PrepU Chapter 17 Questions
The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal? a) 2 b) 4 c) 6 d) 8
6 Explanation: Normal cardiac out put ranges from 5-8 L/min.
The P-wave phase of an electrocardiogram (ECG) represents a) conduction of the impulse throughout the ventricles. b) ventricular polarization. c) ventricular repolarization. d) conduction of the impulse throughout the atria.
conduction of the impulse throughout the atria. Explanation: The P wave indicates atrial depolarization; conduction of the impulse throughout the atria.
When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the a) right ventricle b) left ventricle c) right atrium d) left atrium
right atrium
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? a) Beginning of diastole b) Closure of the semilunar valves c) Closure of the atrioventricular valves d) Isometric contraction
Closure of the atrioventricular valves Explanation: The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? a) Isometric contraction b) Closure of the atrioventricular valves c) Closure of the semilunar valves d) Beginning of diastole
Closure of the atrioventricular valves Explanation: The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.
A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what? a) Closure of the aortic and pulmonic valves b) Relaxation of the ventricles c) Closure of the mitral and tricuspid valves d) Contraction of the ventricles
Closure of the mitral and tricuspid valves Explanation: 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.
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? a) The degree of preload and afterload that exist over a cardiac cycle b) The pressures that exist within the client's right atrium c) The function of the client's mitral and tricuspid valves d) The contractility of the client's cardiac muscle
The pressures that exist within the client's right atrium Explanation: 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.
By what percent can clients reduce their risk of cardiac events the first year after quitting smoking? a) 30% b) 40% c) 50% d) 60%
50% Explanation: Nurses should ask clients who smoke about their willingness to quit at every visit. Clients who quit reduce their risk of cardiac events by 50% after the first year. Nurses can give clients choices about tools to help them quit, such as referrals to behavioral therapy, information about support groups, or medication.
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? a) Second intercostal space, left sternal border b) Third intercostal space, left axillary line c) Fifth intercostal space, left midclavicular line d) Fourth intercostal space, left sternal border
Fifth intercostal space, left midclavicular line Explanation: The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.
Where is the point of maximal impulse (PMI) normally located? a) In the left 5th intercostal space 7 to 9 cm lateral to the sternum b) In the left 5th intercostal space in the anterior axillary line c) In the left 5th intercostal space in the mid axillary line d) In the left 5th intercostal space 10 to 12 cm lateral to the sternum
In the left 5th intercostal space 7 to 9 cm lateral to the sternum Explanation: The PMI is usually located in the left 5th intercostal space, 7 to 9 cm lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a quarter or around 1 to 2.5 cm. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal clients.
The nursing instructor explains to a group of students that what can shorten diastole? a) Blood pressure b) Increased heart rate c) Decreased respirations d) Filling pressures
Increased heart rate Explanation: As the heart rate increases, the length of diastole is shortened. The respiratory rate, blood pressure and filling pressures do not shorten diastole.
Which is true of a third heart sound (S3)? a) It marks atrial contraction. b) It is caused by rapid deceleration of blood against the ventricular wall. c) It is not heard in atrial fibrillation. d) It reflects normal compliance of the left ventricle.
It is caused by rapid deceleration of blood against the ventricular wall. Explanation: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.
When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? a) Right sternal border, 2nd ICS b) Left sternal border , 3rd ICS c) Left mid-clavicular line, 5th ICS d) Right sternal border 4th ICS
Right sternal border, 2nd ICS Explanation: 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.
A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? a) The spread of depolarization and sodium release in the ventricles to cause ventricular contraction b) The spread of depolarization in the atria c) The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle d) 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 Explanation: PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction).
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) heard when the artery is almost totally occluded. b) associated with occlusive arterial disease. c) a normal sound heard in adult clients. d) a wheezing sound.
associated with occlusive arterial disease. Explanation: A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease.
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for a) congestive heart failure. b) left-sided heart failure. c) cardiac murmur. d) constrictive pericarditis.
cardiac murmur. Explanation: A thrill or a pulsation is usually associated with a grade IV or higher murmur.
An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is a) high serum level of high-density lipoproteins. b) high serum level of low-density lipoproteins. c) low-carbohydrate diets. d) diets that are high in antioxidant vitamins.
high serum level of low-density lipoproteins. Explanation: Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis.
