Health Assess 2.0: Cardiovascular
A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.)
-"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"I will be sure to have my blood pressure checked at least every year."
A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?
Capillary refill of 3 seconds
A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?
Sibling who has hypertension
A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?
"The penlight will allow me to look at the pulses in your neck."
A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.)
- Auscultate the apical pulse - Ask the client if they experience shortness of breath - check the color of the clients skin - inspect the extremities for the presence of edema
A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct. - Distention of the jugular vein on one side of the neck is correct. -The left carotid artery pulse is weak is correct
A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply.)
-Instruct the client to sit with their legs uncrossed. - Encourage the client to avoid tobacco products. - Instruct the client to cleanse the area with mild soap - Instruct the client to wear shoes when ambulating
A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1. Elevate the head of the bed 30° and instruct the client to breath normally is the first step. 2. Visualize the anatomy of the heart is the second step. 3. Place the stethoscope to the right sternal border at the second intercostal space is the third step. 4. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. 5. Auscultate the apical pulse for 1 min is the fifth step.
A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report?
A forceful chest movement at the midclavicular line in the fourth intercostal space
A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?
An adolescent who has an s3 heart sound
A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated
D
A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?
Discuss the benefits of meditation with the client
A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?
Have the client lay supine with the head of the bed at a 45° angle.
A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?
Limit sodium intake to less than 3,000 mg/day.
A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?
Palpable dorsalis pedal pulse
