1. Upon admission assessment, the nurse hears a
murmur located at the fifth intercostal space, midclavicular
line. The client asks, “What does that
... [Show More] 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.
2. A client is diagnosed with an abdominal aortic
aneurysm that the physician just wants to “watch” for now.
When teaching the client about signs/symptoms to watch
for, the nurse will base the teaching on which of the
following physiological principles?
A) Small diameter of this vessel will cause it to
rupture more readily.
B) The larger the aneurysm, the less tension placed
on the vessel.
C) As the aneurysm grows, more tension is placed on
the vessel wall, which increases the risk for rupture.
D) The primary cause for rupture relates to increase
in abdominal pressure such as straining to have a bowel
movement.
Ans: C
Feedback: Because the pressure is equal
throughout, the tension in the part of the balloon with the
smaller radius is less than the tension in the section with the
larger radius. The same holds true for an arterial aneurysm
in which the tension and risk of rupture increase as the
aneurysm grows in size. Wall tension is inversely related to
wall thickness, such that the thicker the vessel wall, the
lower the tension, and vice versa. Although arteries have a
thicker muscular wall than veins, their distensibility allows
them to store some of the blood that is ejected from the
heart during systole, providing for continuous flow through
the capillaries as the heart relaxes during diastole. [Show Less]