PrepU ch. 21 assessing heart and neck vessels

A client with heart disease is a current cigarette smoker. What should the nurse include when caring for this client? Select all that apply. -Advise to quit -Arrange for follow-up -Assess willingness to quit -Acknowledge dependence -Assist with finding resources

-Advise to quit -Arrange for follow-up -Assess willingness to quit -Assist with finding resources Explanation: The nurse can follow the 5 A's when assisting a client with smoking cessation. These A's include advising to quit, arranging for follow-up, assessing the client's willingness to quit, and assisting with finding resources. Acknowledging dependence is not an intervention for smoking cessation. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

Which of the following would put the client at risk for falls? Select all that apply. -Dizziness -Hypotension -Confusion -Palpitations -Diaphoresis

-Dizziness -Hypotension -Confusion Explanation: Dizziness, hypotension and confusion may put the client at risk for falls. Palpitations and diaphoresis does not increase fall risk. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 440. Chapter 21: Assessing Heart and Neck Vessels - Page 440

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply. -Quit or do not start smoking -Exercise regularly -Undergo regular cholesterol screening -Eat a low-fiber diet -Undergo regular screening for diabetes

-Quit or do not start smoking -Exercise regularly -Undergo regular cholesterol screening -Undergo regular screening for diabetes Explanation: Important healthy habits to emphasize include following a low-fat diet, regularly exercising, undergoing regular screening for diabetes and cholesterol, and quitting (or continuing not) smoking. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

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 -Family history -Age

-Smoking -Blood pressure -Cholesterol Explanation: Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels.

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. -Consume two to three glasses of red wine daily. -Increase consumption of dairy products.

-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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? a.Hypovolemia b.Occlusion c.Hypervolemia d.Constriction

a. Hypovolemia Explanation: A weak pulse can indicate hypovolemia, shock or decreased cardiac output. Pulse inequality may indicate a constriction or occlusion. Hypervolemia would be manifested by bounding pulses. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 448. Chapter 21: Assessing Heart and Neck Vessels - Page 448

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? a."Do you have any pain or discomfort in your chest?" b."Is the pain worse on exertion?" c."Do you have cramping pain?' d."Is the pain worse when you are lying down?"

a. "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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

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? a.Accentuated b.Diminished c.Normal split d.Wide split

a. Accentuated Explanation: 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 436

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? a.Aortic and pulmonic b.Tricuspid and mitral c.Pulmonic and tricuspid d.Mitral and aortic

a. Aortic and pulmonic Explanation: The closure of the aortic and pulmonic valves creates the second heart sound, which is heard louder over the 2nd intercostal space right sternal border. The closure of the tricuspid and mitral valves creates the first heart sound. The pulmonic and tricuspid valves do not close together. The mitral and aortic valves do not close together. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 436. Chapter 21: Assessing Heart and Neck Vessels - Page 436

The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer? a.Atrial depolarization b.Ventricular depolarization c.Atrial repolarization d.Ventricular repolarization

a. Atrial depolarization Explanation: The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 434. Chapter 21: Assessing Heart and Neck Vessels - Page 434

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? a.Bruits b.Murmurs c.Normal findings d.Gallops

a. Bruits Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 447. Chapter 21: Assessing Heart and Neck Vessels - Page 447

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? a.Client has an increased chest diameter b.Heart rate is irregular c.Respiratory rate is too fast d.Heart enlargement is present

a. 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 449

The nursing instructor explains to a group of students that what can shorten diastole? a.Increased heart rate b.Decreased respirations c.Filling pressures d.Blood pressure

a. Increased heart rate Explanation: Diastole is the phase of the cardiac cycle in which the ventricles relax and fill with blood. As the heart rate increases, the length of diastole is shortened. The respiratory rate, blood pressure and filling pressures do not shorten diastole. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 434. Chapter 21: Assessing Heart and Neck Vessels - Page 434

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? a.Inspect for dependent edema. b.Ensure that the client lies flat for the examination. c.Palpate the carotid pulse. d.Assess for thrills.

