The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

Fifth intercostal space, left midclavicular line

Fourth intercostal space, right sternal boarder

Third intercostal space, left midclavicular line

Second intercostal space, right sternal boarder

Answer and Explanation

The Correct Answer is A

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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Correct Answer is D

Explanation

A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.

B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.

C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.

D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.

A. Severe headache B. Generalized weakness C. Gradual blurry vision D. Chest pain

Correct Answer is A

Explanation

A. A severe headache, often described as a "thunderclap" headache or the worst headache of the patient’s life, is a classic symptom of subarachnoid hemorrhage due to irritation of the meninges and increased intracranial pressure.

B. Generalized weakness may occur in some neurological conditions but is not a hallmark symptom of subarachnoid hemorrhage.

C. Gradual blurry vision is more associated with conditions like increased intracranial pressure or other eye-related issues rather than acute subarachnoid hemorrhage.

D. Chest pain is not typically associated with subarachnoid hemorrhage; it may indicate other conditions such as myocardial infarction or pulmonary issues.

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The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

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Naxlex Comprehensive Predictor Exams

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