Cardiovascular

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? a.Parent who experiences a pulmonary embolism b. Sibling who has hypertension c. Cousin who has diabetes d. child who has epilepsy

B. Sibiling who has hypertension Rational: - Hypertension can have a negative impact on cardiovascular health. An immediate family member, such as a sibling, who has hypertension increases the likelihood that the client will develop hypertension due to genetics.

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? a. Instruct the client to vary the time they go to sleep each night b. Have the client check their bp daily c. Discuss the benefits of meditation with the client. d. Have the client limit their exercise program until the stress has decreased

C. Discuss the benefits of meditation with the client Rationale: The nurse can provide the client with information about meditation which is a stress-reduction activity. The nurse may also discuss other stress-reduction activities, such as yoga, guided imagery, or hobbies

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) a. "I am going to start walking several times a week." b. "I plan to join a support group to help me stop smoking." c. "If my HDL cholesterol levels are high, it can hurt my heart." d. "I will be sure to have my blood pressure checked at least every year." e. "Eating more low-fiber foods and processed carbohydrates will make my heart healthier."

a. "I am going to start walking several times a week." Rationale: CDC recommends that adults engage in at least 150 min per week of activity of moderate physical intensity. b. "I plan to join a support group to help me stop smoking." Rational: Smoking increases the risk for developing cardiovascular disease due to increased oxygen demands, increased clotting, and adverse effects on lipid profiles. d. "I will be sure to have my blood pressure checked at least every year." Rationale: Monitoring blood pressure is a component of screening for cardiovascular health issues. Untreated high blood pressure can increase the risk for developing cardiovascular disease. c. "Eating more low-fiber food and processed carbohydrates will make my heart healthier." Rationale: A heart-healthy diet consists of fruits, vegetables, whole grains, fish, and dairy products. A diet in refined low-fiber grains and processed foods contributes to the development of cardiovascular disease.

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? a. "The penlight will allow me to look at the pulses in your neck." b. "The penlight will allow me to locate your pedal pulse." c. "The penlight will be used to check your skin turgor." d. "The penlight will be used to evaluate the effort that you use to breathe."

a. "The penlight will allow me to look at the pulses in your neck." rationale: Focused lighting, such as from a penlight, will enhance visualization of the blood vessels in the neck to check for pulsations and distention.

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? a. An adolescent who has a S3 heart sounds b. An older adult who has a heart rate of 48/min c. A young adult who has an irregular apical pulse d. A middle adult who has a murmur

a. An adolescent who has a S3 heart sound Rationale: In children and young adults, it is an expected variation to hear the S3 heart sound, which is a vibration that results from rapid filling of the ventricles - heart rate less than 60/min is bradycardia and should be reported - failure of the heart to beat at regular intervals can be life-threatening

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) a. Auscultate the apical pulse b. Ask the client if they experience shortness of breath c. check the color of the client's skin d. auscultate bowel motility e. Inspect the extremities for the presence of edema

a. Auscultate the apical pulse Rationale: Auscultating the rate and rhythm of the apical pulse is included in an assessment of the cardiovascular system. b. Ask the client if they experience shortness of breath Rationale: Shortness of breath can be an indication of alterations in the cardiovascular system that result in fluid accumulation in the lungs c. Check the color of the client's skin Rationale: Inspect the color of the client's skin during a cardiovascular assessment. The presence of pallor, cyanosis, or a grey color indicate an alteration in the cardiovascular system. e. Inspect the extremities for the presence of edema Rationale: Alterations in the efficiency of the cardiovascular system can result in the presence of edema in the lower portion of the body.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider? a. Capillary refill of 3 seconds b. +2 radial pulse c. Fingernail with 160 curvature d. Oxygen saturation 98%

a. Capillary refill of 3 seconds Rationale: Capillary refill should be less than or equal to 2 seconds. This finding should be reported to the provider for further evaluation.

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.) a. Visible pulsations observed in the carotid area on both sides of the neck b. Full, bonding pulse noted bilaterally in the carotid arteries upon palpation c. Distention of the jugular vein on one side of the neck d. Flattening of the jugular veins when the client sits upright. e. The left carotid artery pulse is weak

b. Full, bounding pulse is noted bilaterally in the carotid arteries upon palpation Rationale: May indicate fluid overload or heart failure c. Distention of the jugular vein on one side of the neck Rationale: A distention of one or both jugular veins is not expected and may be an indicator of right-sided heart failure or an obstruction in the blood vessel. This finding should be reported to a provider e. The left carotid artery pulse is weak Rational: Carotid arteries should be moderate in strength bilaterally. A weak pulse can indicate a blockage or narrowing of the artery.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? a. Place the client in high-fowler's position b. Have the client lay supine with the head of their bed at a 45 angle c. Have the client seated with their chin touching their chest d. Place the client in a left lateral position

b. Have the client lay supine with the head of their bed at a 45 angle Rationale: Having the client positioned supine with the head of their bed at a 35- 45 degree angle assists the nurse in visualizing the pulsation of the carotid arteries and the jugular vein.

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) a. Instruct the client to apply warm heat for pain b. Instruct the client to sit with their legs uncrossed c. Encourage the client to avoid tobacco products d. Instruct the client to cleanse the area with mild soap e. Instruct the client to wear shoes when ambulating

b. Instruct the client to sit with their legs uncrossed Rationale : Avoid crossing legs and wearing constructive clothing to prevent decreasing circulation c. Encourage the client to avoid tobacco products Rationale: The chemicals in tobacco cause vasoconstriction and decrease blood flow to extremities d. Instruct the client to cleanse the area with mild soap Rationale: Cleansing the area with a mild soap and lukewarm water promotes wound healing e. Instruct the client too wear shoes when ambulating Rationale: Wearing shoes when ambulating provides protection from further injury *** Avoid using heating pads or bathing with hot water to avoid burns or further injury to extremities***

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommedations should the nurse include? a. Increase intake of red meat b. Limit sodium intake to less than 3,000 mg/day c. Increase intake of foods high in trans fat d. Drink whole milk

b. Limit sodium intake to less than 3,000 mg/day Rationale: A heart-healthy diet aims to reduce the client's sodium intake to no more than 2 to 3 g/day. Excess sodium can lead to hypertension, which is a risk factor for cardiovascular disease.

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? a. Loss of hair on the lower leg b. Cool skin temperature in the lower leg c. Palpable dorsalis pedal pulse d. Regular, uneven wound border

c. Palpable dorsalis pedal pulse Rationale: Pedal pulses remain present in clients who have peripheral venous disease. Absent pedal pulses are consistent with arterial insufficiency - loss of hair is consistent with arterial insufficiency - cool skin temperature in lower leg is consistent with arterial insufficiency

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider? a. The point of maximal impulse (PMI) located at the fifth intercostal space b. Symmetrical chest movements during inhalation and expiration c. Absent visible pulsation in the area of the point of maximal impulse (PMI) d. A forceful chest movement at the midclavicular line in the fourth intercostal space

d. A forceful chest movement at the midclavicular line in the fourth intercostal space Rationale: A forceful thrusting movement of the chest at the PMI is termed a heave of lift. This finding is associated with an enlarged left ventricle. This is an unexpected finding and should be reported to the provider.