A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make?

"A heart murmur is a high-pitched sound due to a narrow valve."

"A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber."

"This means that there is some inflammation around your heart."

"This indicates turbulent (chaotic, random fluctuations) blood flow through a valve."

Answer and Explanation

The Correct Answer is D

A. "A heart murmur is a high-pitched sound due to a narrow valve." While some murmurs may be caused by a narrow valve (stenosis), not all murmurs are high-pitched. Murmurs vary in pitch depending on the cause, so this is not a comprehensive explanation.

B. "A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber." This describes an S3 or S4 sound rather than a murmur. A heart murmur is typically related to turbulent blood flow through valves, not just an inflexible heart chamber.

C. "This means that there is some inflammation around your heart." This statement incorrectly links a murmur to pericarditis or myocarditis, which involve inflammation. A murmur is associated with abnormal blood flow, not inflammation.

D. "This indicates turbulent (chaotic, random fluctuations) blood flow through a valve." A heart murmur is caused by turbulent blood flow, which can occur when blood moves through a valve that is narrow or has regurgitation. This is the correct explanation.

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Correct Answer is B

Explanation

A. Assist the patient to the chair for breakfast. Moving the patient to a chair may exacerbate venous stasis and worsen circulation in this case. This is not the correct action.

B. Check the presence of lower extremity pulses. Brown discoloration and cold, blue feet suggest poor circulation or chronic venous insufficiency. The nurse should assess the pulses to evaluate arterial blood flow in the lower extremities.

C. Apply non-skid socks to feet. While non-skid socks are generally used to prevent falls, this action does not address the circulatory concern indicated by the patient's symptoms.

D. Perform deep tissue massage on bilateral lower extremities to improve blood flow. Massage could be harmful, especially if there is a possibility of a blood clot or poor arterial circulation. This is not a recommended action in this scenario.

A. "I can drink wine in moderation." B. "I will limit my intake of eggs." C. "I will limit my intake of red meat to two times per week." D. "I should cook with olive oil."

Correct Answer is C

Explanation

A. "I can drink wine in moderation." Moderate wine consumption (particularly red wine) is often considered acceptable as part of the Mediterranean diet. This statement does not indicate a need for further teaching.

B. "I will limit my intake of eggs." Eggs can be consumed in moderation on the Mediterranean diet, typically no more than a few times a week. This statement reflects an understanding of the diet and does not indicate a need for further teaching.

C. "I will limit my intake of red meat to two times per week." The Mediterranean diet recommends limiting red meat consumption, but typically to less than two times per week. This statement indicates a need for further teaching as it suggests a higher frequency than recommended.

D. "I should cook with olive oil." Olive oil is a key component of the Mediterranean diet, replacing butter and other fats. This statement reflects correct understanding and does not indicate a need for further teaching.

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A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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