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When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

A.

Enlargement of the heart ventricle

B.

Turbulent blood flow

C.

Persistently slow heart beat

D.

Extreme pulse deficit

E.

Coronary artery blockage

Answer and Explanation

The Correct Answer is A

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.

 

B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.

 

C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.

 

D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.

 

E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.


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Correct Answer is B

Explanation

A. Decreasing dietary protein does not directly affect the spread of respiratory infections. Protein is important for maintaining immune function.

B. Obtaining flu vaccines is an effective way to reduce the spread of respiratory infections, especially among older adults who are at higher risk.

C. Overhydration is not related to infection control and is not necessary in this context.

D. While handkerchiefs may help with containing respiratory droplets, disposable tissues are generally more hygienic.

E. Limiting daily activity is unnecessary for preventing respiratory infections and could negatively impact overall health.

Correct Answer is B

Explanation

A. While posterior to anterior comparisons are used, they do not encompass the entire technique for auscultation.

B. Side-to-side comparison is the correct method as it allows for immediate assessment of differences between lung fields and helps to identify abnormal sounds effectively.

C. Interspace-by-interspace comparison is not a commonly recognized term for this method and can lead to confusion in technique.

D. Proximal to distal comparison is not specific to lung auscultation and does not effectively apply to lung assessment.

E. Top-to-bottom comparison may miss abnormalities in a specific region of the lungs; side-to-side is preferred.

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