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 a) mitral valve stenosis. b) pulmonary hypotension. c) aortic stenosis. d) pulmonary hypertension.
mitral valve stenosis. Explanation: Opening snaps occur early in diastole and indicate mitral valve stenosis.
To function adequately, the nurse knows that the heart valves need to open simultaneously. a) True b) False
False
A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record? a) 2+ b) 1+ c) 4+ d) 3+
4+ Explanation: 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.
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following? a) Right ventricular failure b) Increased central venous pressure c) Decreased cardiac output d) A narrowed vessel
A narrowed vessel Explanation: A swishing sound on auscultation is a bruit which is caused by turbulent blood flow through a narrowed vessel. A bruit does not indicate decreased cardiac output. Increased central venous pressure or right heart failure would be indicated by jugular venous distention
The nurse is 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? a) Administer prescribed diuretic. b) Place the client in supine position. c) Encourage increased PO fluid intake. d) Increase intravenous fluid rate.
Administer prescribed diuretic. Explanation: 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 patient daily; auscultate lung and heart sounds; administer diuretic with order; elevate head of bed for dyspnea.
The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer? a) Ventricular depolarization b) Atrial depolarization c) Ventricular repolarization d) Atrial repolarization
Atrial depolarization Explanation: The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec).
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? a) Gastrointestinal b) Angina c) Musculoskeletal d) Crushing
Angina Explanation: Angina is temporary heart pain, resolving in less than 20 minutes. It can be aggravated by physical activity and stress, or there may be no triggers (unstable angina). This type of pain is not musculoskeletal, gastrointestinal, or crushing.
When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? a) Pulmonic and tricuspid b) Aortic and pulmonic c) Mitral and aortic d) Tricuspid and mitral
Aortic and pulmonic Explanation: The closure of the aortic and pulmonic valves creates the second heart sound, which is heard louder over the 2nd intercostal space right sternal border. The closure of the tricuspid and mitral valves creates the first heart sound. The pulmonic and tricuspid valves do not close together. The mitral and aortic valves do not close together.
A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse? a) Instruct the client to cough and attempt again b) Use the stethoscope to auscultate c) Try using one finger of the dominant hand to locate the pulse d) Ask the client to assume the left lateral position
Ask the client to assume the left lateral position Explanation: 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
Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? a) Auscultate to determine the heart rate and if the rhythm is normal b) Stand at the client's left side and perform the entire assessment from this position c) Listen with the bell for the high pitched sounds of normal S1S2 d) 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 Explanation: The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? a) Temperature b) Respiratory rate c) Heart rate d) Blood pressure
Blood pressure Explanation: With decreased cardiac output, the heart pumps inadequate blood to meet the body's metabolic demands. The blood pressure is most important to assess frequently.
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? a) Closure of the semilunar valves b) Isometric contraction c) Ventricular contraction d) Closure of the atrioventricular (AV) valves
Closure of the semilunar valves Explanation: 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.
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? a) Crescendo b) Crescendo-decrescendo c) Plateau d) Decrescendo
Crescendo-decrescendo Explanation: A crescendo-descrescendo murmur is one that grows louder and then grows softer. A crescendo murmur is one that grows louder while a decrescendo murmur is one that grows softer. A plateau murmur stays the same throughout.
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following? a) Mitral stenosis b) Fever c) Heart murmur d) Hypothyroidism
Mitral stenosis Explanation: An accentuated S1 sound is louder than an S2 sound. This occurs when the mitral valve is wide open and closes quickly such as in hyperkinetic states (e.g., fever, anemia, hyperthyroidism) or mitral stenosis. A heart murmur reflects turbulent blood flow.
A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations? a) AV node b) Purkinje fibers c) Bundle of His d) Sinoatrial node
Sinoatrial node Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here, the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles.
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? a) Grade 5 b) Grade 2 c) Grade 1 d) Grade 6
Grade 5 Explanation: 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 client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessments should focus on the signs and symptoms of what health problem? a) Atherosclerosis b) Heart failure c) Myocardial infarction d) Heart block
Heart failure Explanation: Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis.
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? a) Identify heart sounds that may be inaudible in other positions. b) Assess the impact of the client's heart disease on his mobility. c) Differentiate heart sounds from breath sounds. d) Assess the client's heart sounds while preventing shortness of breath.