a. Inspect for dependent edema. Explanation: Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of nocturia 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 441

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? a.Myocardium b.Epicardium c.Endocardium d.Pericardium

a. 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 433

Which of the following would the nurse consider to be an urgent situation? a.New onset chest pain b.Blood pressure 122/76 c.Heart rate 88 d.Oxygen saturation of 92%

a. New onset chest pain Explanation: A new onset of chest pain would be an urgent situation. The blood pressure, oxygen saturation and heart rate are within normal limits. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? a.Orthopnea b.Tachypnea c.Pneumonia d.Sleep apnea

a. Orthopnea Explanation: A client with heart failure may have fluid in their lungs, making it difficult to breathe when lying flat (orthopnea). An increased respiratory rate is tachypnea. Sleep apnea is a condition where the client has periods of not breathing while sleeping. Pneumonia does not present as described in the question. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

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? a.Palpable b.Soft, rapid, undulating quality c.Pulsation eliminated by light pressure on the vessel d.Level of pulsation changes with changes in position

a. Palpable Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 447. Chapter 21: Assessing Heart and Neck Vessels - Page 447

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition? a.Place the bell of the stethoscope over the apex with client on left side. b.Use the diaphragm of the stethoscope to listen over the right sternal border. c.With the client leaning forward, listen over the left carotid artery. d.With the client supine, place the bell of the stethoscope on the 2nd left intercostal space.

a. Place the bell of the stethoscope over the apex with client on left side. Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 452. Chapter 21: Assessing Heart and Neck Vessels - Page 452

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? a.Shortness of breath b.Painful breathing c.Rapid breathing d.Inability to breathe

a. Shortness of breath Explanation: Clients with heart failure may be short of breath from fluid accumulation in the pulmonary bed. Onset may be sudden with acute or chronic pulmonary edema. It is important to assess how much activity brings on dyspnea, such as rest, walking on a flat surface, or climbing. The other options listed are distracters to the question. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding? a.Sinus arrhythmia b.Sinus bradycardia c.Premature atrial contractions d.Premature ventricular contractions

a. Sinus arrhythmia Explanation: In sinus arrhythmia, the heart rate speeds up and slows down in a cycle, usually becoming faster with inhalation and slower with expiration. Sinus bradycardia is a regular heart rhythm that is a rate less than 60 beats per minute. In premature atrial and ventricular contractions, a beat occurs earlier than the next expected beat and is followed by a pause. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 457. Chapter 21: Assessing Heart and Neck Vessels - Page 457

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? a.Smoking increases the heart's workload and contributes to atherosclerosis. b.Smoking decreases the contractility of the myocardium and contributes to valvular disorders. c.Smoking damages the cardiac conduction system, resulting in dysrhythmias that are entirely preventable. d.Smoking is a central component of metabolic syndrome.

a. 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 441

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as? a.Summation gallop b.Atrial kick c.Ejection clicks d.Diastolic clicks

a. Summation gallop Explanation: Presence of both S3 and S4 is referred to as a "summation gallop." Atrial kick is the additional flow of blood from the atrium to the ventricles as the atrium contract. Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the S1 sound. Diastolic clicks can be found in clients with mitral valve prolapse as the valve does not close properly. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 451. Chapter 21: Assessing Heart and Neck Vessels - Page 451

What finding upon assessment would indicate the client is experiencing shock? a.Systolic blood pressure 50 b.Heart rate 100 c.Respiratory rate 24 d.Temperature 99.5 F

a. Systolic blood pressure 50 Explanation: A systolic blood pressure of 50 would indicate the client is experiencing shock. All other vital signs, while elevated do not indicate shock Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 448

The nurse on the cardiac unit is caring for a client who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this client, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein? a.They more than double the risk of cardiac disease. b.They have no direct correlation with increased risk of cardiac disease. c.They are both sensitive and specific to heart failure. d.They are clinical proof that the client had a coronary event.

a. They more than double the risk of cardiac disease. Explanation: The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

