The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

Loud, at the apex, associated with a palpable thrill.

Very loud, with no stethoscope, thrill easily palpable, heave visible.

Soft, barely heard on auscultation in a quiet room.

Moderately loud, machine-like rumble, not associated with a thrill.

Answer and Explanation

The Correct Answer is A

A.   A grade IV systolic murmur is considered loud and may be associated with a palpable thrill. In mitral valve regurgitation, the murmur is often best heard at the apex of the heart. A thrill, which is a vibration felt on the chest wall, is a sign of a more significant murmur. This description is consistent with a grade IV murmur, which is typically loud and may indeed be associated with a thrill.
B.   Very loud, with no stethoscope, thrill easily palpable, heave visible.
B. A grade V systolic murmur is very loud and can be heard with the stethoscope barely touching the chest. It often comes with a palpable thrill and may be accompanied by a visible heave or lift of the

chest wall. This description is consistent with a grade V murmur, not grade IV. Therefore, it’s not the
correct description for a grade IV murmur.
C.   A soft murmur, barely audible, describes a grade I or grade II systolic murmur. This does not match the characteristics of a grade IV murmur, which is louder and more easily heard. Therefore, this description does not support a grade IV murmur.
D.   A moderately loud murmur, without a thrill, could describe a grade III murmur. Additionally, a "machine-like rumble" is more characteristic of a diastolic murmur, such as those heard in conditions like aortic regurgitation or mitral stenosis, rather than a systolic murmur associated with mitral valve regurgitation.

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Correct Answer is A

Explanation

A. Nailbed clubbing is characterized by an increased angle between the nail and the nailbed, typically greater than 180 degrees. An angle of 200 degrees is consistent with clubbing, which can be a sign of chronic respiratory or cardiovascular conditions, such as chronic lung diseases, congenital heart defects, or other systemic conditions.
B. Consulting with a podiatrist to trim toenails is important for foot care but is not directly related to the finding of nailbed clubbing. The angle of the nailbed is more indicative of a systemic issue rather than a local foot care problem. Therefore, this action does not address the underlying concern suggested by the angle of 200 degrees.
C. While anemia or other blood conditions can affect the nails, the specific finding of a nailbed angle of 200 degrees is more indicative of clubbing rather than issues typically associated with hemoglobin levels. Therefore, while monitoring hemoglobin is important for overall health, it is not the immediate priority in response to the finding of nailbed clubbing.
D. Administering oxygen might be necessary if the client is experiencing symptoms of hypoxia or has a condition affecting oxygenation. However, the finding of nailbed clubbing itself does not immediately necessitate oxygen therapy. Oxygen administration should be based on specific symptoms or clinical indications of hypoxia rather than the nailbed angle alone.

A. Dyspnea. B. Peripheral edema. C. Intercostal retractions. D. Headaches. E. Jugular venous distension.

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

Explanation

A. Dyspnea, or shortness of breath, is a common symptom of heart failure exacerbation. It occurs because the heart is unable to effectively pump blood, leading to pulmonary congestion and fluid accumulation in the lungs. This symptom is significant in confirming an exacerbation of heart failure.
B. Peripheral edema, or swelling of the legs and ankles, is another common sign of heart failure exacerbation. It results from fluid buildup due to the heart's decreased ability to manage blood volume effectively. This finding is indicative of fluid retention and can confirm an exacerbation of heart failure.
C. Intercostal retractions are typically seen in respiratory distress, especially in conditions affecting the lungs or severe respiratory conditions. While they can occur with severe pulmonary congestion in heart failure, they are more directly associated with respiratory issues rather than specifically confirming heart failure exacerbation.
D. Headaches are not a typical or primary symptom of heart failure exacerbation. They can be associated with various conditions but are not specific to heart failure. This symptom is less relevant in confirming an exacerbation of heart failure.
E. Jugular venous distension is a classic sign of right-sided heart failure or fluid overload. It occurs when there is increased pressure in the venous system due to the heart's inability to handle blood volume effectively.

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The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

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Naxlex Comprehensive Predictor Exams

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Correct Answer is A

Explanation

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

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

Explanation

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