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. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.

B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.

C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.

D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.

A. Wrapping the cuff too loosely around the client's arm B. Positioning the client's arm above heart level C. Deflating the cuff too slowly D. Measuring blood pressure right after the client's mealtime

Correct Answer is B

Explanation

A. Wrapping the cuff too loosely around the client's arm: A loosely wrapped cuff can cause an inaccurately high reading, not a low one.

B. Positioning the client's arm above heart level: If the client’s arm is positioned above heart level, the blood pressure reading may be inaccurately low. Blood pressure measurements should always be taken with the arm at heart level.

C. Deflating the cuff too slowly: Deflating the cuff too slowly typically leads to an inaccurately high reading, not a low one.

D. Measuring blood pressure right after the client's mealtime: While digestion can sometimes cause a slight drop in blood pressure, it is not typically a significant factor in obtaining an unusually low reading.

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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

A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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