Identify heart sounds that may be inaudible in other positions. Explanation: Otherwise undetectable heart sounds may be revealed with alternative positioning. These positions are not adopted primarily to relieve shortness of breath or to assess mobility.
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? a) Mitral b) Pulmonic c) Aortic d) Tricuspid
Mitral Explanation: 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 suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position? a) Flat, left lateral b) Sitting upright in a straight back chair c) Supine with head of bed elevated 30 degrees d) Leaning forward while in a sitting position
Leaning forward while in a sitting position Explanation: For best results, the nurse would use the diaphragm of the stethoscope and have the client sit up, lean forward, exhale, and hold his or her breath. The left lateral position may be used to hear an S3 or S4 heart sound or a murmur of mitral stenosis that was not detected in the supine position.
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? a) Pulmonic b) Mitral c) Aortic d) Tricuspid
Mitral Explanation: Mitral valve sounds are usually heard best at and around the cardiac apex.
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? a) Observe for a decrease in jugular venous pressure b) Auscultate for split S1 at the base and apex c) Check for pulse inequality between right and left carotid arteries d) Assess for a difference between the apical and radial pulse
Observe for a decrease in jugular venous pressure Explanation: Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume, so the nurse should observe for a decrease in jugular venous pressure. Assessing the difference in the apical and radial pulses would help the nurse assess for pulse deficit. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction).
The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse? a) Pulsation eliminated by light pressure on the vessel b) Level of pulsation changes with changes in position c) Palpable d) Soft, rapid, undulating quality
Palpable Explanation: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.
The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? a) Palpate each artery individually to compare b) Ask the client to breathe in and out deeply c) Palpate the arteries before auscultating them d) Use the diaphragm of the stethoscope
Palpate each artery individually to compare Explanation: When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold his or her breath for a moment so breath sounds do not conceal any vascular sounds.
A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do? a) Palpate the carotid pulse while auscultating the heart. b) Palpate the apical impulse. c) Use the bell of the stethoscope to help distinguish the sounds. d) Determine the pulse deficit.
Palpate the carotid pulse while auscultating the heart. Explanation: If a nurse is having difficulty differentiating S1 from S2, the nurse should palpate the carotid pulse while auscultating the heart. The harsh sound that occurs with the carotid pulse is the S1 sound. The nurse should use the diaphragm of the stethoscope to auscultate S1 and S2 heart sounds. A pulse deficit is determined if the heart rhythm is found to be irregular. Palpating the apical impulse would not provide any help in differentiating S1 and S2 sounds.
The nurse is assessing the carotid arteries of a client with a history of heart disease. What action should the nurse perform during this assessment? a) Palpate the client's left and right carotid arteries simultaneously. b) Instruct the client to inhale and exhale forcefully during auscultation. c) Palpate the client's carotid arteries prior to auscultation. d) Palpate the client's carotid arteries gently if an occlusion is audible.
Palpate the client's carotid arteries gently if an occlusion is audible. Explanation: If you detect occlusion during auscultation, palpate very lightly to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or even cardiac arrest. Palpation should be performed alternately to avoid cerebral ischemia, and the client should briefly hold the breath during auscultation. Auscultation should precede palpation
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? a) ST segment b) T wave c) QRS complex d) P wave
T wave Explanation: The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization? a) QRS complex b) T wave c) P wave d) ST segment
T wave Explanation: The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur? a) Supine b) Upright, but leaning forward c) Left lateral decubitus d) Upright
Upright, but leaning forward Explanation: 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.
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: a) Accentuated b) Normal Split c) Diminished d) Wide Split
Accentuated Explanation: An accentuated S2 means that the S2 is louder than the S1. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S2 means that the S2 is softer than the S1. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal Split S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide Split S2 is an increase in the usual splitting that persists throughout the entire respiratory cycle and widens on expiration.
hich statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? a) Elevate the head of bed until the examiner can comfortably reach the client b) Listen with the bell for the high pitched sounds of normal S1S2 c) Auscultate to determine the heart rate and if the rhythm is normal d) 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 Explanation: The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.
