The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?
S4 heart sound
Harsh holosystolic murmur at the apex
S3 heart sound
Carotid bruits
The Correct Answer is C
A. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.
B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.
C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.
D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Focused: A focused assessment targets specific concerns or symptoms rather than including a complete health history and physical examination.
B. Comprehensive: A comprehensive assessment includes both a detailed health history and a thorough physical assessment, providing a complete picture of the patient’s health.
C. Ongoing: Ongoing assessments are periodic evaluations to monitor changes or progress in a patient’s condition, not necessarily encompassing a full health history and physical examination.
D. Emergency: Emergency assessments are conducted quickly to address immediate life-threatening issues, not to gather a full health history or perform a comprehensive physical exam.
Correct Answer is C
Explanation
A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.
B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.
C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.
D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.
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