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?
Enlargement of the heart ventricle
Turbulent blood flow
Persistently slow heart beat
Extreme pulse deficit
Coronary artery blockage
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 A
Explanation
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.
Correct Answer is D
Explanation
A. Hyperresonance is often heard in cases of pneumothorax or emphysema, not pneumonia.
B. Bubbling is not a percussed sound but rather a description of breath sounds or fluid.
C. Tympany is typically heard over hollow organs like the stomach and is not expected in lung assessment.
D. Dullness over lung tissue indicates fluid or consolidation, as seen in pneumonia.
E. Resonance is normal over healthy lung tissue but would not be expected over areas of consolidation.