The bicuspid, or mitral, valve is located... a.between the left atrium and the left ventricle. b.between the right atrium and the right ventricle. c.at the beginning of the ascending aorta. d.at the exit of each ventricle near the great vessels.

a. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 432. Chapter 21: Assessing Heart and Neck Vessels - Page 432

An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is... a.high serum level of low-density lipoproteins. b.low-carbohydrate diets. c.high serum level of high-density lipoproteins. d.diets that are high in antioxidant vitamins.

a. high serum level of low-density lipoproteins. Explanation: Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem? a.left-sided heart failure b.palpitations c.hypertension d.dextrocardia

a. left-sided heart failure Explanation: Left-sided heart failure can cause fluid to leak into the lungs, and as a result fine crackles can be heard from the movement of fluid in the lungs on air exchange. Auscultation of fine crackles is not a typical finding associated with clients experiencing palpitations or hypertension. Dextrocardia is a condition in which the heart is situated on the right side. Fine crackles are not a characteristic feature of dextrocardia. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

The nurse assesses a client who has ventricular enlargement. The nurse palpates the left parasternal area but cannot feel the ventricle. Which underlying condition does this client likely have? a.obstructive pulmonary disease b.ischemic heart disease c.arrhythmia d.peripheral vascular disease

a. obstructive pulmonary disease Explanation: With obstructive pulmonary disease, a hyperinflated lung may prevent palpation of an enlarged right ventricle in the left parasternal area. The nurse can more easily feel this high in the epigastric region. Although the client may have an arrhythmia, an abnormal heartbeat, this would not prevent the nurse from being able to palpate the ventricle. Ischemic heart disease is a condition in which there is reduced blood flow to the heart. This would not prevent the nurse from being able to palpate the ventricle. Peripheral vascular disease results in a circulatory problem that causes reduced blood flow to the limbs. There would be no reason for the nurse not to be able to palpate the ventricle with this condition alone. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 446. Chapter 21: Assessing Heart and Neck Vessels - Page 446

A client has engorged jugular veins. What should this finding suggest to the nurse? a.right atrial pressure b.integrity of the aorta c.patency of carotid arteries d.closure of the tricuspid valves

a. right atrial pressure Explanation: Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 439

When evaluating the jugular venous pressure in a client with known coronary artery disease, the nurse explains to the client that the JVP measures the pressure in the... a.right atrium b.left atrium c.right ventricle d.left ventricle

a. right atrium Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 446. Chapter 21: Assessing Heart and Neck Vessels - Page 446

The client is noted to have a pathologic change in ventricular compliance. What information from the cardiac assessment would indicate this? a.A split S2 b.An S3 gallop c.A delayed S3 d.A weak S4

b. An S3 gallop Explanation: In older adults, an S3, sometimes termed "an S3 gallop," usually indicates a pathologic change in ventricular compliance. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 436

The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? a.Hypothyroidism b.Aortic stenosis, with pressure overload of the left ventricle c.Mitral stenosis, with volume overload of the left atrium d.Cardiomyopathy

b. Aortic stenosis, with pressure overload of the left ventricle Explanation: Pressure overload of the left ventricle, as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 448. Chapter 21: Assessing Heart and Neck Vessels - Page 448

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client? a.High-protein, low-fat meals b.Low-fat, low-cholesterol meals c.High-protein, low-carbohydrate meals d.Low-cholesterol, low-carbohydrate meals

b. Low-fat, low-cholesterol meals Explanation: This client should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the client to eat high-protein or low-carbohydrate meals since they are not the focus of the management of elevated cholesterol levels. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 443. Chapter 21: Assessing Heart and Neck Vessels - Page 443

While auscultating heart sounds, asking the client to turn onto a left lying position would help the nurse assess the presence of which of the following? a.Aortic murmurs b.Mitral stenosis c.The first heart sound d.Atrial repolarization

b. Mitral stenosis Explanation: The left lateral position brings the left ventricle closer to the chest wall and accentuates a left-sided S3 or S4 associated with mitral stenosis. A seated position accentuates an aortic murmur. The left lateral position does not accentuate the first heart sound or atrial repolarization. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 452. Chapter 21: Assessing Heart and Neck Vessels - Page 452

