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

Answer and Explanation

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.

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Correct Answer is ["A","D","E","G"]

Explanation

A. Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B. Client's weight is not directly related to documenting a heart murmur.
C. Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D. Intensity of the murmur is important to document, as it helps assess the severity.
E. Location of the murmur is important for identifying which valve or area of the heart is involved.
F. Client's temperature is not directly related to documenting a heart murmur.
G. Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

A. Exophthalmos B. Coarse facial features C. Bowed long bones D. Acorn-shaped cranium

Correct Answer is B

Explanation

A. Exophthalmos, or bulging eyes, is associated with hyperthyroidism (such as in Graves' disease), not acromegaly.
B. This is a hallmark sign of acromegaly. People with acromegaly often develop coarse, enlarged facial features (e.g., thickened lips, enlarged nose, protruding jaw, and enlarged tongue), which occur due to excess growth hormone.
C. While acromegaly can cause abnormal bone growth, especially in the hands and feet, it does not typically result in bowed long bones. This would be more suggestive of conditions like rickets or osteomalacia.
D. While acromegaly can lead to changes in the skull, it does not typically result in a distinctly acorn- shaped cranium. This is not a primary diagnostic feature of acromegaly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?

Correct Answer is B

Explanation

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