Health Assessment Case: Jared Griffin

The nurse is gathering subjective data during a cardiovascular assessment from a patient's spouse. Which question is particarly appropriate fro a patient who has reported that, "My heart seems to skip beats"?

"Have you seen periods when your spouse seems to experience uncommon fatigue?"

Preparing for an electrocardiogram (ECG) is a priority nursing intervention for which patient?

- A patient is reporting, "I feel like my heart is skipping beats" - A patient experiencing diaphoresis and arm pain - A patient who just had a pacemaker placed - A patient newly diagnosed with mild hypokalemia

Which point on the heart will the nurse use to auscultate an apical pulse?

Apex

Which action take during a cardiovascular assessment will best assist the nurse in determining the hemodynamics o the right side of a patient's heart?

Inspection of the jugular venous pulse level

A patient has been recently diagnosed with atrial fibrillation. Which expected outcome will the nurse include in the care plan to adress the resulting anxiety?

Patient will earn and demonstrate effective coping behaviors

The life partner of a patient diagnosed with atrial fibrillation (AF) demonstrates a need for instruction when asking the nurse, "Can you tell me why this is a problem?" What is the nurse's best response?

The abnormal heartbeat results in poor blood flow to the heart

Which assessment findings suggest an arterial vascular system abnormality?

- Absence of hair over the lower legs - Thin, shiny skin over calves

To assess a patient's heart during a physical assessment, which actions will the nurse perform?

- Assess the apex, left sternal border, and the base of the heart for abnormal pulsations - Auscultate over the aortic, pulmonic, tricuspid, and mitral areas, as well as Erb's point - Ask the patient to lie on the left side to assess sounds form the apex of the heart - Assess heart rate and rhythm using the diaphragm of the stethoscope

The medical record states that the patient's pulse is "small and weak." Which characteristic will the nurse expect to detect when performing a cardiovascular assessment on this patient?

- Slow upstroke - Diminished pulse pressure - A prolonged systolic peak

Which patient is expected to have the lowest resting pulse rate (RPR)?

A non-hispanic black male

The nurse is preparing a patient for a cardiovascular assessment. When providing the patient with information concerning the examination, which physical positions will the nurse indicate will be used during the examination?

- Supine - Left lateral - Sitting upright while leaning forward

Which example of nursing documentation best indicates that the patient has peripheral perfusion that reflects adequate cardiac output?

Capillary refill noted in less than 2 seconds

The nurse is providing care for a patient whose partner says, "We're told that he occasionally has an irregular heatbeat. Is that bad?" Which response should the nurse make to best address the partner's concern?

It's normal to experience occasional premature beats

Of the medication Mr. Griffin has been prescribed, which one will the nurse discuss with the surgeon regarding its possible association with the patient's irregular heartbeat?

Oxycodone/acetaminophen

A nurse is discussing the evaluation of an electrocardiograph recently performed on a patient with a nursing student. Which data will the nurse identify for the student as being within normal limits?

- Heart rate is between 60-100 beats/min - A P wave is visible before each QRS complex - The T wave is rounded and smooth

The nurse and a nursing student are reviewing the electrocardiograph (ECG) of a patient diagnosed with atrial fibrillation (AF). Which characteristics noted will the nurse identify as being associated with this cardiac condition?

- Low-amplitude filbrillation waves - Absent P waves - Irregular QRS complexes

When preparing a patient for an electrocardiograph (ECG) the nurse will include which instructural information?

- Sticky backed electrodes will be attached directly to the skin on the patient's arms, legs, and chest - It's important that the patient remain as still and relaxed as possible during the test - The patient will be asked to lie on his or her back for the length of the test, which is 5-10 minutes - The test is painless

When reviewing Mr. Griffin's Medical record, the nurse recognizes what information as being a risk factor for atrial fibrillation?

-History of hypertension - Male over the age of 60

What is the nurse's response when Mr. Griffin asks, "What is the biggest worry about having atrial fibrillation?"

The blood tends to pool in your heart's upper chamber, increasing the risk of developing a clot

A patient is diagnosed with atrial fibrillation (AF) based on electrocardiogram (ECG). Which of the following nursing assessment findings could also be demonstrated by a patient experiencing AF?

- Jugular vein distension - Hisotry of chest pain - Tachycardia - An irregular pulse