A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? a.Apical heart rate 70 beats per minute b.No current medications or treatments c.No edema of extremities noted d.Apical impulse palpated at 5 intercostal space on left

b. No current medications or treatments Explanation: Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client. Apical heart rate 70 beats per minute, no edema of extremities noted, and apical impulse palpated at 5 intercostal space on left are examples of objective data collected by the nurse upon physical examination. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 439-441

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? a.S1 b.S2 c.Preload d.Afterload

b. S2 Explanation: Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 451. Chapter 21: Assessing Heart and Neck Vessels - Page 451

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? a.Chest pain b.Shortness of breath c.Palpitations d.Edema

b. 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? a.The spread of depolarization in the atria b.The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle c.The spread of depolarization and sodium release in the ventricles to cause ventricular contraction d.Relaxation of the ventricles and repolarization of the cells

b. The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle Explanation: PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 434. Chapter 21: Assessing Heart and Neck Vessels - Page 434

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible... a.congestive heart failure. b.angina. c.palpitations. d.acute anxiety reaction.

b. angina. Explanation: Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 440. Chapter 21: Assessing Heart and Neck Vessels - Page 440

The nurse hears a distinctive first heart sound while auscultating a client's heart rate. What does this heart sound represent? a.the ending of diastole b.the beginning of systole c.opening of the mitral valve d.closure of the aortic valve

b. the beginning of systole Explanation: Closure of the AV valves, mitral and tricuspid, produces the first heart sound, S1, which indicates the beginning of systole. The closure of the atrial valve begins a cycle of diastole. During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, shutting the mitral valve. Aortic valve closure produces the second heart sound, S2. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 435

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the... a.second intercostal space at the right sternal border. b.third to fifth intercostal space at the left sternal border. c.apex of the heart near the midclavicular line (MCL). d.fourth or fifth intercostal space at the left lower sternal border.

b. third to fifth intercostal space at the left sternal border. Explanation: Erb's point: Third to fifth intercostal space at the left sternal border. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 438

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? a."Murmur heard over right carotid artery" b."Split sound auscultated over right carotid artery" c."Right carotid bruit auscultated" d."S2 sound heard over right carotid artery."

c. "Right carotid bruit auscultated" Explanation: 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 447

The nurse assesses the client's pulses to be normal. How would the nurse document this information? a.0 b.1+ c.2+ d.4+

c. 2+ Explanation: On most scales, normal pulses are recorded as 2+. Absent pulses are 0, weak pulses are 1+, full or somewhat increased pulses are 3+, and a bounding pulse is a 4+. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 448

The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal? a.2 b.4 c.6 d.8

c. 6 Explanation: Normal cardiac out put ranges from 5-8 L/min. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 436. Chapter 21: Assessing Heart and Neck Vessels - Page 436

A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do? a.Assess for a difference between the apical and radial pulse b.Check for pulse inequality between right and left carotid arteries c.Auscultate for split S1 at the base and apex d.Observe for a decrease in jugular venous pressure

c. Auscultate for split S1 at the base and apex Explanation: A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction); thus, the nurse should auscultate for split S1 at the base and apex to detect this condition. Pulse deficit is detected by assessing the difference in the apical and radial pulses. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels.

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? a.Cardiac circulation b.Cardiac output c.Cardiac cycle d.Cardiac workload

c. Cardiac cycle Explanation: The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 434

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? a.Depression b.Severe muscular exertion c.Decreased cardiac output d.Upper respiratory infection

c. Decreased cardiac output Explanation: 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 440

Which is true of a third heart sound (S3)? a.It marks atrial contraction. b.It reflects normal compliance of the left ventricle. c.It is caused by rapid deceleration of blood against the ventricular wall. d.It is not heard in atrial fibrillation.

c. It is caused by rapid deceleration of blood against the ventricular wall. Explanation: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 458. Chapter 21: Assessing Heart and Neck Vessels - Page 458

