Chapter 17 Prepu

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? 4th left intercostal space 3rd intercostal space left sternal border 2nd intercostal space left sternal border 5th left intercostal space midclavicular line

2nd intercostal space left sternal border

What term is used to describe the degree of vascular resistance to ventricular contraction? Contractile overload Volume overload Preload Afterload

Afterload

When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following? Crescendo Decrescendo Crescendo-decrescendo Plateau

Crescendo-decrescendo

To function adequately, the nurse knows that the heart valves need to open simultaneously. True False

False

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment? Carotid artery pulse Jugular venous pulse Apical impulse Heart sounds

Jugular venous pulse

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

Summation gallop

The nurse is preparing to conduct a physical examination of a client's cardiovascular system. Which of the following instructions should the nurse provide the client in preparation for this examination? (Select all that apply.) "Wear the gown with the opening in the front." "You will be laying on your left side for part of the examination." "You will stand for the examination" "You will be sitting and leaning forward for part of the examination." "I will be conducting the examination from your left side."

"Wear the gown with the opening in the front." "You will be laying on your left side for part of the examination." "You will be sitting and leaning forward for part of the examination."

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? "If you can eliminate red meat from your diet, your risk of heart disease will drop significantly." "Try to ensure that you're screened for heart disease at least once every six months." "Anything that you can do to reduce stress in your life will benefit your heart health." "Your risk for heart disease will drop greatly if you're able to stop smoking."

"Your risk for heart disease will drop greatly if you're able to stop smoking."

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record? 1+ 2+ 3+ 4+

4+ (based off PrepU scale, not sure if it is the same as the one they gave us)

By what percent can clients reduce their risk of cardiac events the first year after quitting smoking? 30% 40% 50% 60%

50%

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

6

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 Diminished Normal Split Wide Split

Accentuated

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? Aortic and pulmonic Tricuspid and mitral Pulmonic and tricuspid Mitral and aortic

Aortic and pulmonic

A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse? Try using one finger of the dominant hand to locate the pulse Ask the client to assume the left lateral position Instruct the client to cough and attempt again Use the stethoscope to auscultate

Ask the client to assume the left lateral position

Which of the following interventions can the nurse use to help a client modify risk factors associated with with hypertension? (Select all that apply). Ask the client to keep a "typical day" record of daily food intake Ask the client to keep an activity log Encourage the client to quit alcohol consumption Encourage the client to limit consumption of potassium rich foods Provide information about aids to promote smoking cessation

Ask the client to keep a "typical day" record of daily food intake Ask the client to keep an activity log Provide information about aids to promote smoking cessation

How should a nurse assess a client for pulse rate deficit? Assess for a difference between the apical and radial pulse Check for pulse inequality between right and left carotid arteries Auscultate for split S1 at the base and apex Observe for a decrease in jugular venous pressure

Assess for a difference between the apical and radial pulse

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

Atrial depolarization

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next? Inspect for a lift. Palpate for a thrill. Auscultate for pulse rate deficit. Listen for a ventricular gallop.

Auscultate for pulse rate deficit.

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

Bruits

A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source? Cardiac Gastrointestinal Musculoskeletal Pulmonary

Cardiac

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 circulation Cardiac output Cardiac cycle Cardiac workload

Cardiac cycle

What do the oscillations in the internal jugular veins reflect? Changing pressures within the right atrium Changing pressures within the left atrium Changing pressures within the right ventricle Changing pressures within the left ventricle

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? Assess for a difference between the apical and radial pulses Check for pulse inequality between right and left carotid arteries Auscultate for split S1 at the base and apex Observe for a decrease in jugular venous pressure

Check for pulse inequality between right and left carotid arteries

Which symptoms would indicate to the nurse the client may be experiencing a cardiac event? Select all that apply. Chest pain Diaphoresis Dyspnea Fatigue Hypotension

Chest pain Diaphoresis Dyspnea Fatigue

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? Isometric contraction Closure of the semilunar valves Beginning of diastole Closure of the atrioventricular valves

Closure of the atrioventricular valves

A nurse is evaluating a client's jugular venous pressure. Which of the following findings would tend to indicate obstructive pulmonary disease? Distention of the jugular vein when the head of the bed is elevated to 60 degrees Jugular vein visible when the client is supine Elevated venous pressure only during expiration Elevated venous pressure only during inspiration

Elevated venous pressure only during expiration

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

Erb point

After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel? Aorta Pulmonary vein Femoral artery Inferior vena cava

Femoral artery

A nurse assesses a client's jugular venous pulse to gather information about which of the following? Left arterial pressure. Left ventricular diastolic filling. Right ventricular pressure. Hemodynamics of the right side of the heart.

Hemodynamics of the right side of the heart.

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? Caucasians usually possess greater lifestyle risks for CAD than African Americans. Hypertension is more prevalent in African Americans than among Caucasians. Hypertension is seen more in white women than in African-American women. Hispanic Americans have a higher rate of CAD than white Americans.

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? Assess the client's heart sounds while preventing shortness of breath. Identify heart sounds that may be inaudible in other positions. Assess the impact of the client's heart disease on his mobility. Differentiate heart sounds from breath sounds.

Identify heart sounds that may be inaudible in other positions.

The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. Increased cardiac output Decreased cardiac output Increased blood pressure Decreased blood pressure Increased heart rate

Increased cardiac output Increased blood pressure Increased heart rate

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? Increased pressure within the ventricle Inability of the atria to contract Inflammation of the pericardial sac Incompetent mitral valve

Inflammation of the pericardial sac

The nurse is assessing a client's heart and neck vessels. Which technique would be mostappropriate to use when examining the client's jugular venous pulse? Perform the exam with the client in a supine position. Have the client look straight ahead with chin slightly lifted. Have the client sit up at a 90-degree angle. Inspect the suprasternal notch or around the clavicles.

Inspect the suprasternal notch or around the clavicles.

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 Tricuspid Aortic Pulmonic

Mitral

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? Aortic Pulmonic Mitral Tricuspid

Mitral

A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following? Hypothyroidism Fever Mitral stenosis Heart murmur

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? S1 Ventricular gallop Murmur S2

Murmur

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? Orthopnea Tachypnea Pneumonia Sleep apnea

Orthopnea (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.)

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

Palpable

The nurse is preparing to assess a client's carotid arteries. Which nursing action would be mostappropriate? Palpate each artery individually to compare. Palpate the arteries before auscultating them. Use the diaphragm of the stethoscope. Ask the client to breathe in and out deeply.

Palpate each artery individually to compare.

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

Palpating carotid pulses simultaneously.

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 Make the client sit upright Avoid frequent repositioning Perform only auscultation

Perform palpation lightly

What is the most important physical sign of acute pericarditis? Pericardial friction rub Intense pain Elevated white cell count Murmur heard over the left sternal border

Pericardial friction rub

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following? Pericardial friction rub Midsystolic click Summation gallop Aortic ejection click

Pericardial friction rub

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. Use the diaphragm of the stethoscope to listen over the right sternal border. With the client leaning forward, listen over the left carotid artery. With the client supine, place the bell of the stethoscope on the 2nd left instercostal space.

Place the bell of the stethoscope over the apex with client on left side.

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 Diminished heart sounds Changes on expiration Split S2 on inspiration

Presence of an S3

What is the most important lifestyle changes a client can make to improve cardiovascular health? Quitting smoking Eating a diet high in fat Living a more sedentary lifestyle Getting less exercise and more rest

Quitting smoking

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? Chest pain Shortness of breath Palpitations Edema

Shortness of breath

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? Premature ventricular contractions Atrial fibrillation Sinus arrhythmia Premature atrial contractions

Sinus arrhythmia

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

The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions? The apical impulse will be irregular due to normal, age-related physiological changes. The apical impulse may be more difficult to palpate than in a younger client. The apical impulse will be found in a more medial location than in a younger client. The apical impulse will be easier to palpate if the client is in a standing position.

The apical impulse may be more difficult to palpate than in a younger client.

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 have developed a cardiac conduction problem. The client may be experiencing symptoms of heart failure. The client's cardiac problem is being adequately compensated for. The client may be at increased risk for myocardial infarction.

The client may be experiencing symptoms of heart failure.

The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding? The client's ventricles are not contracting simultaneously. The client's aortic valve is incompetent. The client has left ventricular hypertrophy. The client's atria are not synchronized with the ventricles.

The client's ventricles are not contracting simultaneously.

A client complains of palpitations and a feeling of anxiety. Which of the following would be most appropriate for the nurse to keep in mind? This is a normal response by the heart's conduction system. This is the body's response to an increase in cardiac output. The heart is attempting to increase cardiac output. The heart is responding to increased renal perfusion.

The heart is attempting to increase cardiac output.

Where are the heart and great vessels located in the human body? The mediastinum, between the lungs above the diaphragm The mediastinum, between the lungs below the diaphragm The peritoneum, above the diaphragm The peritoneum, below the diaphragm

The mediastinum, between the lungs above the diaphragm

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 spread of depolarization in the atria The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle The spread of depolarization and sodium release in the ventricles to cause ventricular contraction Relaxation of the ventricles and repolarization of the cells

The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle

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 False

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. Consume two to three glasses of red wine daily.

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes.

A client complains of chest pain. The nurse understands that chest pain can have causes other than cardiac pain, thus follows up with the client regarding the timing and quality of this pain. Which of the following would indicate cardiac pain as opposed to other types? Select all that apply. Tends to occur after meals Worsens with activity Is relieved with antacids May occur at any time Radiates to left shoulder and down the left arm Has a squeezing sensation around the heart

Worsens with activity May occur at any time Radiates to left shoulder and down the left arm Has a squeezing sensation around the heart

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 congestive heart failure. angina. palpitations. acute anxiety reaction.

angina

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

apex of the heart.

The semilunar valves are located between the left atrium and the left ventricle. between the right atrium and the right ventricle. at the exit of each ventricle at the beginning of the great vessels. at the beginning of the ascending aorta.

at the exit of each ventricle at the beginning of the great vessels.

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

between the left atrium and the left ventricle.

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 high serum level of low-density lipoproteins. low-carbohydrate diets. high serum level of high-density lipoproteins. diets that are high in antioxidant vitamins.

high serum level of low-density lipoproteins.

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 pulmonary emphysema. diastolic murmurs. patent ductus arteriosus. increased central venous pressure.

increased central venous pressure.

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? left-sided heart failure palpitations hypertension dextrocardia

left-sided heart failure

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? 1+ 2+ 3+ 4+

2+

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? Second intercostal space, left sternal border Third intercostal space, left axillary line Fourth intercostal space, left sternal border Fifth intercostal space, left midclavicular line

Fifth intercostal space, left midclavicular line

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

Flat neck veins

A nurse auscultates a murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur? Grade I/VI Grade VI/VI Grade II/VI Grade V/VI

Grade V/VI

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 Turn the client on the right side; if the rub persists, it is pericardial Auscultate the base of the heart; if a rub is present, it is pericardial Auscultate the upper back; if a rub is present, it is pleural

Have the client hold his or her breath; if the rub persists, it is pericardial

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? Hypertension in his grandparents Weight patterns within his family Diabetes mellitus in his extended family Heart attacks in his father and siblings

Heart attacks in his father and siblings