Ch. 21 Assessing heart and neck vessels

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

"Your risk for heart disease will drop greatly if you're able to stop smoking."

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations should the nurse include as appropriate for reducing a person's risk? Select all that apply.

-Eat foods low in sodium -Walk for atleast 30 minutes/day. -Use relaxation techniques to manage stress.

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

2

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?

2+

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next?

Auscultate for pulse rate deficit.

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.

The nurse is using COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the ìAî in this assessment model?

Do you have any other symptoms together with your chest pain, such as nausea, sweating?

The nurse has assessed a client's neck vessels and is now preparing to auscultate the client's heart sounds. What action should the nurse perform during this phase of assessment?

Elevate the head of the client's bed to 30 degrees.

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?

Fifth intercostal space, left midclavicular line.

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

Hypertension is more prevalent in African Americans than among Caucasians.

The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following?

Identify heart sounds that may be inaudible in other positions.

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?

Inspect the suprasternal notch or around the clavicles.

The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate?

Palpate each artery individually to compare

A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do?

Palpate the carotid pulse while auscultating the heart

The nurse is assessing the carotid arteries of a client with a history of heart disease. What action should the nurse perform during this assessment?

Palpate the client's carotid arteries gently if an occlusion is audible.

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. The nurse should document which of the following?

Pericardial friction rub

The nurse's auscultation of a 22-year-old client's apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding?

Recognize this as a normal assessment finding in this client.

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?

Systematically listen to the entire precordium.

A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization?

T wave

The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions?

The apical impulse may be more difficult to palpate than in a younger client.

The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement?

The client may be experiencing symptoms of heart failure.

The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?

The client's ventricles are not contracting simultaneously.

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be normal in a healthy client?

The jugular venous pulse is not visible when the client is sitting upright.

The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?

diminished

The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?

closure of the atrioventricular valves

A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?

heart failure

The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?

increased jugular venous pressure

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following?

myocardium

A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations?

sinoatrial node

After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point?

third to fifth intercostal space at the left sternal border.