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique? a.Auscultating all heart sounds with the bell and diaphragm. b.Palpation of the point of maximum impulse on the chest. c.Palpating carotid pulses simultaneously. d.Inspecting bilateral jugular veins.

c. Palpating carotid pulses simultaneously. Explanation: Carotid pulse palpation should be conducted by feeling one side at a time; otherwise the client my become dizzy or lightheaded. All other assessment techniques are correct. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 448

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? a.Premature ventricular contractions b.Atrial fibrillation c.Sinus arrhythmia d.Premature atrial contractions

c. Sinus arrhythmia Explanation: A heart rate that speeds with inspiration and slows with exhalation is termed sinus arrhythmia. This is often a normal rhythm in young children and well-conditioned athletes. Premature ventricular contractions and premature atrial contractions occur earlier than expected. Atrial fibrillation causes the ventricles to beat irregularly. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 449. Chapter 21: Assessing Heart and Neck Vessels - Page 449

Which of the following assessment findings would signal a pathophysiological finding to the nurse? a.S1 is softer than S2 when the nurse listens at the base of the client's heart. b.Auscultation at the client's apex reveals that S1 is louder than S2. c.The intensity of the client's S1 varies between beats. d.S2 is split when the nurse asks the client to inhale deeply but is not split on exhalation.

c. The intensity of the client's S1 varies between beats. Explanation: S1 is usually louder than S2 at the apex, while the opposite can be true when listening at the base of the heart. Normal physiological splitting of S2 is accentuated on inspiration and disappears on exhalation. Varying intensity of S1 is associated with a heart block or arrhythmia. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 457

The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client's heart sounds? a.Arrhythmia b.An opening snap c.Wide splitting d.S3 sound

c. Wide splitting Explanation: Wide splitting occurs when a bundle branch block delays activation of the right ventricle. It also can happen when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle. The nurse would not expect to auscultate an arrhythmia since it is a reflection of heart rate. An opening snap indicates that the mitral valve is mobile and "snaps" during early diastole from high atrial pressure, such as with mitral stenosis. Blood rushes into ventricles abnormally resistant to filling, distending the ventricular walls and causing vibration that results in a S3 sound. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 437. Chapter 21: Assessing Heart and Neck Vessels - Page 437

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's... a.base of the heart. b.pulmonic valve area. c.apex of the heart. d.second left interspace.

c. apex of the heart. Explanation: S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 435. Chapter 21: Assessing Heart and Neck Vessels - Page 435

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? a.Temperature b.Respiratory rate c.Heart rate d.Blood pressure

d. Blood pressure Explanation: With decreased cardiac output, the heart pumps inadequate blood to meet the body's metabolic demands. The blood pressure is most important to assess frequently. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels, p. 448. Chapter 21: Assessing Heart and Neck Vessels - Page 448

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following? a.Hypertension in his grandparents b.Weight patterns within his family c.Diabetes mellitus in his extended family d.Heart attacks in his father and siblings

d. Heart attacks in his father and siblings Explanation: Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 443

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? a.Impaired Breathing Pattern b.Activity Intolerance c.Ineffective Health Maintenance d.Ineffective Tissue Perfusion

d. 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Assessing Heart and Neck Vessels.

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? a.Assess for a difference between the apical and radial pulse b.Check for pulse inequality between right and left carotid arteries c.Auscultate for split S1 at the base and apex d.Observe for a decrease in jugular venous pressure

d. Observe for a decrease in jugular venous pressure Explanation: Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume, so the nurse should observe for a decrease in jugular venous pressure. Assessing the difference in the apical and radial pulses would help the nurse assess for pulse deficit. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

The sinoatrial node of the heart is located on the... a.anterior wall of the left atrium. b.anterior wall of the right atrium. c.upper intraventricular system. d.posterior wall of the right atrium.

d. posterior wall of the right atrium. Explanation: 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. Reference: Chapter 21: Assessing Heart and Neck Vessels - Page 433