Health assessment

An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is

High serum level of low density lipoproteins

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How should this documentation be corrected?

"Right carotid bruit auscultated"

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? Select all that apply.

-Cholesterol -Blood pressure -Smoking

Which symptoms would indicate to the nurse the client may be experiencing a cardiac event? Select all that apply.

-Dyspnea -Diaphoresis -Chest pain -Fatigue

The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply.

-Increased cardiac output -Increased blood pressure -Increased heart rate

A 25-year-old client presents to the health care clinic for a routine physical. Which lifestyle practices in the client's history should the nurse provide teaching about to assist the client to reduce the risk of developing coronary heart disease? Select all that apply.

-Smokes 5 cigarettes a day for 5 years. -High stress job as a financial analyst -Family history of heart attack before the age of 50

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

1+ pulses

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next?

2nd intercostal space left sternal border

The area known as Erb's point is the third site for auscultation on the precordium. Where is it located?

3rd left rib space

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?

4 +

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

6

The nursing instructor is discussing assessment of the heart with students. A student states that he has a client with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A thrill

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?

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 this heart sound? S2 is:

Accentuated

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action?

Administer a prescribed diuretic

the nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurses best action?

Administer prescribed diuretic

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

Aortic and Pulmonic

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

Apical impulse

A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?

Ask the client to assume the left lateral position

How should a nurse assess a clients pulse rate for deficit?

Assess for a difference between the apical and radial pulse

The semilunar valves are located

At the exit of each ventricle at the beginning of the great vessels

The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer?

Atrial depolarization

As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?

Atrioventricular (AV) node

which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds

Auscultate to determine the heart rate and if the rhythm is normal

The bicuspid, or mitral, valve is located

Between the left atrium and the left ventricle

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

Blood pressure

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?

Bradycardia

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

Bruits

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?

Client has an increased chest diameter

The S4 heart sound

Can be heard during diastole

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?

Cardiac cycle

A nurse is unable to palpate the apical impulse on a client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter

A nurse is unable to palpate the apical pulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter

The nurse is analyzing data from the assessment of a clients head and neck vessels. The clients first heart sound corresponds with what event in the cardiac cycle?

Closure of the atrioventricular valves

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?

Decreased cardiac output

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this client?

Eat low-fat, low-cholesterol meals

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

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

The nurse is assessing a clients heart and neck vessels. Which technique is most appropriate to use when examining the clients jugular venous pulse?

Have the client sit up at a 45 degree angle and inspect the suprasternal clavicles

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia

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

Increased central venous pressure

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?

Ineffective tissue perfusion

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

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

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment?

Jugular venous pulse

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

Left mid clavicular line at the fifth intercostal space

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?

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?

Mitral

A 25 year old optical technician comes to the clinic for evaluation of fatigue. As a 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?

Mitral Valve

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?

Murmur

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

Observe for a decrease in jugular venous pressure

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?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?

Orthopnea

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Orthopnea

The nurse is conducting a workshop on the measurement of jugular venous pulsations. As a part of instruction, the nurse tells the student 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?

Palpable

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

Palpating carotid pulses simultaneously

What is the most important physical sign of acute pericarditis

Pericardial Friction rub

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

Precordium

The nurse places the stethoscope at the 2nd and 3rd left intercostal space close to the sternum to assess what heart sound?

Pulmonic

The nurses the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound?

Pulmonic

The term "base of the heart" refers to which of the following areas of the heart?

Right and left 2nd intercostal space, close to the sternum

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse charts "swooshing sound heard over right carotid artery." How should this documentation be corrected?

Right carotid bruit auscultated

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?

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?

Shortness of breath

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?

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

The sternal angle at the 2nd rib space is also known as what?

The aortic area

Which of the following assessment findings would signal a pathophysiological finding to the nurse?

The intensity of the clients S1 varies between beats

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

The mediastinum, between the lungs above the diaphragm

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

Third to fifth intercostal space