Assessment Exam 2 Heart

The nurse auscultates an S4 heart sound when assessing a client. Where on the client's rhythm strip should the nurse identify that this sound occurs? Click to select the correct part of the image.

If present, the S4 heart sound is auscultated at the end of the PR interval/beginning of the QRS complex.

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

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 client is experiencing severe sepsis. What assessment finding would the nurse expect? a. 1+ pulses b. Heart rate 88 c. Blood pressure 140/80 c. Respiratory rate 14

a. 1+ pulses The blood pressure, heart rate, and respiratory rate are all within normal limit. Weak pulses would be expected.

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? a. Atherosclerotic stenotic carotid arteries b. Congenital stenotic carotid arteries c. Stenotic aortic valve d. Atherosclerotic pulmonic valve

a. Atherosclerotic stenotic carotid arteries If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the client's age would negate the likely existence of a congenital problem.

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

a. 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.

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

a. 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? a. Murmur b. Ventricular gallop c. S1 d. S2

a. 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.

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

a. 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.

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

b. 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? a. External jugular vein b. Carotid artery c. Sternomastoid d. Internal jugular vein

b. 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 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 2 b. Grade 5 c. Grade 1 d. Grade 6

b. Grade 5 Grade 1: Very faint, heard only after the listener has "tuned in"; may not be heard in all positions Grade 2: Quiet, but heard immediately on placing the stethoscope on the chest Grade 3: Moderately loud Grade 4: Loud Grade 5: Very loud, may be heard with a stethoscope partly off the chest Grade 6: May be heard with the stethoscope entirely off the chest

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

b. Ineffective Tissue Perfusion The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance.

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? a. Assess for a difference between the apical and radial pulse b. 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

b. 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).

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. palpitations. b. angina. c. congestive heart failure. d. acute anxiety reaction.

b. 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.

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

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

b. third to fifth intercostal space at the left sternal border. Erb's point: Third to fifth intercostal space at the left sternal border.

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. Mitral and aortic c. Aortic and pulmonic d. Tricuspid and mitral

c. 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.

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

c. 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

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. Aortic b. Pulmonic c. Mitral d. Tricuspid

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

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

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

c. 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.

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. a. Consume two to three glasses of red wine daily. b. Increase consumption of dairy products. c. Use a low sodium seasoning to flavor food. d. Choose foods like bananas and sweet potatoes. e. Walk briskly 30 minutes per day.

c. Use a low sodium seasoning to flavor food. d. Choose foods like bananas and sweet potatoes. e. Walk briskly 30 minutes per day. Encouraging physical activity, decreasing dietary intake of sodium, and increasing dietary intake of potassium, such as in bananas and sweet potato, are lifestyle modifications that can promote sustaining a healthy blood pressure. Excess alcohol consumption is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for hypertension should avoid increasing consumption of these foods.

The S4 heart sound a. is usually due to a heart murmur. b. is often termed ventricular gallop. c. can be heard during diastole. d. can be heard during systole.

c. can be heard during diastole. If present, S4 can be heard late in diastole, just before S1.

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? a. diameter b. amplitude c. duration d. location

c. 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.

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

c. left-sided heart failure Left-sided heart failure can cause fluid to leak into the lungs, and as a result fine crackles can be heard from the movement of fluid in the lungs on air exchange. Auscultation of fine crackles is not a typical finding associated with clients experiencing palpitations or hypertension. Dextrocardia is a condition in which the heart is situated on the right side. Fine crackles are not a characteristic feature of dextrocardia.

Where is Erb's point located? a. 4th left rib space b. 4th right rib space c. 3rd right rib space d. 3rd left rib space

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

d. Atrial depolarization The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec).

Which 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. 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. Auscultate to determine the heart rate and if the rhythm is normal

d. 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.

What is located at the right and left 2nd intercostal spaces next to the sternum? a. Pulmonary vein b. Apex of the heart c. Aortic valve d. Base of the heart

d. Base of the heart The right ventricle narrows as it rises to meet the pulmonary artery just below the sternal angle. This is called the "base of the heart" and is located at the right and left 2nd intercostal spaces next to the sternum.

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

d. 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.

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

d. 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.

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

d. Summation gallop Presence of both S3 and S4 is referred to as a "summation gallop." Atrial kick is the additional flow of blood from the atrium to the ventricles as the atrium contract. Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the S1 sound. Diastolic clicks can be found in clients with mitral valve prolapse as the valve does not close properly.

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

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

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

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

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

d. right atrial pressure Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves.