During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

Bronchitis

Heart failure

Pneumonia

Tuberculosis

Answer and Explanation

The Correct Answer is B

A. Bronchitis primarily causes coughing and mucus production, and does not specifically relate to trouble breathing while lying down.

B. Heart failure often leads to orthopnea (difficulty breathing while lying flat) and paroxysmal nocturnal dyspnea (waking up at night with difficulty breathing). These symptoms align with the client's reported issues.

C. Pneumonia usually presents with acute symptoms such as cough, fever, and chest pain, rather than the specific nocturnal breathing difficulty described.

D. Tuberculosis typically involves symptoms like chronic cough, night sweats, and weight loss, rather than difficulty breathing while lying down.

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Correct Answer is C

Explanation

A. Pulmonic and tricuspid: The tricuspid valve's closure is not primarily audible at the 2nd intercostal space right sternal border; it is better heard at the lower left sternal border.

B. Mitral and aortic: The mitral valve is best heard at the apex of the heart, not the 2nd intercostal space right sternal border.

C. Aortic and pulmonic: The 2nd intercostal space right sternal border is the area where the aortic and pulmonic valves are auscultated. The louder S2 here indicates the closure of these valves, with the aortic valve being the primary source of sound in this area.

D. Tricuspid and mitral: These valves are best heard at other locations, with the tricuspid valve near the lower left sternal border and the mitral valve at the apex.

A. Caffeine intake B. Post meal C. Stress D. Drinking a glass of water E. Time of day

Correct Answer is ["A","C","E"]

Explanation

A. Caffeine intake: Can cause a temporary increase in blood pressure due to its stimulant effects.

B. Post meal: While eating can cause temporary changes in blood pressure, it is less likely to be a significant factor compared to other causes.

C. Stress: Can lead to temporary increases in blood pressure due to the body's stress response.

D. Drinking a glass of water: Typically does not significantly affect blood pressure unless there is an underlying issue such as dehydration.

E. Time of day: Blood pressure can naturally vary throughout the day, often being higher in the morning and lower in the evening.

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During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

Correct Answer is C

Explanation

After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?

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