Which area would the nurse assess for a murmur due to aortic valve stenosis?
Right 5th intercostal space at the sternal border
Right 2nd intercostal space at the sternal border
Left 5th intercostal space at the mid-clavicular line
Left 2nd intercostal space at the mid-clavicular line
The Correct Answer is C
Choice A reason: The right 5th intercostal space at the sternal border is near the tricuspid valve, where murmurs from tricuspid regurgitation or stenosis are typically heard. Aortic valve stenosis murmurs, caused by turbulent flow through a narrowed aortic valve, are not prominent here, making this an incorrect assessment site.
Choice B reason: The right 2nd intercostal space at the sternal border is the aortic area, ideal for auscultating aortic valve stenosis murmurs. These murmurs are harsh, crescendo-decrescendo, and systolic, radiating to the carotid arteries due to turbulent blood flow through the stenosed aortic valve, making this the correct site.
Choice C reason: The left 5th intercostal space at the mid-clavicular line is the mitral valve area, where mitral regurgitation or stenosis murmurs are heard. Aortic valve stenosis murmurs originate from the aortic root and are not best detected here, rendering this choice incorrect.
Choice D reason: The left 2nd intercostal space at the mid-clavicular line is near the pulmonic valve, where pulmonic stenosis murmurs are auscultated. Aortic valve stenosis murmurs are not prominent in this area, as they are specific to the aortic region, making this an incorrect choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.
Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.
Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.
Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.
Correct Answer is C
Explanation
Choice A reason: The right 5th intercostal space at the sternal border is near the tricuspid valve, where murmurs from tricuspid regurgitation or stenosis are typically heard. Aortic valve stenosis murmurs, caused by turbulent flow through a narrowed aortic valve, are not prominent here, making this an incorrect assessment site.
Choice B reason: The right 2nd intercostal space at the sternal border is the aortic area, ideal for auscultating aortic valve stenosis murmurs. These murmurs are harsh, crescendo-decrescendo, and systolic, radiating to the carotid arteries due to turbulent blood flow through the stenosed aortic valve, making this the correct site.
Choice C reason: The left 5th intercostal space at the mid-clavicular line is the mitral valve area, where mitral regurgitation or stenosis murmurs are heard. Aortic valve stenosis murmurs originate from the aortic root and are not best detected here, rendering this choice incorrect.
Choice D reason: The left 2nd intercostal space at the mid-clavicular line is near the pulmonic valve, where pulmonic stenosis murmurs are auscultated. Aortic valve stenosis murmurs are not prominent in this area, as they are specific to the aortic region, making this an incorrect choice.
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