A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nausea and diaphoresis. The nurse should prepare for which treatment? a) Open heart surgery b) Morphine and observation c) Nitroglycerin with no restrictions on activity d) Balloon angioplasty
Balloon angioplasty Explanation: The client's symptoms are consistent with a myocardial infarction. Treatment includes nitroglycerin, bedrest to decreased oxygen consumption, thrombolytics, or angioplasty. Open heart surgery may be indicated, depending on the results of the angioplasty. Pain medication may be prescribed along with other treatments for myocardial infarction; but morphine alone, with only observation is not likely.
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? a) Bradycardia b) Normal c) Tachycardia d) Decreased
Bradycardia Explanation: The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60 to 100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased, but this is not a proper documentation term.
A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do? a) Assess for a difference between the apical and radial pulses b) Observe for a decrease in jugular venous pressure c) Check for pulse inequality between right and left carotid arteries d) Auscultate for split S1 at the base and apex
Check for pulse inequality between right and left carotid arteries Explanation: The nurse should check for pulse inequality between the right and left carotid arteries, because differences in the amplitude or rate of the carotid pulse may indicate stenosis. Pulse deficit is detected by assessing the difference in the apical and radial pulses. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume.
What is responsible for the inspiratory splitting of S2? a) Closure of aortic then tricuspid valves b) Closure of mitral then tricuspid valves c) Closure of aortic then pulmonic valves d) Closure of mitral then pulmonic valves
Closure of aortic then pulmonic valves Explanation: During inspiration, the closures of the aortic valve and pulmonic valves separate slightly, and this may be heard as two audible components instead of as a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, the examiner may not hear it away from the left second intercostal space. Because it is a low-pitched sound, the examiner may not hear it without use of the bell of the stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting
Which of the following events occurs at the start of diastole? a) Closure of the tricuspid valve b) Opening of the pulmonic valve c) Closure of the aortic valve d) The first heart sound (S1) is produced
Closure of the aortic valve Explanation: At the beginning of diastole, the valves that allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).
The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear? a) Diminished b) Split c) Accentuated d) Varying
Diminished Explanation: A client with mitral insufficiency would most likely exhibit a diminished S1 sound. A split S1 sound would be heard with conduction delays and ventricular ectopy. An accentuated S1 sound would be heard in hyperkinetic states and mitral stenosis. Varying S1 sound would be heard with atrial fibrillation.
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? a) Pulmonary vein b) Femoral artery c) Aorta d) Inferior vena cava
Femoral artery Explanation: The large veins and arteries leading directly to and away from the heart are the great vessels and include the superior and inferior vena cava, the pulmonary artery and vein, and the aorta. The femoral artery is a distracter for the question.
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem? a) Peripheral arterial disease (PAD) b) Heart failure c) Venous thromboembolism d) Myocardial infarction
Heart failure Explanation: 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 patients with elevated JVD have heart failure.
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, which information would the nurse include? a) Caucasians usually possess greater lifestyle risks for CAD than African Americans. b) Hypertension is more prevalent in African Americans than among Caucasians. c) Hispanic Americans have a higher rate of CAD than white Americans. d) Hypertension is seen more in white women than in African-American women.
Hypertension is more prevalent in African Americans than among Caucasians. Explanation: Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations.
A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this? a) Poorer conduction of electrical impulses in the heart due to fatty tissue b) Increased difficulty in locating the heart c) Increased distance from the apex of the heart to the pre cordium d) Weaker ventricles due to low compliance
Increased distance from the apex of the heart to the pre cordium Explanation: In addition, it may be difficult to palpate the apical impulse in clients who are obese or barrel chested because these conditions increase the distance from the apex of the heart to the pre cordium. The other answers are not likely reasons for the nurse's inability to find the apical pulse.
A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data? a) Activity Intolerance b) Ineffective Tissue Perfusion c) Impaired Breathing Pattern d) Ineffective Health Maintenance
Ineffective Tissue Perfusion Explanation: The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance.
A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? a) Inflammation of the pericardial sac b) Increased pressure within the ventricles c) Inability of the atria to contract d) Incompetent mitral valve
Inflammation of the pericardial sac Explanation: A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.
Variations in the presentation of S1 are due to alterations in which heart valve? a) Aortic b) Tricuspid c) Pulmonic d) Mitral
Mitral Explanation: 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 nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse? a) Ventricular gallop b) Venous hum c) Midsystolic click d) Opening snap
Midsystolic click Explanation: 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.
