Upon admission assessment, the nurse hears a murmur located at the fifth intercostal space, midclavicular line. The client asks, "What does that mean?" The nurse will base her answer on which of the following physiologic principles?
A) "You have been exposed to an infection that went into your blood stream."
B) "You have a heart valve that is diseased."
C) "You heart has been pumping your blood so hard, that the pressure has damaged your valves."
D) "Your heart has enlarged, so naturally your valves had to enlarge as well."
Ans: B
Feedback:
Turbulence is often accompanied by vibrations of the blood and surrounding cardiovascular structures. Some of these vibrations are in the audible range and can be heard using a stethoscope. For example, a heart murmur results from turbulent flow through a diseased heart valve. The other distractors are not feasible.
You might also like to view...
Which of the following clients are at risk for developing a platelet clot? Select all that apply
A) A COPD client experiencing an acute exacerbation requiring intravenous steroids B) A trauma client who had a splenectomy following injury and laceration of the liver C) A school-aged child prescribed iron supplements for iron deficiency anemia D) A breast cancer client receiving chemotherapy E) An acute myocardial infarction client with elevated troponin levels
Client education is an important aspect of medication administration, so a nurse is discussing the use of an oral pediatric syringe for the caregiver to use at home. What information should the nurse share with the caregiver?
a. The syringe allows for precise measurement of the drug. b. The syringe is interchangeable for IV use and oral use. c. The plunger will make it easy to squirt the drug into the back of the throat. d. A syringe and a teaspoon are interchangeable.
Which of the following would be part of providing appropriate nonverbal support when managing a drug/alcohol crisis?
A) using the victim's name B) asking clear, simple questions C) maintaining eye contact D) responding to feelings
Which of the following is part of the outer eye?
A. pupil B. sclera C. uvea D. lacrimal apparatus