbecued ribs and canned baked beans may contain high levels of saturated fats, sugar, and sodium, which are not recommended for someone recovering from a myocardial infarction.

A. Measure the client's ankle circumference. B. Measure from the client's heel to the gluteal fold. C. Measure from the client's heel to the popliteal space. D. Measure the length of the client's feet.

Correct Answer is C

Explanation

A. Measure the client's ankle circumference. This is a correct action, as the ankle circumference is necessary to ensure that the stockings fit snugly and provide the proper amount of compression to prevent venous stasis.

B. Measure from the client's heel to the gluteal fold. This measurement would be appropriate for thigh-high stockings, not knee-high stockings.

C. Measure from the client's heel to the popliteal space. For knee-high stockings, measuring from the heel to the popliteal space (behind the knee) ensures the stockings fit properly without cutting off circulation or causing discomfort.

D. Measure the length of the client's feet. Foot length is not necessary for knee-high stockings, as their primary function is to apply compression from the ankle to the knee.

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A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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