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? a) Murmur b) S1 c) Ventricular gallop d) S2
Murmur Explanation: 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 group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following? a) Endocardium b) Epicardium c) Pericardium d) Myocardium
Myocardium Explanation: The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The epicardium is the serous membrane that covers the outer surface of the heart; the endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart. The pericardium is a tough indistensible loose-fitting fibroserous sac that attaches to the great vessels and thereby surrounds the heart.
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? a) Perform palpation lightly b) Make the client sit upright c) Avoid frequent repositioning d) Perform only auscultation
Perform palpation lightly Explanation: The presence of a bruit indicates occlusion of the carotid artery & pressing on the artery could compromise blood flow to the brain. On detecting the bruit of the carotid artery, the nurse should palpate very lightly to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or even cardiac arrest. In particular, avoid area of the carotid sinus. Making the client sit in an upright position and preventing frequent position changes is not necessary. Performing only auscultation may not give complete information.
What is the most important physical sign of acute pericarditis? a) Elevated white cell count b) Pericardial friction rub c) Intense pain d) Murmur heard over the left sternal border
Pericardial friction rub Explanation: 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 patient 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
The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition? a) With the client leaning forward, listen over the left carotid artery. b) With the client supine, place the bell of the stethoscope on the 2nd left instercostal space. c) Place the bell of the stethoscope over the apex with client on left side. d) Use the diaphragm of the stethoscope to listen over the right sternal border.
Place the bell of the stethoscope over the apex with client on left side. Explanation: This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the patient turned to the left. The carotid arteries are auscultated one at a time for bruits. The 2nd left intercostal space is the location to hear pulmonic valve conditions.
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? a) Diminished heart sounds b) Changes on expiration c) Presence of an S3 d) Split S2 on inspiration
Presence of an S3 Explanation: 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.
While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate? a) Edema b) Shortness of breath c) Palpitations d) Chest pain
Shortness of breath Explanation: Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect.
A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? a) Premature atrial contractions b) Atrial fibrillation c) Premature ventricular contractions d) Sinus arrhythmia
Sinus arrhythmia Explanation: A heart rate that speeds with inspiration and slows with exhalation is termed sinus arrhythmia. This is often a normal rhythm in young children and well-conditioned athletes. Premature ventricular contractions and premature atrial contractions occur earlier than expected. Atrial fibrillation causes the ventricles to beat irregularly.
A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following? a) Heart rate b) Cardiac output c) Systolic blood pressure d) Stroke volume
Stroke volume Explanation: Stroke volume is the amount of blood pumped from the heart with each contraction. Cardiac output (CO) is the amount of blood pumped by the ventricles during a given period of time (usually 1 min) and is determined by the stroke volume (SV) multiplied by the heart rate (HR): SV × HR = CO. Neither systolic blood pressure nor heart rate measure the quantity indicated.
When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as? a) Atrial kick b) Diastolic clicks c) Ejection clicks d) Summation gallop
Summation gallop Explanation: Presence of both S3 and S4 is referred to as a "summation gallop." Atrial kick is the additional flow of blood from the atrium to the ventricles as the atrium contract. Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the S1 sound. Diastolic clicks can be found in clients with mitral valve prolapse as the valve does not close properly.
A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment? a) Start by auscultating the client's breath sounds. b) Use the bell rather than the diaphragm. c) Systematically listen to the entire precordium. d) Auscultate prior to inspection and palpation.
Systematically listen to the entire precordium. Explanation: When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apex or from the apex to the base. Both the diaphragm and bell are used. Inspection and palpation usually precede auscultation. It is not necessary to begin with breath sounds.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? a) ST segment b) QRS complex c) T wave d) P wave
T wave Explanation: The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement? a) The client's cardiac problem is being adequately compensated for. b) The client may be at increased risk for myocardial infarction. c) The client may have developed a cardiac conduction problem. d) The client may be experiencing symptoms of heart failure.
The client may be experiencing symptoms of heart failure. Explanation: With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation.
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? a) The client's atria are not synchronized with the ventricles. b) The client's ventricles are not contracting simultaneously. c) The client's aortic valve is incompetent. d) The client has left ventricular hypertrophy.
The client's ventricles are not contracting simultaneously. Explanation: A split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction). This finding is not associated with an incompetent aortic valve, left ventricular hypertrophy, or lack of synchronicity between the atria and ventricles.
