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

Explanation

A. Smoking, hypertension, obesity, diabetes, and high cholesterol: These are all well-established major risk factors for heart disease and should be included in the patient's history.
B. Personality type, high cholesterol, diabetes, and smoking: While personality type may contribute to stress, the other factors listed are more directly linked to heart disease.
C. Alcohol consumption, obesity, diabetes, stress, and high cholesterol: Alcohol consumption may be a risk factor, but smoking and hypertension are more significant.
D. Family history, hypertension, stress, and age: While family history, age, and hypertension are important, this option misses key factors like obesity, smoking, and diabetes.

A. Client's blood pressure B. Client's weight C. Client's respiratory rate D. Intensity of the murmur E. Location of the murmur F. Client's temperature G. Timing of the murmur H. Client's medication history

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.

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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

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Correct Answer is A

Explanation

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

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