The nurse is assessing a client with coronary artery disease. Which question should the nurse ask to assess for angina?
Do you experience palpitations while at rest?
Do you feel short of breath when laying down?
Do you experience chest pain when you exercise?
Do you feel short of breath when walking up stairs?
The Correct Answer is C
Choice A reason: Palpitations, or the sensation of a fluttering or racing heart, are more commonly associated with cardiac arrhythmias or anxiety rather than classic angina pectoris. While ischemia can trigger arrhythmias, asking about pain during exertion is the more specific and standard diagnostic inquiry for stable angina.
Choice B reason: Shortness of breath when lying flat is known as orthopnea, a clinical sign of pulmonary congestion and left-sided heart failure. While heart failure often coexists with coronary artery disease, orthopnea is not the primary symptom used to define or assess the presence of anginal chest pain.
Choice C reason: Angina pectoris is defined as chest pain or pressure that occurs when myocardial oxygen demand exceeds supply, most commonly during physical exertion or emotional stress. Asking about pain during exercise directly assesses for stable angina, which is a hallmark symptom of significant atherosclerotic narrowing in the coronary arteries.
Choice D reason: Dyspnea on exertion is a non-specific symptom that can indicate either cardiac or pulmonary dysfunction. While it can be an "anginal equivalent" in some populations, such as the elderly or women, asking specifically about chest pain remains the standard assessment for traditional angina in a client with CAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The tripod position is a classic physical sign of respiratory distress, commonly seen in patients with COPD or acute asthma. By leaning forward and bracing the arms, the client optimizes the use of accessory muscles (sternocleidomastoid and pectorals) to assist in thoracic expansion and ease the work of breathing.
Choice B reason: While the position might look stiff, in a clinical respiratory context, it is not primarily indicative of musculoskeletal pain. It is a purposeful physiological maneuver to improve ventilation. Documenting it as musculoskeletal discomfort would be a clinical misinterpretation of the patient's acute respiratory compensation strategy.
Choice C reason: This position is the opposite of relaxed. It indicates a high "work of breathing" and physiological stress. A relaxed position would involve leaning back or sitting upright without the need for external bracing of the arms to maintain adequate alveolar ventilation and gas exchange.
Choice D reason: Normal postural alignment involves an upright spine without the need for auxiliary support to maintain lung volume. The tripod position is an abnormal, compensatory posture that indicates the client is struggling to breathe, and it must be documented as an objective finding of respiratory effort.
Correct Answer is C
Explanation
Choice A reason: Hypertrophic cardiomyopathy is a structural medical diagnosis characterized by the pathological thickening of the ventricular myocardium. While this condition can frequently cause a systolic murmur due to outflow tract obstruction, the sound of turbulence itself is documented as a murmur, not as the name of the underlying disease.
Choice B reason: A pleural friction rub is an adventitious breath sound, not a heart sound. It is a dry, grating sound caused by the inflammation of pleural surfaces rubbing together during respiration. It can be distinguished from cardiac sounds by asking the client to hold their breath; a pleural rub will disappear, while a cardiac sound persists.
Choice C reason: A murmur is the specific clinical term used to describe the "swooshing" or "blowing" sound produced by turbulent blood flow. This turbulence can be caused by valvular stenosis (narrowing), regurgitation (leaking), or high-flow states. Documentation should include the murmur's timing in the cardiac cycle, intensity, pitch, and location.
Choice D reason: Congestive heart failure is a clinical syndrome resulting from the heart's inability to pump sufficient blood to meet metabolic demands. While heart failure may be accompanied by abnormal sounds like an S3 gallop or murmurs related to ventricular dilation, it is a complex systemic diagnosis rather than a descriptor for a specific acoustic finding.
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