In order for the nurse to assess jugular venous pressure (JVP), the client should be in which of the following positions? a) The head of the bed raised 60 degrees b) The client lying supine c) The head of the bed raised 90 degrees d) The head of the bed raised 30 degrees
The head of the bed raised 60 degrees Explanation: Jugular venous pressure reflects pressure in the right atrium or central venous pressure. With the head of the bed positioned at 60 degrees, the nurse can measure the jugular venous pressure because the "top" of the internal jugular vein is now visible, so the vertical distance from the sternal angle or right atrium can be measured. With the head of the bed positioned at 30 degrees, the jugular venous pressure cannot be measured because venous undulation is above the jaw and therefore, not visible. With the head of the bed positioned at 90 degrees, the veins are barely discernible above the clavicle, making measurement impossible. The jugular venous pressure cannot be measured with the client in a supine position because the head needs to be elevated slightly in order to bring the vein into view.
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? a) The heart is responding to increased renal perfusion. b) This is the body's response to an increase in cardiac output. c) This is a normal response by the heart's conduction system. d) The heart is attempting to increase cardiac output.
The heart is attempting to increase cardiac output. Explanation: Palpitations may occur with an abnormality of the heart's conduction system or during the heart's attempt to increase cardiac output by increasing the heart rate. Palpitations may cause the client to feel anxious.
The nurse on the cardiac unit is caring for a patient who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this patient, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein? a) They are clinical proof that the patient had a coronary event. b) They more than double the risk of cardiac disease. c) They have no direct correlation with increased risk of cardiac disease. d) They are both sensitive and specific to heart failure.
They more than double the risk of cardiac disease. Explanation: The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible a) angina. b) congestive heart failure. c) palpitations. d) acute anxiety reaction.
angina. Explanation: Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw.
During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's a) second left interspace. b) pulmonic valve area. c) apex of the heart. d) base of the heart.
apex of the heart. Explanation: S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).
The nurse is having difficulty locating a client's point of maximum impulse. What should the nurse do to facilitate this assessment? a) have the client lay supine b) assist the client into a left lateral decubitus position c) place the client into a high-Fowler's position d) assist the client to sit with the legs dangling
assist the client into a left lateral decubitus position Explanation: 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.
The semilunar valves are located a) at the exit of each ventricle at the beginning of the great vessels. b) between the left atrium and the left ventricle. c) between the right atrium and the right ventricle. d) at the beginning of the ascending aorta.
at the exit of each ventricle at the beginning of the great vessels. Explanation: The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels.
The semilunar valves are located a) between the left atrium and the left ventricle. b) at the beginning of the ascending aorta. c) at the exit of each ventricle at the beginning of the great vessels. d) between the right atrium and the right ventricle.
at the exit of each ventricle at the beginning of the great vessels. Explanation: The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels.
The semilunar valves are located a) between the right atrium and the right ventricle. b) between the left atrium and the left ventricle. c) at the exit of each ventricle at the beginning of the great vessels. d) at the beginning of the ascending aorta.
at the exit of each ventricle at the beginning of the great vessels. Explanation: 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 a) between the left atrium and the left ventricle. b) at the beginning of the ascending aorta. c) between the right atrium and the right ventricle. d) at the exit of each ventricle near the great vessels.
between the left atrium and the left ventricle. Explanation: The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.
The anterior chest area that overlies the heart and great vessels is called the a) endocardium. b) epicardium. c) myocardium. d) precordium.
precordium. Explanation: The anterior chest area that overlies the heart and great vessels is called the precordium.
A patient with prehypertension is in the clinic for counseling. All lifestyle modifications are important in preventing or managing hypertension. Which modification would be the best to implement first for this patient? a) weight loss to BMI under 25 kg/m2 b) regular exercise for at least 30 minutes a day c) smoking cessation d) elimination of alcohol consumption
regular exercise for at least 30 minutes a day Explanation: Regular exercise provides many benefits, including lowering the risk of hypertension.
A client has engorged jugular veins. What should this finding suggest to the nurse? a) integrity of the aorta b) closure of the tricuspid valves c) right atrial pressure d) patency of carotid arteries
right atrial pressure Explanation: Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves
A client has engorged jugular veins. What should this finding suggest to the nurse? a) patency of carotid arteries b) right atrial pressure c) integrity of the aorta d) closure of the tricuspid valves
right atrial pressure Explanation: Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves.
