Chapter 17: Heart and Neck Vessels Assessment

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 Explanation: 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.

A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take during the remainder of the physical assessment of the carotid arteries?

Perform palpation lightly

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." Explanation: Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet.

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client's electronic medical record?

2+

When a patient is obese or has a thick chest wall, what is difficult to palpate?

Apical impulse Explanation: Obesity or a thick chest wall makes palpation of the apical impulse difficult

How should a nurse assess a client for pulse rate deficit?

Assess for a difference between the apical and radial pulse

A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure?

Auscultation of an S3 heart sound Explanation: The development of a pathologic S3 may be the earliest sign of heart failure. This sound signals resistance of the ventricles to filling. A split S1 heard over the apex of the heart may indicate a conduction delay between the ventricles. Grade III.VI murmur indicates a valve malfunction. Jugular venous distention may be seen with heart failure of the right side of the heart but is not the first sign.

A nurse monitors a client at risk for the onset of premature ventricular contractions. The nurse should monitor the client's cardiac rhythm for which characteristic feature?

Beats that occur earlier than the next expected beat Explanation: Premature ventricular contractions are characterized by beats that occur earlier than the next expected beat. The P waves are absent, with wide QRS complexes followed by a compensatory pause. The rhythm usually resumes with the next beat. QRS complexes are wide and bizarre, not narrow, and the P wave is usually absent.

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

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

Client has an increased chest diameter Explanation: 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 impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

Do you have any pain or discomfort in your chest?" Explanation: The first question the nurse asks should be broad as this will encourage the client to share more detail regarding the source of the pain. Chest pain is one of the most serious and important symptoms often signaling coronary artery disease, potentially leading to myocardial infarction. All of the other options are more specific; these questions should only be asked when the nurse needs to narrow the focus of the cardiovascular examination.

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

Erb point Explanation: Erb's point is auscultated at the 3rd intercostal space at the left sternal border. The aortic area is located at the second intercostal space at the right sternal border. The mitral area is located at the fifth intercostal space near the left mid-clavicular line. The pulmonic area is located at the 2nd or 3rd intercostal space at the left sternal border

A client, scheduled for pacemaker insertion, does not understand why the device is needed. Where should the nurse identify the location of the sinoatrial node on the diagram when instructing the client about the surgery?

Explanation: A small electrical impulse that fires in the sinoatrial (SA) node in the right atrium generates the normal heartbeat. The SA node functions as the "pacemaker" of the heart. Cells in the SA node possess a property that enables the cardiac cells to generate their own impulses.

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

Fifth intercostal space, left midclavicular line Explanation: The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.

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

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. Explanation: 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.

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Inflammation of the pericardial sac Explanation: A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Inflammation of the pericardial sac Explanation: A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

Inspect for dependent edema. Explanation: Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of noctouria results from the redistribution of fluid at night, forcing the client to get up to void more frequently. The client should only be told to lie flat for the physical examination if the client is hypovolemic and the neck veins need to be visualized. Palpation of the carotid pulse is useful for determining whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.

The nurse is performing a cardiac examination of a client with shortness of breath and palpitations. The nurse listens to the heart with the client sitting upright, then has him change to a supine position, and finally has him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?

Mitral The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If the examiner does not listen in a quiet room to the heart in this position with both the diaphragm and bell, it is possible to miss significant murmurs such as mitral stenosis.

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 Explanation: 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. Reference:

A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following?

Myocardium Explanation: The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels

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

Palpate each artery individually to compare. Explanation: 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.

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. Explanation: If you detect occlusion during auscultation, palpate very lightly to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or even cardiac arrest. Palpation should be performed alternately to avoid cerebral ischemia, and the client should briefly hold the breath during auscultation. Auscultation should precede palpation.

A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?

Patient C Explanation: Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

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 Explanation: 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 completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?

Shortness of breath Explanation: Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect.

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 what location?

Sinoatrial node Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here, the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles.

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

Systematically listen to the entire precordium. Explanation: When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apex or from the apex to the base. Both the diaphragm and bell are used. Inspection and palpation usually precede auscultation. It is not necessary to begin with breath sounds.

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. Explanation: 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 preparing to assess a client's carotid arteries. Which of the following would be most appropriate?

The mediastinum, between the lungs above the diaphragm Explanation: The heart and great vessels are located in the mediastinum between the lungs and above the diaphragm from the center to the left of the thorax. Therefore, the other options are incorrect.

The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.

True

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply.

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes. Explanation: Encouraging physical activity, decreasing dietary intake of sodium, and increasing dietary intake of potassium, such as in bananas and sweet potato, are lifestyle modifications that can promote sustaining a healthy blood pressure. Excess alcohol consumption is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for hypertension should avoid increasing consumption of these foods.

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle. Explanation: 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 o

increased central venous pressure. Explanation: 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.

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?

ineffective Tissue Perfusion Explanation: The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance.

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