Chapter 21: Assessing Heart and Neck Vessels

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

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

a) 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.

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

a) 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.

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

a) 65-year-old male with a 5-year history of diabetes mellitus 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

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? a) Atrioventricular (AV) node b) Sinoatrial (SA) node c) Bundle of His d) Purkinje fibers

a) 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.

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

a) 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.

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) Tachycardia c) Decreased d) Norma

a) Bradycardia 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 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? a) Client has an increased chest diameter b) Heart enlargement is present c) Respiratory rate is too fast d) Heart rate is irregular

a) 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.

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern? a) Decreased cardiac output b) Severe muscular exertion c) Depression d) Upper respiratory infection

a) Decreased cardiac output Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day. Severe muscular exertion and an upper respiratory infection may be associated with fatigue, but not the pattern mentioned in the scenario.

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? a) Grade V/VI b) Grade I/VI c) Grade II/VI d) Grade VI/VI

a) 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.

A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this? a) Increased distance from the apex of the heart to the pre cordium b) Increased difficulty in locating the heart c) Weaker ventricles due to low compliance d) Poorer conduction of electrical impulses in the heart due to fatty tissue

a) Increased distance from the apex of the heart to the pre cordium I n 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 nurse monitors a client at risk for the onset of premature ventricular contractions. The nurse should monitor the client's cardiac rhythm for which characteristic feature? a) Premature beats followed by compensatory pause b) P wave preceding every QRS complex c) QRS complexes that are short and narrow d) Irregular QRS complexes with absent P wave

a) Premature beats followed by compensatory pause Premature ventricular contractions are characterized by premature beats followed by a compensatory pause. The P waves are absent with wide QRS complexes followed by a compensatory pause. The rhythm usually resumes with the next beat. QRS complexes are wide and bizarre not narrow and the P wave is usually absent.

During auscultation of the heart, a nurse hears an extra heart sound immediately after S at the second left intercostal space. What should the nurse do to further assess this finding? a) Watch the client's respirations while listening for effect on the heart sound b) Observe the jugular vein for distention at 30, 60, and 90 degrees of head elevation c) Ask the client about previous history of cardiac problems such as heart failure d) Ask the client to lean forward to bring the left ventricle closer to the chest wall

a) Watch the client's respirations while listening for effect on the heart sound The nurse must differentiate whether this heart sound is normal or abnormal. A normal split S is heard best during inspiration and disappears during expiration. If splitting does not disappear on expiration, this may be suggestive of heart disease. Jugular vein distention occurs with right-sided heart failure or an increase in venous return to the right side of the heart. Having the client lean forward helps to assess the left ventricle and listen for diastolic murmurs. If the split does not disappear during expiration the nurse should ask the client about previous history of cardiac problems such as heart failure.

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) Ineffective Health Maintenance d) Impaired Breathing Pattern

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.

Variations in the presentation of S1 are due to alterations in which heart valve? a) Aortic b) Mitral c) Tricuspid d) Pulmonic

b) 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? a) Pulmonic b) Mitral c) Tricuspid d) Aortic

b) 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

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? a) Bisferiens pulse b) Pulsus alternans c) Paradoxical pulse d) Bigeminal pulse

b) 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.

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S and S are normal. The nurse recognizes this as what dysrhythmia? a) Premature atrial contractions b) Sinus arrhythmia c) Atrial fibrillation d) Premature ventricular contractions

b) Sinus arrhythmia A heart rate that speeds with inspiration and slows with exhalation is termed sinus arrhythmia. This is often a normal rhythm in young children and wellconditioned athletes. Premature ventricular contractions and premature atrial contractions occur earlier than expected. Atrial fibrillation causes the ventricles to beat irregularly

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

b) 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.

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? a) bundle of His b) sinoatrial node c) atrioventricular node d) Purkinje fibers

b) 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.

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

c) 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.

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

c) 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 father 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 be fore auscultating heart sounds.

A nurse auscultates the heart of a client with hypertension for the past ten (10) years. With the client in the left lateral position, the nurse hears a heart sound that occurs just before S1. The nurse recognizes this sound as what pathological process? a) Splitting of S2 that does not disappear with expiration b) Turbulence within the ventricles caused by rapid filling c) Atrial contractions heard as vibrations against stiff walled ventricles d) Abnormal contraction of the ventricles due to a conduction delay

c) Atrial contractions heard as vibrations against stiff walled ventricles Long-standing hypertension causes stiffening of the ventricles. This produces an S4 heart sound, heard best with the bell of the stethoscope over the apical area with the client in a supine or left lateral position. The sound is produced as the atria contract and produce vibrations from blood flow into stiff walled ventricles. Abnormal contraction of the ventricles due to a conduction delay would produce a split S1. Turbulence within the ventricles caused by rapid filling is an acute finding and most often the result of acute heart failure. Splitting of S2 that does not disappear with expiration is suggestive of heart disease.

