Health Assessment Ch 17

third to fifth intercostal space at the left sternal border.

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the

Palpate each artery individually to compare

The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate?

Palpating carotid pulses simultaneously.

The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique?

Clean the stethoscope

The nurse positions the client for auscultation of heart sounds. What does the nurse do first?

high serum level of low-density lipoproteins.

The nurse should explain to the client that a risk factors for coronary heart disease is

Heart failure

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?

Mitral

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?

associated with occlusive arterial disease.

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

apex of the heart.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's

Decreased cardiac output

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?

Have the client hold his or her breath; if the rub persists, it is pericardial

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Murmur

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?

True

The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.

Bruits

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Place the bell of the stethoscope over the apex with client on left side.

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?

The client may be experiencing symptoms of heart failure.

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?

Angina

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

precordium.

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

Diminished

The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear?

2+

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?

increased central venous pressure.

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of

Right atrium

The nurse assesses the apical pulse while conducting a cardiovascular exam. The nurse notes the client has an irregular pulse. Which of the following chambers of the heart should be further assessed?

Presence of an S3

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?

Mitral

Variations in the presentation of S1 are due to alterations in which heart valve?

Apical impulse

When a patient is obese or has a thick chest wall, what is difficult to palpate?

Accentuated

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?

Systematically listen to the entire precordium.

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?

Hypertension is more prevalent in African Americans.

A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include?

Smoking increases the heart's workload and contributes to atherosclerosis.

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Orthopnea

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

Ineffective Tissue Perfusion

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?

Blood pressure

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

Flat neck veins

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

Myocardium

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?

Auscultate for pulse rate deficit.

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next?

Mitral stenosis

A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following?

Atrial contractions heard as vibrations against stiff walled ventricles

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?

Inflammation of the pericardial sac

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?

Inflammation of the pericardial sac

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

inflammation of the pericardial sac

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Observe for a decrease in jugular venous pressure

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

Auscultate for split S1 at the base and apex

A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do?

Check for pulse inequality between right and left carotid arteries

A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?

Sinoatrial node

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?

Client has an increased chest diameter

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?

Myocardium

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?

Closure of the semilunar valves

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?

Cardiac cycle

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

Heart attacks in his father and siblings

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

Inspect the suprasternal notch or around the clavicles.

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?

The pressures that exist within the client's right atrium

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?

Auscultate with the client in a variety of different positions.

The nurse is auscultating a client's heart sounds and hears what she believes to be a murmur. How should the nurse proceed with gathering further assessment data related to the suspected murmur?

Palpable

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?

"Your risk for heart disease will drop greatly if you're able to stop smoking."

The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

Mitral

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?

Palpate each artery individually to compare.

The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate?

"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."

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.)

Smoking, Blood pressure, Cholesterol

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices?

6

The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?

Increased heart rate

The nursing instructor explains to a group of students that what can shorten diastole?

A narrowed vessel

When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following?

S1

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

The mediastinum, between the lungs above the diaphragm

Where are the heart and great vessels located in the human body?

The amount of blood in the ventricles at the end of diastole

Which of the following statements most accurately describes preload?

Pericardial friction rub

While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following?

Shortness of breath

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?