N125 Case Study Heart and Neck Muscles

Dev reports feeling pressure on his chest sometimes, stating that it stops when he sits down and rests. Dev also tells the nurse that he feels tired a lot lately. He states, "I guess that's part of growing older." To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the RN ask the client? To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the RN ask the client? "Why do you feel your fatigue is related to your age?" "Can you describe the quality of your fatigue?" "What do you do when you feel tired?" "At what time of day do you feel most fatigued?"

"At what time of day do you feel most fatigued?" Fatigue related to stress or depression may be worse in the morning or may be present all day, while fatigue related to decreased cardiac output may worsen in the evening. Tomas tells the RN that he gets progressively more fatigued throughout the day.

The nurse is able to palpate the apical impulse after Dev turns midway to his left side. The nurse considers whether to percuss the client's precordium. Dev's medical record contains the results of several diagnostic tests completed prior to his admission to the hospital. Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? Select all that apply Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? Creatine phosphokinase (CPK). Carotid ultrasound. Serum liver enzymes. Chest x-ray. Echocardiogram.

*Chest x-ray.* Chest percussion helps outline the borders of the heart to detect enlargement. Enlargement of the heart is more accurately detected with a chest x-ray. *Echocardiogram.* Chest percussion helps outline the borders of the heart to detect enlargement. Enlargement of the heart is more accurately detected using an echocardiogram.

It is most important for the nurse to obtain further information related to which aspects of the client's care? Select all that apply Hygiene practices. Sleep patterns. Exercise habits. Dietary needs. Herbs or purgatives used.

*Dietary needs*. While there are few commonly held beliefs in Hinduism, many Hindus are vegetarians, so the nurse should assess the client's dietary needs. *Herbs or purgatives used.* Ayuveda, a traditional Hindu system of medicine, uses a combination of herbs, purgatives, and rubbing oils to treat illnesses.

The nurse observes a pulsation low and laterally on the neck at the area of the left internal jugular vein but is unable to palpate the pulsation. What action should the nurse take? What action should the nurse take? Use a stethoscope to auscultate the pulsation. Palpate the pulsation again, using less pressure. Reposition the client's head and attempt to palpate again. Document the level at which the pulsation is observed.

*Document the level at which the pulsation is observed.* Venous pulsations are not palpable. The nurse should document the level at which the pulsations are observed.

No carotid bruit is heard. After completing the assessment, the nurse reminds Dev to call if anything is needed and leaves the room. The nurse documents the findings and prepares to report the findings to the HCP. Which assessment data are important for the nurse to report to the client's HCP? Select all that apply Which assessment data are important for the nurse to report to the client's HCP? Presence of S1 and S2 heart sounds. Onset of an S3 heart sound. Observed jugular vein distention. Noted absence of a carotid bruit. Client's subjective report of dyspnea.

*Onset of an S3 heart sound.* This is an abnormal finding, indicative of a change in the client's status, and should be included in the nurse's report. *Observed jugular vein distention.* This is an abnormal finding, indicative of a change in the client's status, and should be included in the nurse's report. *Client's subjective report of dyspnea.* This is an abnormal finding, indicative of a change in the client's status, and should be included in the nurse's report.

The nurse places Dev supine in a Semi-Fowler's position. To inspect for jugular vein distention, what actions should the nurse take? Select all that apply To inspect for jugular vein distention, what actions should the nurse take? Place the client in a Fowler's position with his head straight. Lower the head of the bed while observing the neck veins. Remove the client's pillow and turn his head away slightly. Assist the client to lean forward at a 30 to 45° angle. Place the client in a Semi-Fowler's position.

*Remove the client's pillow and turn his head away slightly.* Turning the client's head slightly away allows the nurse to best measure the height of any jugular vein pulsations. *Place the client in a Semi-Fowler's position.* Raising the head of the bed to a 30 to 45° angle is the first step when assessing jugular vein distention.

Meet the Client: Mr. Dev KapurMr. Dev Kapur is a 58-year-old male who moved to the area from India 20 years ago. He is admitted directly to the cardiac telemetry unit from his physician's office with a history of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort. List possible symptoms to consider

Age: 58 y/o C/S: Moved from India 20 yrs ago Hx: Frequent dyspnea, dizziness, minor chest discomfort

After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate? After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate? Palpate both radial pulses simultaneously. Auscultate the apical pulse for 1 minute. Compare the ulnar pulse to the radial pulse. Ask the client if he experiences palpitations.

Auscultate the apical pulse for 1 minute. Auscultation of the apical pulse 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 transmission of the pulse to a distal site, such as the radial pulse site.

The nurse's further assessment confirms the finding of an S3 heart sound. After determining that the client has developed an S3 heart sound, the nurse reassesses the client. What assessment should the nurse include? Check for jugular vein distention. Note the onset of nailbed clubbing. Check for diminished skin elasticity. Assess for orthostatic hypotension.