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) Auscultate to determine the heart rate and if the rhythm is normal d) 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 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 nurse understands that the cardiac event that cycles the beginning of systole is what? a) Relaxation of the ventricles b) Contraction of the ventricles c) Closure of the mitral and tricuspid valves d) Closure of the aortic and pulmonic valves

c) 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? a) Isometric contraction b) Ventricular contraction c) Closure of the semilunar valves d) Closure of the atrioventricular (AV) valves

c) 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.

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

c) 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.

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

c) 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.

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) Ventricular gallop b) S1 c) Murmur d) S2

c) 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 performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? a) Apical impulse palpated at 5 intercostal space on left b) Apical heart rate 70 beats per minute c) No current medications or treatments d) No edema of extremities noted

c) No current medications or treatments Subjective data is data collected from the client. No current medications or treatments is information the nurse obtained from the client. Apical heart rate 70 beats per minute, no edema of extremities noted, and apical impulse palpated at 5 intercostal space on left are examples of objective data collected by the nurse upon physical examination.

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 only auscultation b) Make the client sit upright c) Perform palpation lightly d) Avoid frequent repositioning

c) Perform palpation lightly 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.

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) Split S2 on inspiration b) Diminished heart sounds c) Presence of an S3 d) Changes on expiration

c) Presence of an S3 Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S3 and an S4 , which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse and seen in cardiac tamponade or obstructive lung disease. A split S2 does not change the amplitude of a client's pulse.

A 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) Systolic blood pressure b) Cardiac output c) Stroke volume d) Heart rate

c) Stroke volume 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.

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) Radiates to left shoulder and down the left arm b) Is relieved with antacids c) Worsens with activity d) May occur at any time e) Tends to occur after meals f) Has a squeezing sensation around the heart

c) Worsens with activity, d) May occur at any time, a) Radiates to left shoulder and down the left arm, f) 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.

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? a) Normal split b) Wide split c) Diminished d) Accentuated

d) 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.

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

d) Assess for a difference between the apical and radial pulse The nurse should assess the pulse deficit by assessing the difference in the apical and radial pulse. Pulse deficit is the difference between the apical and peripheral/radial pulses. 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). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume but does not cause a pulse deficit.

A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure? a) Jugular venous distention at 30 degrees b) Grade III/VI systolic murmur c) Split S1 heard over the apex of the heart d) Auscultation of an S3 heart sound

d) Auscultation of an S3 heart sound The development of a pathologic S3 may be the earliest sign of heart failure. This sound signals resistance of the ventricles to filling. A split S1 heard over the apex of the heart may indicate a conduction delay between the ventricles. Grade III.VI murmur indicates a valve malfunction. Jugular venous distention may be seen with heart failure of the right side of the heart but is not the first sign.

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

d) 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.

Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy? a) Bounding b) Normal c) Diminished d) Displaced

d) Displaced The nurse should expect to find a displaced apical pulse for a client with left ventricular hypertrophy. In ventricular hypertrophy, the apical pulse may be larger than 1 to 2 cm, displaced, more forceful, or of longer duration. Bounding apical pulse is not a characteristic of ventricular hypertrophy

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

d) Elevated venous pressure only during expiration Clients with obstructive pulmonary disease may have elevated venous pressure only during expiration. An inspiratory increase in venous pressure, called Kussmaul's sign, may occur in clients with severe constrictive pericarditis. Distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate right-sided heart failure. It is normal for the jugular veins to be visible when the client is supine.

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) Incompetent mitral valve b) Increased pressure within the ventricles c) Inability of the atria to contract d) Inflammation of the pericardial sac

d) Inflammation of the pericardial sac 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.

A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following? a) Endocardium b) Epicardium c) Pericardium d) Myocardium

d) Myocardium The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels.

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

d) Palpate the carotid pulse simultaneously If a nurse experiences difficulty differentiating S1 from S2 , palpate the carotid pulse simultaneously. 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 25-year-old client presents to the health care clinic for a routine physical. Which lifestyle practices in the client's history are most important for the nurse to provide teaching in assisting the client to reduce the risk for the development of coronary heart disease? Select all that apply. a) High-stress job as a financial analyst b) Family history of heart attack before age 50 years c) Exercises 30 minutes 5 days a week d) Smokes 5 cigarettes daily for past 5 years e) Adds salt to foods regularly f) Ten pounds over ideal body weight

d) Smokes 5 cigarettes daily for past 5 years, b) Family history of heart attack before age 50 years, a) High-stress job as a financial analyst Risk factors for the development of coronary heart disease for this client include tobacco use, family history of heart attack before age 50 years, and a high-stress job. Exercise would tend to lower the client's risk for heart disease, not increase it. Although the client is 10 pounds over his ideal body weight, there is no evidence that he is overweight or obese. Also, although the client adds salt to his food regularly, there is no indication that he has high blood pressure.

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

d) 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.