The nurse notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating? a) premature ventricular contractions b) premature atrial contractions c) atrial fibrillation d) sinus arrhythmia
sinus arrhythmia Explanation: In a sinus arrhythmia the heart varies cyclically, usually speeding up with inspiration and slowing down with expiration. In atrial fibrillation the ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may seem regular. In premature atrial contractions a beat of atrial origin comes earlier than the next expected normal beat. A pause follows, and then the rhythm resumes. In premature ventricular contractions a beat of ventricular origin comes earlier than the next expected normal beat. A pause follows, and the rhythm resumes.
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.) a) "Wear the gown with the opening in the front." b) "You will be sitting and leaning forward for part of the examination." c) "You will stand for the examination" d) "I will be conducting the examination from your left side." e) "You will be laying on your left side for part of the examination."
• "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." Explanation: When preparing the client for a physical examination of the cardiovascular system, the nurse should instruct the client to put on the examination gown with the opening in the front for access to fully auscultate the chest wall. The nurse should tell the client he will be both left lying and sitting, leaning forward for part of the examination. These positions help bring the ventricular apex and left ventricular outflow tract closer to the chest wall, enhancing detection of the point of maximal impulse (PMI) and aortic insufficiency. The client will be supine, side lying or sitting during the examination but will not be standing. The nurse will conduct the examination from the patient's right side, not the left.
Which of the following interventions can the nurse use to help a client modify risk factors associated with with hypertension? (Select all that apply). a) Encourage the client to limit consumption of potassium rich foods b) Ask the client to keep an activity log c) Encourage the client to quit alcohol consumption d) Ask the client to keep a "typical day" record of daily food intake e) 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 Explanation: Interventions that would modify risk factors associated with hypertension include changing dietary intake, increasing physical activity and promoting smoking cessation. Asking the client to keep a "typical day" record of daily intake can help the nurse identify good diet choices and areas for improvement. Asking the client to keep an activity log offers the nurse objective information about the client's activity level in order to provide the client with strategies for increasing physical activity to the recommended 30 minutes per day. Providing information regarding smoking cessation is a step toward moving the client to the contemplation stage in the Stages of Change model. Moderate alcohol consumption per day of two drinks for men and one drink per day for women is considered acceptable for clients diagnosed with hypertension. Dietary intake of more than 3500 mg of potassium daily is encouraged for clients with hypertension.
A nurse receives a client from the cardiac catheterization laboratory. The client is on bed rest and has a weight on the puncture site of the right groin. What must the nurse assess for frequently? Select all that apply. a) Pulses proximal to the puncture site b) Bleeding at the puncture site c) Hematoma at the puncture site d) Increased blood pressure, which could cause excess bleeding or hematoma
• Hematoma at the puncture site • Bleeding at the puncture site • Increased blood pressure, which could cause excess bleeding or hematoma Explanation: Left-sided heart catheterization involves placing a catheter through the femoral artery to the coronary arteries where dye is used for visualization. Following the procedure, the client is on bed rest and the puncture site and distal circulation must be monitored frequently. Nursing staff also monitor blood pressure and cardiac rhythm.
A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply. a) Use relaxation techniques to manage stress. b) Limit alcohol intake to 3 drinks per day. c) Walk for at least 30 minutes/day. d) Avoid eating dark chocolate. e) Eat foods low in sodium.
• Use relaxation techniques to manage stress. • Walk for at least 30 minutes/day. • Eat foods low in sodium. Explanation: Measures to reduce the risk of CHD include eating 3½ ounces equivalent of cocoa such as dark chocolate each day to help lower blood pressure; eating foods low in saturated fats, trans fatty acids, cholesterol, and sodium; participating in an active exercise program such as walking at least 30 minutes per day; limiting alcohol intake to 2 drinks per day for men and 1 drink per day for women; managing stress by reducing personal stress as much as possible, trying muscle relaxation and deep breathing.
A client 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. a) Tends to occur after meals b) Radiates to left shoulder and down the left arm c) Is relieved with antacids d) Has a squeezing sensation around the heart e) May occur at any time f) Worsens with activity
• Worsens with activity • May occur at any time • Radiates to left shoulder and down the left arm • Has a squeezing sensation around the heart Explanation: 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.