The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:
An occlusion of the right coronary artery
An aneurysm of the descending aorta
Decreased fluid in the pericardial sac
Distortion of one or more heart valves
The Correct Answer is D
Choice A reason: This is not a correct interpretation. An occlusion of the right coronary artery is a blockage of the blood flow to the right side of the heart, which can cause a heart attack or ischemia. This condition does not produce a systolic murmur, but rather chest pain, shortness of breath, sweating, or nausea. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice B reason: This is not a correct interpretation. An aneurysm of the descending aorta is a bulging or weakening of the wall of the large artery that carries blood from the heart to the lower body. This condition does not produce a systolic murmur, but rather a pulsating mass in the abdomen, back pain, or abdominal pain. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice C reason: This is not a correct interpretation. Decreased fluid in the pericardial sac is a condition where the amount of fluid that surrounds and cushions the heart is reduced. This can be caused by dehydration, infection, or inflammation. This condition does not produce a systolic murmur, but rather a pericardial friction rub, which is a scratching or grating sound that occurs when the layers of the pericardium rub against each other. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.
Choice D reason: This is the correct interpretation. Distortion of one or more heart valves is a condition where the shape or function of the valves that regulate the blood flow through the heart is altered. This can be caused by congenital defects, rheumatic fever, endocarditis, or aging. This condition can produce a systolic murmur, which is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve. The location and the intensity of the murmur can help identify which valve is affected. A systolic murmur in the second intercostal space to the right of the sternum can indicate a problem with the aortic valve.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Increasing the SA to AV node conduction time is not the goal of using diltiazem for variant angina. Diltiazem is a calcium channel blocker that slows down the conduction of electrical impulses in the heart, but this is not the main mechanism of action for relieving variant angina. Variant angina is caused by spasms of the coronary arteries that reduce blood flow to the heart muscle.
Choice B reason: This is the correct answer. Decreasing coronary artery spasm is the goal of using diltiazem for variant angina. Diltiazem relaxes the smooth muscle of the coronary arteries and prevents them from contracting. This improves the blood supply to the heart and reduces the pain and ischemia associated with variant angina.
Choice C reason: Diltiazem does not cause hyperexcitability in the myocardium. This is a false statement. Diltiazem has the opposite effect of reducing the contractility and excitability of the heart muscle. This lowers the oxygen demand of the heart and helps prevent anginal attacks.
Choice D reason: Increasing the heart rate is not the goal of using diltiazem for variant angina. Diltiazem actually decreases the heart rate by blocking the calcium channels in the sinoatrial node and the atrioventricular node. This reduces the workload of the heart and the oxygen consumption. A high heart rate can worsen angina by increasing the oxygen demand of the heart.
Correct Answer is C
Explanation
Choice A reason: The second intercostal space, right of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, right of sternum, is the location where the aortic valve can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice B reason: The third intercostal space, left of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The third intercostal space, left of sternum, is the location where the pulmonary valve, which separates the right ventricle and the pulmonary artery, can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice C reason: The second intercostal space, left of sternum, is the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, left of sternum, is the location where the aortic murmur will be most audible, as it is the closest to the aorta, the largest artery in the body. ³
Choice D reason: The fourth intercostal space, left mid-clavicular line, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The fourth intercostal space, left mid-clavicular line, is the location where the tricuspid valve, which separates the right atrium and the right ventricle, can be best heard, but not the location where the aortic murmur will be most audible. ³
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