Check for jugular vein distention. An S3 heart sound may be an early indicator of the onset of heart failure, so the nurse should assess the client for other signs of heart failure, including jugular vein distention.

During the admission assessment, the nurse first measures Mr. Kapur's vital signs and oxygen saturation. The vital signs and oxygen saturation are within normal parameters, although the radial pulse rhythm is irregular. Based on Mr. Kapur's report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next? Based on Mr. Kapur's report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next? Ask the client to stand and then recheck the blood pressure. Place the client in a supine position and observe for orthopnea. Measure the apical and radial pulse rates at the same time. Determine if the client is currently experiencing any angina.

Determine if the client is currently experiencing any angina. Because the client has a history of chest discomfort, the nurse should first determine if the client is currently experiencing angina. Angina should be treated immediately to reduce the risk for myocardial damage. Mr. Kapur denies any current symptoms, including angina.

The nurse is able to distinguish the LUB-dup sequence of S1 and S2 and continues the assessment. After inching the diaphragm of the stethoscope to the left second intercostal space, the nurse hears a split S2 during the client's inspiration. What action should the nurse take in response to this finding? What action should the nurse take in response to this finding? Document this normal finding on the initial assessment record. Confirm the finding on the bedside cardiac telemetry monitor. Assess for a change in the client's oxygen saturation reading. Contact the healthcare provider (HCP) to report the assessment finding.

Document this normal finding on the initial assessment record. A split S2 is a normal finding that can be heard in some people as the result 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 second intercostal space.

The client's apical rate is 92 and irregular, consistent with the radial pulse. The nurse implements cardiac telemetry monitoring, obtains oxygen for PRN use, and begins treatment for Mr. Kapur's irregular heart rhythm as prescribed. After gathering the initial priority data, the nurse interviews Mr. Kapur to gather subjective data related to his cardiac function. During the interview, Mr. Kapur asks the nurse to call him Dev. To gather data about Dev's history of chest pain, how should the nurse begin? To gather data about Dev's history of chest pain, how should the nurse begin? Encourage the client to describe his chest discomfort. Determine if the chest pain has radiated to other sites. Question the client about the frequency of his symptoms. Ask the client to rate his chest pain on a numeric scale.

Encourage the client to describe his chest discomfort. Because chest pain can manifest in a number of different ways, the nurse should begin by obtaining information related to any type of chest discomfort so that further responses by the client include information related to any type of chest discomfort he has experienced.

The RN completes the interview and prepares to assess the client's heart and neck vessels. Health Promotion and Maintenance: Inspection of the PrecordiumThe 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? Health Promotion and Maintenance: Inspection of the PrecordiumThe 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? Assist the client to a left side-lying position with his chest and back exposed. Open the back of the client's gown while he sits on the side of the bed. Help the client to a supine position on the bed with his chest exposed. Loosen the client's gown and ask him to lean forward in the bedside chair.

Help the client to a supine position on the bed with his chest exposed. A supine position with the chest exposed provides the best exposure for inspection of the precordium.

While interviewing Dev, the nurse learns that the client is Hindu. Before developing the client's plan of care, what information is most important for the nurse to obtain regarding the client's spirituality? Before developing the client's plan of care, what information is most important for the nurse to obtain regarding the client's spirituality? Whether the client participates in formal religious services regularly. How the client's spiritual beliefs impact his health care expectations. What beliefs the client holds regarding the existence of a higher power. The role played by a spiritual advisor within the client's faith tradition.

How the client's spiritual beliefs impact his health care expectations. In planning care, the RN should try to determine how the client's spiritual and cultural beliefs impact the expectations for care in the healthcare setting.

The nurse chooses to defer percussion because the client's test results provide more accurate information regarding cardiac enlargement. All results are within normal limits. The nurse uses a stethoscope for auscultation of the client's heart and plans to begin auscultation at the aortic area. How should the nurse plan to continue auscultation from that site? How should the nurse plan to continue auscultation from that site? Move the stethoscope back and forth across the sternum. Slide the stethoscope over and up in an "X" pattern. Lift the stethoscope from one valve area to the next. Inch the stethoscope across and down in a "Z" pattern.

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

After preparing the client, the nurse visually inspects the precordium by first observing for an apical impulse. The nurse is unable to observe the apical impulse. The nurse next assesses for a left ventricular heave. The nurse should observe the force of the impulse at what location? The nurse should observe the force of the impulse at what location? Left midclavicular line, 2nd intercostal space. Left sternal border, 4th intercostal space. Right sternal border, 2nd intercostal space. Left midclavicular line, 5th intercostal space.

Left midclavicular line, 5th intercostal space. A left ventricular heave is seen at the apex, located at the left midclavicular line, 5th intercostal space. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle.

