During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?
Peripheral vascular disease
Fluid and electrolyte disturbances
Heart failure
Atrial-septal defect
The Correct Answer is C
A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Normally auscultated over the trachea refers to bronchial breath sounds, which are louder and higher-pitched and heard over the trachea, not the lower lungs.
B. Vesicular breath sounds and normal in that location are low-pitched and soft, heard over the peripheral lung fields, and normal for the lower lobes.
C. Bronchial breath sounds and normal in that location would be expected near the trachea and bronchi, not over the peripheral lung fields.
D. Bronchovesicular breath sounds and normal in that location are typically heard over the major bronchi, not the posterior lower lobes.
Correct Answer is A
Explanation
A. Tachycardia is a common sign of hyperthyroidism, as elevated thyroid hormones increase heart rate and metabolic rate.
B. Dyspnea is not typically associated with hyperthyroidism; more commonly, hyperthyroid patients experience tachypnea (increased rate of breathing), but not necessarily dyspnea.
C. Constipation is more commonly associated with hypothyroidism, where metabolic slowing occurs.
D. Atrophied nodular thyroid gland is not typical of hyperthyroidism; a goiter (enlarged thyroid) is more commonly seen.
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