Cardiovascular

he nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

"Right carotid bruit auscultated" Bruits are swooshing sounds similar to the sound of the blood pressure. They result from turbulent blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. Neither split sounds nor an S2 is heard over arteries.

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

Cardiac cycle The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next?

2nd intercostal space left sternal border Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

he nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next?

2nd intercostal space left sternal border Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

Where is Erb's point located?

3rd left rib space Erb's point is located on the left side of the chest. Walk the fingers one rib space at the left sternal border (approximately 1 inch apart) to locate the 3rd intercostal space (ICS) on the left; this is the third site for auscultation, Erb's point. Walk the fingers to the 4th or 5th ICS for the fourth site, called the tricuspid area. Move the fingers along the 5th ICS to the midclavicular line for the 5th location, the mitral area.

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A thrill Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe this heart sound? S2 is:

Accentuated An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal Split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide Split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration.

he client is noted to have a pathologic change in ventricular compliance. What information from the cardiac assessment would indicate this?

An S3 gallop In older adults, an S3, sometimes termed "an S3 gallop," usually indicates a pathologic change in ventricular compliance.

An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist?

Atherosclerotic stenotic carotid arteries If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the client's age would negate the likely existence of a congenital problem.

The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer?

Atrial depolarization The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec).

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

Auscultate to determine the heart rate and if the rhythm is normal The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.

The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?

Auscultate with the client in a variety of different positions. If a murmur is suspected, the nurse should auscultate with the client in different positions because some murmurs occur or subside according to the client's position. The bell and diaphragm should be used. Controlled exhalation and inhalation will not significantly enhance the assessment process.

nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?

Bradycardia The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60-100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased but this is not a proper documentation term.

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Bruits Distinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. A gallop is a generic term for an additional heart sounds heard besides the normal S1 and S2 sound.

A nurse is unable to palpate the apical impulse on a client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical pulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

Decreased cardiac output Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day. Severe muscular exertion and an upper respiratory infection may be associated with fatigue, but not the pattern mentioned in the scenario.

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

Flat neck veins

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his or her breath; if the rub persists, it is pericardial Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.

A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?

Hypertension is more prevalent in African Americans than among Caucasians. Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations.

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

Is normally smaller than the male heart The total size of the heart is approximately that of a clenched adult fist. The female heart is normally smaller and weighs less than the male heart across all age groups. The female heart does not consistently beat more slowly than a male heart.

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

Murmur Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?

Orthopnea Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse?

Palpable The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be most appropriate?

Palpate each artery individually to compare. When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold the breath for a moment so breath sounds do not conceal any vascular sounds.

While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings?

Pericardial friction rub A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A mid-systolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?

Pericardial friction rub A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A midsystolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

Pericardial friction rub The pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. A murmur is a blowing or swooshing sound that occurs due to turbulent blood flow through the heart or great vessels. One normal variation in heart sounds is the split heart sound. When the valves close at the same time, one S2 is heard for both valves. If the valves close at slightly different times, however, two discernible components of the same sound are heard, a situation referred to as a split heart sound. Aortic ejection sounds are best heard at the apex.

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?

Place the bell of the stethoscope over the apex with client on left side. This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the client turned to the left. The carotid arteries are auscultated one at a time for bruits. The 2nd left intercostal space is the location to hear pulmonic valve conditions.

Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client?

Presence of an S3 Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S3 and an S4 which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse & seen in cardiac tamponade or obstructive lung disease. A split S2 does not change the amplitude of a client's pulse.

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

Right carotid bruit auscultated Bruits are swooshing sounds similar to the sound of the blood pressure. They result from turbulent blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. Neither split sounds nor an S2 is heard over arteries.

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply.

Smoking Blood pressure Cholesterol Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors.

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis. Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome.

A client has had consecutive blood pressure readings in the 130s/80s for the last week of evaluation. This would be classified as

Stage 1 hypertension The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

The client may be experiencing symptoms of heart failure. With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation.

The nurse is assessing the jugular venous pressure (JVP) of a 72-year-old client with recent complaints of fatigue, shortness of breath, and swollen ankles. What cardiac phenomena are represented by the oscillations that the nurse observes in the client's internal jugular veins?

The pressures that exist within the client's right atrium JVP is a visible manifestation of the varying pressures in the client's right atrium. It does not directly indicate contractility, valve function, preload, or afterload.

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle. The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of

increased central venous pressure. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

left midclavicular line at the fifth intercostal space The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.

The sinoatrial node of the heart is located on the

posterior wall of the right atrium. The sinoatrial (SA) node (or sinus node) is located on the posterior wall of the right atrium near the junction of the superior and inferior vena cava.

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the

third to fifth intercostal space at the left sternal border. Erb's point: Third to fifth intercostal space at the left sternal border.