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 B

Explanation

A. Adventitious sounds (e.g., wheezing, crackles, or stridor) are abnormal sounds that may be heard in addition to breath sounds. They do not specifically correlate with decreased breath sounds.
B. When there is obstruction in the bronchial tree (such as in conditions like asthma, chronic obstructive pulmonary disease (COPD), or a foreign body obstruction), the airflow is reduced, leading to decreased breath sounds in the affected areas.
C. Whispered pectoriloquy refers to hearing whispered sounds through the stethoscope, which would be more clearly heard with consolidation or lung tissue becoming more solid (e.g., in pneumonia), not with decreased breath sounds.
D. In consolidation (such as pneumonia), breath sounds are typically increased or bronchial, not decreased. The consolidation makes the lung tissue more solid, which can amplify breath sounds.

A. Lesions that run together. B. Annular lesions that have grown together. C. Lesions arranged in a line along a nerve route. D. Lesions that are grouped or clustered together.

Correct Answer is A

Explanation

A. Confluent lesions merge into each other, forming a larger area of affected skin.
B. Annular lesions are ring-shaped, not confluent, so this option does not match the description.
C. This describes a linear arrangement, such as with shingles, not confluent lesions.
D. Grouped or clustered lesions are not confluent but are typically close together, such as in herpes simplex infections.

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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

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

Correct Answer is B

Explanation

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

Correct Answer is A

Explanation

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