The nurse assesses the carotid artery pulse volume 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 should the nurse do next? Reassure the client that his right artery sounds "clear" and listen on the left side. Listen at the base of the neck again, this time using the diaphragm of the stethoscope. Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. Press the bell of the stethoscope more firmly against the base of the neck and listen again.

Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. The RN should auscultate each carotid artery systematically, including the base of the neck, the mid-cervical area, and the angle of the jaw.

The nurse assesses the murmur more completely. To determine the grade of the murmur, what action should the nurse take? To determine the grade of the murmur, what action should the nurse take? Listen in surrounding areas for the extent of radiation of the sound. Assess for a change in the murmur during a change in the client's position. Determine the location on the client's chest where the murmur is best heard. Note how easily the murmur is heard by gradually lifting the stethoscope.

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

How should the nurse begin the carotid artery assessment? How should the nurse begin the carotid artery assessment? Palpate one artery while listening to the other side with a stethoscope. Palpate one artery and then palpate the artery on the opposite side. Gently compress both arteries simultaneously to compare the volume Avoid palpation and only use a stethoscope to listen to each artery.

Palpate one artery and then palpate the artery on the opposite side. This technique allows the nurse to effectively and thoroughly assess each artery.

During auscultation, the nurse has difficulty distinguishing S1 from S2 because of the client's irregular heart rhythm. While continuing to listen at the aortic site, what action should the RN take? Observe the P wave on the telemetry monitor. Watch the client's inhalation and exhalation. Palpate the carotid artery pulse. Check for a pulse deficit.

Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, the nurse can distinguish S1 as the sound that occurs with each pulsation.

The nurse hears a grade 3 systolic murmur at the apical site but does not hear either an S3 or S4 heart sound. What action should the nurse take next? What action should the nurse take next? Document the findings and report the murmur to the charge nurse. Repeat auscultation across the chest using the bell of the stethoscope. Continue assessment of heart sounds across the client's posterior thorax. Plan to repeat the assessment in 1 hour, after the client rests.

Repeat auscultation across the chest using the bell of the stethoscope. After completing assessment with the diaphragm of the stethoscope, the nurse should repeat the sequence using the bell of the stethoscope. The bell of the stethoscope is used to listen for relatively lower pitched sounds than the diaphragm.

A left ventricular heave is not observed. The nurse uses the palmar aspects of the fingers to palpate across the precordium. To begin palpation at the base of the heart, where should the nurse palpate first? Right sternal border, 2nd intercostal space. Right sternal border, 4th intercostal space. Left sternal border, 5th intercostal space. Left midclavicular line, 5th intercostal space.

Right sternal border, 2nd intercostal space. This is the location of the aortic site. The aortic and pulmonic sites are found at the base of the heart.

Before attempting to palpate again, the nurse should give the client what instruction? Before attempting to palpate again, the nurse should give the client what instruction? Lift his left arm above his head. Turn onto his right side. Externally rotate his right shoulder. Roll half-way to his left side.

Roll half-way to his left side. Turning half-way to the left side moves the apex of the heart closer to the chest wall, so it is easier to palpate.

The nurse places the diaphragm of the stethoscope at the second right interspace. In listening at this site, what should the nurse attempt to distinguish first? In listening at this site, what should the nurse attempt to distinguish first? S1 and S2 heart sounds. Diastolic heart murmur. S3 and S4 heart sounds. Systolic heart murmur.

S1 and S2 heart sounds. The nurse should begin by listening for the normal heart sounds, S1 and S2, before attempting to distinguish abnormal heart sounds, such as S3 and S4 or heart murmurs.

The nurse uses the SBAR method when communicating with the primary HCP. Which are components of the SBAR method? Select all that apply The nurse uses the SBAR method when communicating with the primary HCP. Which are components of the SBAR method? Assessment. Response. Recommendation. Action. Situation.

Situation Background Assessment Recommendation END Based on the nurse's prompt report of Mr. Kapur's change in condition, the HCP prescribes medications to treat early onset heart failure. Treatment is effective, and Dev is discharged 5 days later.

The nurse continues the assessment, ending at the apical site. The nurse hears a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope. How should the nurse identify this sound? Diastolic murmur. Systolic murmur. S4 heart sound. S3 heart sound.

Systolic murmur. Murmurs are often heard as a swooshing sound. Systolic murmurs coincide with the S1 heart sound.

While listening to the client's heart sounds at the apical site, the nurse now hears a dull soft sound following S2. What action will help the nurse confirm the presence of this sound? What action will help the nurse confirm the presence of this sound? Move the diaphragm of the stethoscope to the base of the heart. Use the bell of the stethoscope to continue listening at the apical site. Palpate the apical impulse while listening at the base of the heart. Place the bell of the stethoscope at the right sternal border at the third interspace.

Use the bell of the stethoscope to continue listening at the apical site. A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope.