Chapter 14
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following? Right ventricular failure or a narrowed vessel
A narrowed vessel A swishing sound on auscultation is a bruit which is caused by turbulent blood flow through a narrowed vessel. A bruit does not indicate decreased cardiac output. Increased central venous pressure or right heart failure would be indicated by jugular venous distention.
The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?
Diminished A client with mitral insufficiency would most likely exhibit a diminished S1 sound. A split S1 sound would be heard with conduction delays and ventricular ectopy. An accentuated S1 sound would be heard in hyperkinetic states and mitral stenosis. Varying S1 sound would be heard with atrial fibrillation.
A 68-year-old mechanic presents to the emergency room for shortness of breath. The examiner is concerned about a cardiac cause and measures the client's jugular venous pressure (JVP). It is elevated. Which of the following conditions is a potential cause of elevated JVP? Constrictive pericarditis or left-sided heart failure
constrictive pericarditis One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis and superior vena cava syndrome. The other noted pathologies are less likely to result in elevated JVP.
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 very loud murmur that can be heard with the stethoscope partly off the chest is graded as Grade 5. A Grade 1 is very faint and a Grade 6 can be heard with the stethoscope entirely off the chest. A Grade 2 is quiet but heard immediately on placing the stethoscope on the chest.
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
Observe for a decrease in jugular venous pressure 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).
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?
SA NODA- pacemaker of heart
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?
The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle
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?
Sinus arrhythmia 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.
When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?
Summation gallop 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.
A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?
4+ The strength of the pulse is evaluated on a scale from 0 to 4 as follows: 0 = Absent; 1+ = Weak; 2+ = Normal; 3+ = Increased; 4+ = Bounding.
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 angina or congestive heart failure
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.
During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's Apex of heart or second left interspace.
Apex of heart S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).
A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?
Ask the client to assume the left lateral position If unable to locate the apical impulse, ask the client to turn to the left lateral position. This displaces the heart towards the left chest wall and relocates the apical impulse farther to the left. Using one finger is appropriate after locating the pulse for a more accurate palpation. Coughing will not assist in location of the apical impulse. The nurse should locate the apical impulse by palpation before auscultating heart sounds.
An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist? Congenital stenotic carotid arteries Atherosclerotic pulmonic valve Stenotic aortic valve Atherosclerotic stenotic carotid arteries
Atherosclerotic stenotic carotid arteries If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the client's age would negate the likely existence of a congenital problem.
The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer?
Atrial depolarization The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec).
As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?
Atrioventricular (AV) node Explanation: The SA node, with inherent rhythmicity, generates impulses (at a rate of 60-100 per minute) that are conducted over both atria, causing them to contract simultaneously and send blood into the ventricles. The AV node slightly delays incoming electrical impulses from the atria, then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum. The electrical impulse then travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles, causing them to contract almost simultaneously.
A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next?
Auscultate for pulse rate deficit. Explanation: If the nurse detects an irregular rhythm, the nurse needs to auscultate for a pulse rate deficit, which may provide further evidence of atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. The client also should be referred for further evaluation because irregular rhythms may predispose the client to decreased cardiac output, heart failure, or emboli. It would not be necessary to inspect for a lift or palpate for a thrill. These would most likely have already been completed. Listening for a ventricular gallop would occur later, when the nurse is auscultating for normal and abnormal heart sounds.
Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?
Auscultate to determine the heart rate and if the rhythm is normal Explanation: The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.
A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nause and diaphoresis. The nurse should prepare for which treatment?
Balloon angioplasty-surgical widening of a blocked or narrowed blood vessel, especially a coronary artery, by means of a balloon catheter. The client's symptoms are consistent with a myocardial infarction. Treatment includes nitroglycerin, bedrest to decreased oxygen consumption, thrombolytics, or angioplasty. Open heart surgery may be indicated, depending on the results of the angioplasty. Pain medication may be prescribed along with other treatments for myocardial infarction; but morphine alone, with only observation is not likely.
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 output or Cardiac cycle
Cardiac Cycle The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.
Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle?
Carotid artery The carotid arteries are located in the depression between the trachea and the sternomastoid muscle in the anterior neck. They follow bilaterally along the trachea from clavicle to jaw. The internal jugular vein is found in the sternal notch. The more superficial external jugular vein is visible in the depression above the middle of the clavicle.
What do the oscillations in the internal jugular veins reflect?
Changing pressures within the right atrium The oscillations that you see in the internal jugular veins, and often in the externals, reflect changing pressures within the right atrium.
A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?
Check for pulse inequality between right and left carotid arteries Explanation: The nurse should check for pulse inequality between the right and left carotid arteries, because differences in the amplitude or rate of the carotid pulse may indicate stenosis. Pulse deficit is detected by assessing the difference in the apical and radial pulses. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume.
What is responsible for the inspiratory splitting of S2?
Closure of aortic then pulmonic valves During inspiration, the closures of the aortic valve and pulmonic valves separate slightly, and this may be heard as two audible components instead of as a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, the examiner may not hear it away from the left second intercostal space. Because it is a low-pitched sound, the examiner may not hear it without use of the bell of the stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency?
Diminished A client with mitral insufficiency would most likely exhibit a diminished S1 sound. A split S1 sound would be heard with conduction delays and ventricular ectopy. An accentuated S1 sound would be heard in hyperkinetic states and mitral stenosis. Varying S1 sound would be heard with atrial fibrillation.
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. Explanation: To auscultate, position yourself on the client's right side. The client should be supine with the upper trunk elevated 30 degrees. Use the diaphragm of the stethoscope to auscultate all areas of the precordium for high-pitched sounds. Use the bell of the stethoscope to detect (differentiate) low-pitched sounds or gallops.
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?
Fifth intercostal space, left midclavicular line 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 breath, if the rub persist it is pericardial Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.
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 Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis. Edema happens when your small blood vessels leak fluid into nearby tissues.
Which is true of a third heart sound (S3)?
It is caused by rapid deceleration of blood against the ventricular wall. 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.
Where would the nurse expect to find the point of maximum impulse (PMI) when assessing an older client with a history of cardiomegaly with a hypertrophied left ventricle?
Lateral and inferior to the 4th and 5th intercostal space (ICS) and the midclavicular line (MCL) The enlarged heart of cardiomegaly displaces the point of maximum impulse (PMI) laterally and inferiorly. The nurse would observe for a heave or lift, which appears as a forceful thrusting on the chest and results from an enlarged left ventricle. A right ventricular heave is observed at the lower left sternal border. The remaining options would not be appropriate assessment points when considering the client's history.
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?
Low-fat, low-cholesterol meals This client should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the patient to eat high-protein or low-carbohydrate meals since they are not the focus of the management of elevated cholesterol levels.
A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur?
Mitral Mitral valve sounds are usually heard best at and around the cardiac apex.
Variations in the presentation of S1 are due to alterations in which heart valve?
Mitral The sound of S1 is produced at the onset of systole, which is the closure of the mitral and tricuspid valves. The variations in the intensity of S1 are due to the position of the mitral valve at the start of systole and can cause the sound to be accentuated, diminished, or variable. The tricuspid valve is involved when there is a split S1, which causes the ventricles to contract at different times. The aortic and pulmonic valve closures produce the sound of S2.
When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest?
Right sternal border, 2nd ICS Aortic Stenosis is a midsystolic ejection murmur begins after S1, crescendos, and then decrescendos before S2. It radiates upward to the right second ICS and into the neck. It is soft to loud, with a medium pitch and harsh quality. It is associated with ejection click, split S2. It's best heard over the 2nd or 3rd right intercostal space.
The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?
Place the bell of the stethoscope over the apex with client on left side. 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 patient 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.
17s Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client?
Presence of an S3 Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S3 and an S4, which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse and seen in cardiac tamponade or obstructive lung disease. A split S2 does not change the amplitude of a client's pulse.
A client has engorged jugular veins. What should this finding suggest to the nurse?
Right atrial pressure 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.
The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding? Premature ventricular contractions or sinus arrhythmia
Sinus arrhythmia 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.
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. 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 client with heart disease is concerned about the safety of engaging in sexual intercourse with his spouse. He says that he can walk a block or two without feeling any symptoms, but cannot handle any strenuous exercise. How should the nurse respond?
Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart. Taking his blood pressure immediately before sex is not necessary.
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.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization?
T wave The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization?
T wave The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
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. Explanation: The jugular venous pulse is not normally visible with the client sitting upright. Jugular venous distention and a visible jugular venous pulse in a supine position are pathologic findings.
A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur?
Upright, leaning forward Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). The examiner can further hear this soft murmur by having the client hold his or her breath in exhalation.
During auscultation of the heart, a nurse hears an extra heart sound immediately after S2 at the second left intercostal space. What should the nurse do to further assess this finding? Ask the client to lean forward to bring the left ventricle closer to the chest wall or Watch the client's respirations while listening for effect on the heart sound
Watch the client's respirations while listening for effect on the heart sound The nurse must differentiate whether this heart sound is normal or abnormal. A normal spilt S2 is heard best during inspiration ad disappears during expiration. If splitting does not disappear on expiration, this may be suggestive of heart disease. Jugular vein distention occurs with right-sided heart failure or an increase in venous return to the right side of the heart. Having the client lean forward helps to assess the left ventricle and listen for diastolic murmurs. If the split does not disappear during expiration the nurse should ask the client about the previous history of cardiac problems such as heart failure.
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following?
mitral stenosis An accentuated S1 sound is louder than an S2 sound. This occurs when the mitral valve is wide open and closes quickly such as in hyperkinetic states (e.g., fever, anemia, hyperthyroidism) or mitral stenosis. A heart mur
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for cardiac murmur or left-sided heart failure
cardiac murmur A thrill or a pulsation is usually associated with a grade IV or higher murmur.
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 (Mitral and Tricuspid) The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.
A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply. limit dark chocolate intake Walk for at least 30 minutes/day. Limit alcohol intake to 3 drinks per day. Use relaxation techniques to manage stress. Eat foods low in sodium.
eat foods low in sodium walk for at least 30 min a day use relaxation techniques to manage stress Measures to reduce the risk of CHD include eating 3½ ounces equivalent of cocoa such as dark chocolate each day to help lower blood pressure; eating foods low in saturated fats, trans fatty acids, cholesterol, and sodium; participating in an active exercise program such as walking at least 30 minutes per day; limiting alcohol intake to 2 drinks per day for men and 1 drink per day for women; managing stress by reducing personal stress as much as possible, trying muscle relaxation and deep breathing.
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? impaired breathing pattern or Ineffective Tissue Perfusion
ineffective tissue perfusion 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.
