HESI Case Study: Heart and Neck Vessel

To obtain information that will help distinguish whether the clients fatigue is cardiac in nature, what questio should the RN ask the client?

At what time of day do you feel most fatigued? Rationale: Fatigue r/t to stress or depression may be worse in the morning or may be present all day. while fatigue r/t to decreased cardiac output may worsen in the evening.

After palpating an irregular pulse rythm at the left radial pulse site, what action should the nurse take to confirm the clients heart rate?

Auscultate the apical pulse for 1 minute. Rationale: Auscultation of the apical pulse site is the most accurate method to determine heart rate and rhythm because the nurse is listening directly over the heart, rather than depending on the sound transmission of the pulse to a distal site, such as the radial pulse site.

which test can the nurse review to obtain the same information that might be obtained during precordial percussion?

Chest X ray &Echocardiogram Rationale: Chest percussion helps outline the boarders of the heart to detect enlargement. Enlargement of the heart is more accurately detetced with a chest xray and echocardiogram.

Based on Mr. Kapurs report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next?

Determine if the client is currently experiencing any angina. Rationale: Because the client has a history of chest discomfort, the nurse should first determine if the client is experiencing any angina. Agina should be treated immediately to reduce the risk of myocardial infraction.

It is most important for the nurse to obtain further information related to which aspect of the client's care? (choose the answers r/t to the clients culture)

Dietary needs Herbs or purgatives used

To gather data about Dev (mr. Kapur) history of chest pain, how should the nurse begin?

Encourage the client to describe his chest discomfort. Rationale: Because chest pain can manifest in a number of different ways, the nusre should begin by obtaining information r/t at any type of chest discomfort so that further responses by the client include info r/ to any type of chest discomfort he has experience.

The nurse begins the Physical assessment by inspecting the client's precordium. The nurse completes the interview and prepares to assess the client's heart and neck vessels. How should the nurse prepare the client for inspection of the precordium?

Help the client in a supine position on the bed with his chest exposed. Rationale: a supine position with chest exposed provides the best inspection of the precordium.

How should the nurse plan to continue auscultation from the aortic area?

Inch the stethoscope across and down in a "Z" pattern. Rationale: inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard.

To d/m the grade of the murmur, what action should the nurse take?

Note how easily the murmur is heard by gradually lifting the stethoscope. Rationale: Murmurs are graded best by the intensity of the sound, ranging from a grade 1 murmur, which is barely audible, to a grade 6 murmur, which can be heard by the stehtoscope lifted off of the chest wall.

During auscultation the nurse has difficulty distinguishing s1 from s2 because of the clients irregular hr. while continuing to listen to the aortic site, what action should the nurse take?

Palpate the carotid artery pulse. Rationale: s1 occurs simultaneously with the carotid artery pulse. by gently palpating the carotid artery pulse, the nurse can distinguish s1 as the sound that occurs with each pulsation.

To begin palpation at the base of the heart, where should the nurse palpate first?

Right sternal boarder, 2nd ICS. rationale: this is the location of the aortic site. the aoritic and pulmonic sites are located at the base of the heart.

Before attempting to palpate again, the nurse should give the client what instruction?

Roll half-way to his left side. Rationale; turning half-way to his left side moves the apex of the heart closer to the chest wall, so it's easier to palpate.

In listening to the second right intercostal space, what should the nusre attempt to distinguish first?

S1 and S2 Heart sounds. Rationale: the nurse should begin by listening to the normal heart sounds, s1 n s2, before attempting to distinguish abnormal heart sounds, such as s3 and s4 heart murmurs.

The nurse now finds an s3 heart sound. what assessment should the nurse include?

check for JVD. an s3 heart sound maybe an early indicator of the onset of heart failure, so the nurse should assess the client for other signs of heart failure, such as JVD.

Nurse observes a pulsation low on the neck @ area of left internal jugular vein, but unable to palpate the pulsation. What action should nurse take next?

document the level at the pulsation is observed. Rationale: venous palpations are not palpable, so document.

After inching the diaphragm of the stethoscope to the left ICS, the nurse hears a split s2 sound during the client's inspiration. what action should the nurse take in response to this finding?

document this findng as normal on the initial assessment record. Rationale: a split s2 is a normal finding that can be heard in in some ppl a/r of the slightly asynchronous closing of the aortic and pulmonic valves. a split s2 is heard best during inspiration at the pulmonic site, the left ICS.

Before developing the client's plan of care, what information is most important for the nurse to obtain regarding the client's spirtuatlity?

how the client's spiritual beliefs impact his healthcare expectations. Rationale; in planning care, the rn should try to d/m how the client's spiritual and cultural beliefs impact the expectations for the care in the healthcare setting.

The nurse should observe the force of the impulse at which position? (left ventricular heave)

left midclavicular line, 5th ICS.

The nurse assess the CAP as +2. the nurse then listens for a carotid bruit by placing the bell of the stethoscope at the base of the neck on the right side. the nurse does not hear a bruit. what does nurse do next?

move the bell of the stetho up the right side of the neck to the mid-clavicular area. Rationale: The nurse should ausculatate each carotid artery systematically, including the base of the neck, the mid-clavicular area, and the angle of the jaw.

how should the nurse being a carotid artery assessment?

palpate one artery and then palpate the artery on the opposite side.

To assess for JVD, what actions should the nurse take?

remove the clients pillow and turn his head slightly away. & place the client in a semi-Fowler's position. Rationale Semi-Fowlers--> raising the head of the bed to a 3-045 degree angle is1st step to assess JVD.

The nurse hears a grade 3 murmur but not s3 or s4 sound. What action should the nurse take next?

repeat auscultation across the chest using the bell of the stethoscope.

The nurse hears a swooshing sound that coincides with s1 while listening to the diaphragm of the stetho. how should the nrs identify this sound?

systolic murmur. Rationale: murmurs are often heard as swooshing sounds. systolic murmurs concide with the s1 heart sound.

while listening at the apical site, the nurse hears a dull, soft sound following s2. what action will help confirm the presence of this sound?

use the bell of the stethoscope to continue listetning at the apical site.