HA - Unit 2 - Chapter 21: Assessing Heart and Neck Vessels

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of obstructive lung disease. left-sided heart failure. premature ventricular contractions. aortic stenosis.

obstructive lung disease. Paradoxical pulse is a palpable decrease in pulse amplitude on quiet inspiration. The pulse becomes stronger with expiration. Causes include obstructive lung disease.

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? Abdominal pain Orthopnea Hematochezia Tenesmus

Orthopnea Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

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

Hypovolemia 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.

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

2+ 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+.

Where is Erb's point located? 4th left rib space 3rd right rib space 4th right rib space 3rd left rib space

3rd left rib space Erb's point is located on the left side of the chest. Walk the fingers one rib space at the left sternal border (approximately 1 inch apart) to locate the 3rd intercostal space (ICS) on the left; this is the third site for auscultation, Erb's point. Walk the fingers to the 4th or 5th ICS for the fourth site, called the tricuspid area. Move the fingers along the 5th ICS to the midclavicular line for the 5th location, the mitral area.

The nurse assesses a client's neck as shown. What is the nurse assessing? Carotid artery Thyroid gland Internal jugular vein External jugular vein

Carotid artery The carotid arteries are located in the depression between the trachea and sternomastoid muscle in the anterior neck and run parallel to the trachea from clavicle to jaw bilaterally. The internal jugular vein is deeper and nearer the carotid artery. Because of its location, it usually is not visible; because it is a vein, it is not palpable. The external jugular vein is visible in the depression above the middle of the clavicle. It is lateral instead of anterior to the sternomastoid muscle and travels from the clavicle up to the jaw line. The thyroid gland is located anteriorly over the trachea.

Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle? Internal jugular vein External jugular vein Sternomastoid Carotid artery

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.

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A thrill A thrust A heave A normal finding

A thrill Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.

A client seeks medical attention for a new onset of palpitations. What should the nurse consider as the reason for this client's symptom? Select all that apply. Fatigue Anxiety An arrhythmia Cardiac ischemia Low cardiac output

An arrhythmia Low cardiac output Palpitations may occur with an abnormality of the heart's conduction system, or an arrhythmia. It can also occur if the heart is attempting to increase cardiac output by increasing the heart rate. Chest pain and discomfort as associated with cardiac ischemia. Palpitations may cause the client to feel anxious. Fatigue is not associated with palpitation.

The nurse working in a hospital reviews the assessment notes for a 67-year-old male client's heart and neck vessels. Click to highlight the findings that indicate to the nurse that the client is experiencing heart failure. Chest is symmetric with no scars. Apex of the heart located left of the anterior axillary line . Client reports shortness of breath and jugular vein distention is observed. Ventricular gallop present . Normal S1 and S2 sounds, with regular rate and rhythm, no murmur. Client denies grating pain in the left lower lung base and chest pain radiating to the left lower jaw . Client presents with edema of the lower legs, ankles, and feet .

Apex of the heart located left of the anterior axillary line Client reports shortness of breath and jugular vein distention is observed. Ventricular gallop present . Client presents with edema of the lower legs, ankles, and feet . Specific assessment findings help to determine the disease process that is affecting the heart. Shortness of breath, jugular vein distention, and edema of the lower extremities occur in heart failure and are caused by an accumulation of excess fluid in the systemic circulation. Ventricular gallop occurs in heart failure and is caused by altered left ventricular compliance at the end of the filling phase of diastole. When a client is experiencing heart failure, the left ventricle may be displaced and located at the left anterior axillary line instead of the typical location of the left midclavicular line. Grating pain at the left lower lung base is associated with a pulmonary condition. Chest pain that radiates to the left lower jaw is associated with an acute myocardial infarction. The client denies both of these types of pain.

During assessment, the nurse notes an irregular rhythm. What should the nurse do next? Assess for a pulse deficit. Notify the physician. Reposition the client and reassess. Document finding.

Assess for a pulse deficit. If an irregular rhythm is identified, the nurse should check for a pulse deficit. The information should then be documented and the physician can be notified. There is no need to reposition the client.

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 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? Bundle of His Sinoatrial (SA) node Purkinje fibers Atrioventricular (AV) node

Atrioventricular (AV) node 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 is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do? 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

Auscultate for split S1 at the base and apex 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.

In which order should a nurse perform the appropriate physical assessment techniques to assess the carotid artery? Inspect then auscultate Auscultate then palpate Palpate then auscultate Inspect then palpate

Auscultate then palpate Carotid arteries should always be first auscultated and then palpated because palpation may increase or slow the heart rate, therefore, changing the strength of the carotid impulse heard. The carotid artery cannot be inspected, but its pulsation can be.

The nurse is participating in a health fair and performing cholesterol screens. One person has hypercholesterolemia. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? Ethnicity Alcohol intake Gender Asthma

Gender Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women. The other factors are less significant.

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? Inspect for dependent edema. Ensure that the client lies flat for the examination. Palpate the carotid pulse. Assess for thrills.

Inspect for dependent edema. 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.

A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse? Ventricular gallop Venous hum Midsystolic click Opening snap

Midsystolic click The nurse would expect to find a midsystolic click on auscultation in the client diagnosed with mitral valve prolapse. A ventricular gallop is the third heart sound and is associated with decreased myocardial contractility, myocardial failure, congestive heart failure, and volume overload of the ventricle. A venous hum is a benign sound caused by turbulence of blood in the jugular veins. An opening snap is heard with the opening of a stenotic or stiff mitral valve.

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 Mitral valve sounds are usually heard best at and around the cardiac apex.

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? Aortic murmurs Mitral stenosis The first heart sound Atrial repolarization

Mitral stenosis 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.

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 Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? 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

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 nursing instructor is teaching nursing students proper techniques of assessment of the heart and neck vessels. The nursing instructor determines understanding when the students state which of the following? Select all that apply. Palpate the carotid arteries one at a time. Palpate the carotid arteries before auscultating them. Auscultate for a pulse rate deficit if the heart rhythm is irregular. Place the client in a left lateral position when palpating apical pulsation. Palpate the carotid pulse when auscultating the heart for abnormal heart sounds.

Palpate the carotid arteries one at a time. Auscultate for a pulse rate deficit if the heart rhythm is irregular. Place the client in a left lateral position when palpating apical pulsation. Palpate the carotid pulse when auscultating the heart for abnormal heart sounds. Carotid arteries should be palpated one at a time; bilateral palpation may decrease cerebral blood flow. The nurse should auscultate the carotid arteries before palpating them. Palpation may increase or decrease the heart rate, changing the sound of the carotid impulse. If an irregular rhythm is detected, the nurse should auscultate for a pulse deficit. Placing the client in a left lateral position brings the heart closer to the chest wall making it easier to assess apical pulsation. Palpating the carotid pulse while listening to the heart for S1 and S2 will help differentiate between the two; a harsh sound heard from the carotid pulse is S1.

A nurse experiences difficulty differentiating S1 from S2 when auscultating a client's heart sounds. What is an appropriate action by the nurse? Turn the client to the left side Listen with the bell of the stethoscope Palpate the carotid pulse while auscultating Ask the client to hold the breath

Palpate the carotid pulse while auscultating If a nurse experiences difficulty differentiating S1 from S2, the nurse should palpate the carotid pulse while listening to the heart. The harsh sound that occurs with the carotid pulse is S1. Turning the client to the left side helps to displace the heart towards the chest wall and is helpful when it is difficult to locate the apical pulse. Listening with the bell of the stethoscope is for auscultation of abnormal heart sounds. It is not appropriate to ask the client to hold the breath to assess heart sounds.

A client has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this client. On what would the nurse base interventions? Patterns of subjective and objective data Patterns of test results Areas for care planning Areas that the client requests

Patterns of subjective and objective data Cardiac testing ranges from low-risk ECG to more invasive cardiac catheterization. Laboratory and diagnostic testing helps confirm and expand information obtained through subjective and objective data collection. Results from such tests help identify patterns of data that indicate areas for care planning and interventions. "Patterns of test" results is a partially correct option, but it does not recognize the subjective data gathered from the client. Care planning, like interventions, is based on both subjective and objective data clusters. If the client requests help in certain areas, that is subjective data.

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 A pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the client is upright and leaning forward. Acute pericarditis, elevated white cell count, and a murmur heard over the left sternal border would not be the primary physical sign of the condition.

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 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.

The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound? Pulmonic Aortic Left ventricular Right ventricular

Pulmonic The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum.

Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client admitted with left ventricular failure? Paradoxical pulse Bigeminal pulse Bisferiens pulse Pulsus alternans

Pulsus alternans The nurse would find pulsus alternans in the client with left ventricular failure. Pulsus alternans is characterized by changes in amplitude from beat to beat and is usually seen in left ventricular failure. Paradoxical pulse is a decrease in pulse amplitude on quiet inspiration and is seen in pericardial tamponade, constrictive pericarditis and obstructive lung disease. Bigeminal pulse has one normal beat followed by a premature contraction and is seen in premature ventricular contractions. Bisferiens pulse has a double systolic peak and is seen in aortic regurgitation, combined aortic stenosis and regurgitation.

The term "base of the heart" refers to which of the following areas of the heart? 5th left intercostal space, midclavicular line 4th left intercostal space, high in the epigastrium 1st and 2ndintercostal space, close to the sternum Right and left 2nd intercostal spaces, close to the sternum

Right and left 2nd intercostal spaces, close to the sternum The site at which the right ventricle narrows as it rises to meet the pulmonary artery at the level of the sternum is called the "base of the heart." It is located at the right and left 2nd intercostal spaces close to the sternum.

The nurse is auscultating heart tones. To auscultate the aortic area, the nurse would place the stethoscope where? Right second intercostal space to apex of heart Second and third left intercostal spaces close to sternum Second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line Second to fifth intercostal spaces, centered over the sternum

Right second intercostal space to apex of heart The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum.

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

Shortness of breath 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.

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 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.

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

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 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? Advise him to avoid sexual intercourse Recommend that he assume the missionary position while engaging in intercourse Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Encourage him to take his blood pressure immediately before engaging in sexual intercourse

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.

The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output? Tachycardia; hypotension Tachycardia; hypertension Bradycardia; hypotension Bradycardia; hypertension

Tachycardia; hypotension A low cardiac output would be exhibited by tachycardia and hypotension.

The nurse is assessing the jugular venous pressure (JVP) of a 72-year-old client with recent complaints of fatigue, shortness of breath, and swollen ankles. What cardiac phenomena are represented by the oscillations that the nurse observes in the client's internal jugular veins? The pressures that exist within the client's right atrium The contractility of the client's cardiac muscle The function of the client's mitral and tricuspid valves The degree of preload and afterload that exist over a cardiac cycle

The pressures that exist within the client's right atrium JVP is a visible manifestation of the varying pressures in the client's right atrium. It does not directly indicate contractility, valve function, preload, or afterload.

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 Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. 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. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity. Gastrointestinal pain may occur after meals and is relieved with antacids.

The nurse is having difficulty locating a client's point of maximum impulse. What should the nurse do to facilitate this assessment? have the client lay supine assist the client to sit with the legs dangling place the client into a high-Fowler's position assist the client into a left lateral decubitus position

assist the client into a left lateral decubitus position If unable to identify the apical impulse with the client supine, assist the client to roll partly onto the left side or the left lateral decubitus position. The nurse was unable to locate the client's point of maximum impulse in the supine position. Sitting with the legs dangling and the high-Fowler's position are not positions that will help locate the point of maximum impulse.

While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is a normal sound heard in adult clients. a wheezing sound. associated with occlusive arterial disease. heard when the artery is almost totally occluded.

associated with occlusive arterial disease. A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease.

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 semilunar valves are located 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. The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.

The P-wave phase of an electrocardiogram (ECG) represents conduction of the impulse throughout the ventricles. conduction of the impulse throughout the atria. ventricular repolarization. ventricular polarization.

conduction of the impulse throughout the atria. The P wave indicates atrial depolarization; conduction of the impulse throughout the atria.

A client presents with the following signs and symptoms: a 5-lb weight gain in the past week, coughing up pink-tinged sputum, crackles in bilateral lung fields, difficulty lying flat, and reports waking up in the middle of the night extremely short of breath. Based on these findings, the nurse suspects which of the following disorders? orthopnea coronary artery disease heart failure paroxysmal nocturnal dyspnea

heart failure The client is exhibiting signs and symptoms of heart failure, which include unexpected weight gain (fluid), fluid in the lungs (backing up from the left ventricle, which is unable to pump the blood forward) causing pink-tinged sputum, orthopnea (difficulty lying flat), and paroxysmal nocturnal dyspnea or PND (waking up in the middle of the night very short of breath). Orthopnea and PND are signs and symptoms of heart failure; they are not disorders. Coronary artery disease presents with chest pain that is relieved with rest, shortness of breath with exertion, and fatigue.

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

"Do you have any pain or discomfort in your chest?" 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.

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

Afterload Afterload refers to the degree of vascular resistance to ventricular contraction.

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

An S3 gallop In older adults, an S3, sometimes termed "an S3 gallop," usually indicates a pathologic change in ventricular compliance.

The nurse is caring for a client in a medical-surgical unit and reviews the above assessment notes. Which is the priority question that the nurse should ask the client?

"How long have your feet been swollen?" When blood flow out of the heart is reduced, blood returning to the heart through the veins backs up, causing fluid to accumulate in the dependent areas of the body. Usually standing exacerbates leg edema. It is important to understand how long the client has been experiencing edema as well as the level of severity. The notes do not mention any sort of chest pain, the client is afebrile, and the client's weight change is insignificant, making these findings normal.

The nurse suspects a client's chest pain is of cardiac origin when the client states which of the following? "The pain gets better when I rest." "The pain worsens when I cough." "The pain improves if I lean forward." "It's a burning pain that goes up into my throat."

"The pain gets better when I rest." Chest pain that occurs with exertion is generally relieved by rest. This occurs because the demand for oxygen is greater than the supply, causing ischemic pain, which is relieved with rest. Pain when coughing or pain that improves by leaning forward is more common with pleuritic pain. Burning pain that goes up into the throat is associated with gastroesophageal reflux disease (GERD).

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action? Place the client in supine position. Administer prescribed diuretic. Encourage increased PO fluid intake. Increase intravenous fluid rate.

Administer prescribed diuretic. Jugular vein distention, weight gain, dyspnea, orthopnea, PND, S3 or S4, and edema indicate excess fluid volume such as occurs with heart failure. The nurse should monitor edema, intake, and output; weigh client daily; auscultate lung and heart sounds; administer diuretic with order; elevate head of bed for dyspnea.

What is responsible for the inspiratory splitting of S2? Closure of aortic then pulmonic valves Closure of mitral then tricuspid valves Closure of aortic then tricuspid valves Closure of mitral then pulmonic valves

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.

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 1 Grade 6 Grade 2 Grade 5

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 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 When a murmur can be heard with the stethoscope partly off the chest this is graded as Grade V/VI. A Grade I/VI is very faint and a Grade VI/VI can be heard with the stethoscope off the chest.

The finding of a fourth heart sound (S4) is considered benign under which of the following conditions? Healthy adolescence Healthy older adulthood Adult male with atrial fibrillation Adult female in the third trimester of pregnancy

Healthy adolescence Healthy older adults and trained athletes may exhibit a 4th heart sound that does not denote a pathological process. This would not be the case in an adolescent, a pregnant woman, or a client with a dysrhythmia.

Variations in the presentation of S1 are due to alterations in which heart valve? Aortic Pulmonic Mitral Tricuspid

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 S1are 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.

Variations in the presentation of S1 are due to alterations in which heart valve? Aortic Pulmonic Mitral Tricuspid

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.

A client is diagnosed with mitral valve stenosis. Using the diagram, where should the nurse identify this valve when teaching the client about the health problem?

The mitral valve separates the left atrium and ventricle.

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 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).

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. 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 base of the heart. pulmonic valve area. apex of the heart. second left interspace.

apex of the heart. S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).

The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's apical pulse. breath sounds. jugular veins. carotid arteries.

apical pulse. The apical impulse may be impossible to palpate in clients with pulmonary emphysema.

After conducting a physical examination of a client, the nurse suspects hypertrophy of the left ventricle. What is a characteristic of the apical impulse that is useful in confirming this suspicion? duration amplitude diameter location

duration The duration of the apical impulse can provide information about hypertrophy of the left ventricle. Amplitude of the apical impulse offers information about possible thyroid dysfunction, severe anemia, and aortic stenosis. If the client is in the left decubitus position during the physical examination, the diameter can be measured to determine if there is left ventricular enlargement. Lateral displacement of the apical impulse can provide information about possible heart failure, cardiomyopathy, and ischemic heart disease.

The nurse is caring for an older adult client. Which of the following findings would be considered normal when comparing the client's current assessment findings to those of five years ago? altered mental status elevated blood pressure decreased body mass index frequent heart palpitations

elevated blood pressure In the older adult, changes in the heart and BP are primarily due to age-related stiffening of the vasculature and decreased responsiveness to stress hormones. Blood and pulse pressures increase as a result of the stiffened blood vessels. Additionally, body mass index increases, causing the heart to work harder. Heart palpitations are not normal and could be a sign of atrial fibrillation. Altered mental status is not a normal age-related finding.

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. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.

The anterior chest area that overlies the heart and great vessels is called the endocardium. epicardium. myocardium. precordium.

precordium. The anterior chest area that overlies the heart and great vessels is called the precordium.

The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should be referred to a cardiologist for further evaluation. be examined again in 6 months. restrict exercise and strenuous activities. recognize that this finding is normal in adolescents.

recognize that this finding is normal in adolescents. A physiologic S3 heart sound is a benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults.

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 right atrium left atrium right ventricle left ventricle

right atrium

During a physical examination, a nurse notes that the client has a slow, regular pulse. On the cardiac monitor the nurse notes that the QRS complexes are regular and there are normal P waves. The ventricular rate is found to be 54 beats per minute. The nurse recognizes that this client may have an abnormality in which part of the conduction system? bundle of His Purkinje fibers sinoatrial node atrioventricular node

sinoatrial node The client may have problem with the sinoatrial node. The cardiac monitor shows a normal P wave which indicates that the impulse originated in the sinoatrial node. The QRS complex is regular showing that the atrioventricular node and the rest of the conduction system are functioning well; and the problem lies at the higher level of the conduction system. The Bundle of His, Purkinje fibers, and atrioventricular nodes are lower to the sinoatrial node and therefore have no contribution to impulse origination in this case.

The right 2nd rib space is the first location for cardiac auscultation and is also known as: Erb's point. the tricuspid area. the aortic area. the mitral area.

the aortic area. The most important landmark is the sternal angle at the right 2nd rib space. Erb's point, the aortic area, and the mitral area are located on the left side of the chest.

Which client is at greatest risk for the development of coronary heart disease? 45-year-old female with a total cholesterol level of 20 0mg/dL 65-year-old male with a 5-year history of diabetes mellitus 35-year-old male who smokes ½-pack of cigarettes daily 55-year-old female with a family history of heart attack after the age of 65 years

45-year-old female with a total cholesterol level of 20 0mg/dL The client with the greatest risk is the older male with diabetes because he has three risk factors-advancing age, male gender, and diabetes. The other clients have 1-2 risk factors present.

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 Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

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+ 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.

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 Normal cardiac out put ranges from 5-8 L/min.

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?

A small electrical impulse that fires in the sinoatrial (SA) node in the right atrium generates the normal heartbeat. The SA node functions as the "pacemaker" of the heart. Cells in the SA node possess a property that enables the cardiac cells to generate their own impulses.

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

Accentuated 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.

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 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.

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? Hypothyroidism Aortic stenosis, with pressure overload of the left ventricle Mitral stenosis, with volume overload of the left atrium Cardiomyopathy

Aortic stenosis, with pressure overload of the left ventricle 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.

The nurse is assisting a student nurse in assessing the hepatojugular reflux on a client. Which action by the student nurse would need the nurse to intervene to stop? Applies pressure for greater than 10 seconds Applies pressure over the left upper quadrant Uses the palmar side of the hand Uses a pressure of approximately 30 to 40 mm Hg

Applies pressure over the left upper quadrant The hepatojugular reflux is used to assess for multiple cardiac conditions. The nurse should press gently on the liver using the palmar side of the hand. The gentle pressure of 30 to 40 mm Hg should be applied to the right upper quadrant or the middle abdomen for at least 10 seconds but can be applied for up to one minute. A positive result is noted when the height of the neck veins increase by 3 centimeters or more. A positive result of the hepatojugular reflux test is highly sensitive and specific for right ventricular fluid overload.

A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. 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 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? Stenotic aortic valve Atherosclerotic pulmonic valve Atherosclerotic stenotic carotid arteries Congenital 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.

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Listen with the bell for the high pitched sounds of normal S1S2 Elevate the head of bed until the examiner can comfortably reach the client Auscultate to determine the heart rate and if the rhythm is normal Stand at the client's left side and perform the entire assessment from this position

Auscultate to determine the heart rate and if the rhythm is normal 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 is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? Temperature Respiratory rate Heart rate Blood pressure

Blood pressure 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.

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 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.

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 The continuous rhythmic movement of blood during contraction and relaxation of the heart is the 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 left 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? 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 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.

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? Client has an increased chest diameter Heart rate is irregular Respiratory rate is too fast Heart enlargement is present

Client has an increased chest diameter 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.

A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what? Closure of the mitral and tricuspid valves Closure of the aortic and pulmonic valves Relaxation of the ventricles Contraction of the ventricles

Closure of the mitral and tricuspid valves The beginning of systole occurs when the pressure in the ventricles exceeds the pressure in the atrium, causing the mitral and tricuspid valves to close. This closure produces the first heart sound (S1). The ventricles contract and empty of the blood volume, which causes the pressure to drop and the aortic and pulmonic valves close. This produces the second heart sound (S2). Relaxation and contraction of the ventricles do not produce heart sounds.

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? Isometric contraction Closure of the atrioventricular (AV) valves Closure of the semilunar valves Ventricular contraction

Closure of the semilunar valves Closure of the semilunar valves, which are the aortic and pulmonic valves, causes the second heart sound, S2. The closure of these valves signals the end of systole. Isometric contraction occurs when all valves are closed, which occurs just before systole, in which no sound is produced. Closure of the AV valves produces the S1 heart sound, which is the beginning of systole. Ventricular contraction is the occurrence of systole, which produces not sound but causes ejection of blood from the ventricles.

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

Dizziness Hypotension Confusion Dizziness, hypotension and confusion may put the client at risk for falls. Palpitations and diaphoresis does not increase fall risk.

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 Erb's point is auscultated at the 3rd intercostal space at the left sternal border. The aortic area is located at the second intercostal space at the right sternal border. The mitral area is located at the fifth intercostal space near the left mid-clavicular line. The pulmonic area is located at the 2nd or 3rd intercostal space at the left sternal border.

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

False

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem? Venous thromboembolism Heart failure Peripheral arterial disease (PAD) Myocardial infarction

Heart failure Jugular venous distention (JVD) is associated with heart failure, tricuspid regurgitation, and fluid volume overload. The neck veins appear full, and the level of pulsation may be have elevated jugular venous pressure greater than 3 cm (about 1 1/4 in.) above the sternal angle. About 75% of clients with elevated JVD have heart failure.

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 When the sympathetic nervous system is stimulated, epinephrine and norepinephrine are released which causes an increased heart rate and cardiac output and increase in the blood pressure.

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

Increased heart rate 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.

What nursing diagnosis would be most appropriate for a client admitted with heart failure? Ineffective tissue perfusion Acute pain Risk for denial Impaired gas exchange

Ineffective tissue perfusion Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders

Which is true of splitting of the second heart sound? It is best heard over the pulmonic area with the bell of the stethoscope. It normally increases with exhalation. It is best heard over the apex. It does not vary with respiration.

It is best heard over the pulmonic area with the bell of the stethoscope. S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low pressure system. The bell is best used because it is a low pitched sound. S2 splitting normally increases with inhalation.

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 The jugular venous pulse is important for determining the hemodynamics of the right side of the heart. The level of the jugular venous pressure reflects right atrial (central venous) pressures, and usually right ventricular diastolic filling pressure. The carotid artery pulse is a centrally located pulse on both sides of the neck that supply blood and oxygen to the neck and head. The apical pulse is located on chest in the mitral valve area and is the result of left ventricle movement during systole. Heart sounds, such as S1 and S2, are produced by the closure of the valves and are auscultated over the entire precordium.

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 The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If the examiner does not listen in a quiet room to the heart in this position with both the diaphragm and bell, it is possible to miss significant murmurs such as mitral stenosis.

A nurse cares for a client with acute pericarditis. The nurse should monitor the client for the onset of which clinical manifestation of cardiac tamponade? Third heart sound Flattened jugular veins Bounding heart sounds Paradoxical pulse

Paradoxical pulse Paradoxical pulse is characterized by a decrease in systolic pressure by more than 10mmHg during inspiration. Signs of cardiac tamponade are tachycardia, distended not flattened jugular veins, and muffled heart sounds. The third heart sound or bounding heart sound, an S3 is not normally present.

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 intercostal space.

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 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.

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 Nurses work with clients over time to modify lifestyle choices that reflect healthy behaviors. The most important are stopping smoking, reducing high blood pressure, and reducing high cholesterol.

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? Left sternal border , 3rd ICS Right sternal border, 2nd ICS Right sternal border 4th ICS Left mid-clavicular line, 5th ICS

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.

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

S2 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.

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 The heart and great vessels are located in the mediastinum between the lungs and above the diaphragm from the center to the left of the thorax. Therefore, the other options are incorrect.

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? They more than double the risk of cardiac disease. They have no direct correlation with increased risk of cardiac disease. They are both sensitive and specific to heart failure. They are clinical proof that the client had a coronary event.

They more than double the risk of cardiac disease. The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.

A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur? Upright Upright, but leaning forward Supine Left lateral decubitus

Upright, but 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.

The nurse is reviewing dietary changes for a client with hypertension in order to manage the condition. What should the nurse include in the teaching? Select all that apply. Consume 2,300 mg sodium per day. Use alcohol in moderation. Have a dietary intake of more than 3,500 mg of potassium per day. Include more fruits and vegetables in meals. Use low-fat dairy products with reduced saturated and total fat.

Use alcohol in moderation. Have a dietary intake of more than 3,500 mg of potassium per day. Include more fruits and vegetables in meals. Use low-fat dairy products with reduced saturated and total fat. The nurse should include using alcohol in moderation, having a dietary intake of more than 3,500 mg of potassium per day, including more fruits and vegetables during meals, and using low-fat dairy products with reduced saturated and total fat in the teaching. A client with hypertension should limit sodium consumption to no more than 1,500 mg of sodium per day.

The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to ask the client to hold her breath. palpate the arteries before auscultation. place the diaphragm of the stethoscope over the artery. ask the client to breathe normally.

ask the client to hold her breath. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so that breath sounds do not conceal any vascular sounds.

The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include grade 1 grade 2 grade 3 grade 4

grade 2 Grade 2 murmurs are quiet but heard immediately on placing the stethoscope on the chest.

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. Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the third intercostal space right of the midclavicular line at the third intercostal space left midclavicular line at the fifth intercostal space right of midclavicular line at the fifth intercostal space

left midclavicular line at the fifth intercostal space The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.

After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply. stress caffeine intake time of day post meal volume of water intake

stress caffeine intake time of day Stress, amount of caffeine consumed, and the time of day the blood pressure is assessed are all factors for a possible increase in the systolic blood pressure. Stress and caffeine can cause fluctuations in the blood pressure over the course of 24 hours. Blood pressure tends to be higher in the late afternoon and lower in the evenings. Blood pressure changes are not expected after consuming a meal or with an increased volume of water intake.

While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of pulmonary hypertension. aortic stenosis. mitral valve stenosis. pulmonary hypotension.

mitral valve stenosis. Opening snaps occur early in diastole and indicate mitral valve stenosis.