The nurse is assessing a client with heart failure. Which finding is of greatest concern?
1. Mitral murmur
2. Diffuse wheezes
3. Capillary refill of 2 seconds
4. Clubbed nails
Correct Answer: 1
Rationale 1: Mitral stenosis is a common cause of heart failure. A mitral murmur could be indicative of mitral stenosis.
Rationale 2: Wheezes are associated with bronchial constriction, but not pulmonary edema.
Rationale 3: Capillary refill of 2 seconds is normal.
Rationale 4: Clubbed nails are a sign of impaired oxygenation, but are more commonly associated with respiratory problems, not heart failure.
Global Rationale: Mitral stenosis is a common cause of heart failure. A mitral murmur could be indicative of mitral stenosis. Wheezes are associated with bronchial constriction, but not pulmonary edema. Capillary refill of 2 seconds is normal. Clubbed nails are a sign of impaired oxygenation, but are more commonly associated with respiratory problems, not heart failure.
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