HA prepU ch 17 heart and neck vessels

Variations in the presentation of S1 are due to alterations in which heart valve?

mitral

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

The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action?

Closure of the atrioventricular valves

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

Accentuated

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

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

Bruits

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

Assess for a difference between the apical and radial pulse

A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do?

Auscultate for split S1 at the base and apex

The nurse positions the client for auscultation of heart sounds. What does the nurse do first?

Clean the stethoscope

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.

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.

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.

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

Palpate each artery individually to compare

A triage nurse is working in the emergency department of a busy hospital. Four clients 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 client would be the nurse's highest priority?

Patient C

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

S1

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

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.

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

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

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

flat neck veins

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

grade 5

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 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.

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

What is the most important physical sign of acute pericarditis?

pericardial friction rub