NUR 3065 - PrepU Chapter 14
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 what location? AV node Bundle of His Sinoatrial node Purkinje fibers
Sinoatrial node Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here, the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles.
The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. Increased cardiac output Decreased cardiac output Increased blood pressure Decreased blood pressure Increased heart rate
Increased cardiac output Increased blood pressure Increased heart rate Explanation: When the sympathetic nervous system is stimulated, epinephrine and norepinephrine are released which causes an increased heart rate and cardiac output and increase in the blood 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 Health Maintenance Activity Intolerance Ineffective Tissue Perfusion Impaired Breathing Pattern
Ineffective Tissue Perfusion Explanation: The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion. There are not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance.
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? Increased pressure within the ventricles Incompetent mitral valve Inflammation of the pericardial sac Inability of the atria to contract
Inflammation of the pericardial sac Explanation: A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.
The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client? Low-fat, low-cholesterol meals High-protein, low-carbohydrate meals Low-cholesterol, low-carbohydrate meals High-protein, low-fat meals
Low-fat, low-cholesterol meals Explanation: This client should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the client to eat high-protein or low-carbohydrate meals since they are not the focus of the management of elevated cholesterol levels.
A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A thrill A thrust A normal finding A heave
A thrill Explanation: Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? Angina Musculoskeletal Gastrointestinal Crushing
Angina Explanation: Angina is temporary heart pain, resolving in less than 20 minutes. It can be aggravated by physical activity and stress, or there may be no triggers (unstable angina). This type of pain is not musculoskeletal, gastrointestinal, or crushing.
When a client is obese or has a thick chest wall, what is difficult to palpate? Apical impulse JVP Sternal angle Grade 4 murmur
Apical impulse Explanation: Obesity or a thick chest wall makes palpation of the apical impulse difficult.
Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Elevate the head of bed until the examiner can comfortably reach the client Listen with the bell for the high pitched sounds of normal S1S2 Auscultate to determine the heart rate and if the rhythm is normal Stand at the client's left side and perform the entire assessment from this position
Auscultate to determine the heart rate and if the rhythm is normal Explanation: The nurse should focus on one sound at a time when auscultating the precordium. Start by determining the rate and rhythm. The examiner should stand at the client's right side to perform the assessment. The client should be lying in the supine positions with the head of the bed elevated at 30 degrees. The diaphragm of the stethoscope is used to listen for the high pitched should of normal heart sounds.
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? Tachycardia Normal Bradycardia Decreased
Bradycardia Explanation: The proper documentation of this rate is bradycardia, a rate less than 60 beats per minute. The normal adult heart rate is 60 to 100 beats per minute. Tachycardia is a heart rate above 100 beats per minute. This heart rate is decreased, but this is not a proper documentation term.
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? Murmurs Normal findings Gallops Bruits
Bruits Explanation: Distinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. A gallop is a generic term for an additional heart sounds heard besides the normal S1 and S2 sound.
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? S2 Ventricular gallop Murmur S1
Murmur Explanation: Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.
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? Epicardium Myocardium Pericardium Endocardium
Myocardium Explanation: The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels.
A client has sought care with complaints of increasing swelling in her feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem? Myocardial infarction Heart block Atherosclerosis Heart failure
Heart failure Explanation: Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis.
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem? Heart failure Myocardial infarction Venous thromboembolism Peripheral arterial disease (PAD)
Heart failure Explanation: Jugular venous distention (JVD) is associated with heart failure, tricuspid regurgitation, and fluid volume overload. The neck veins appear full, and the level of pulsation may be have elevated jugular venous pressure greater than 3 cm (about 1 1/4 in.) above the sternal angle. About 75% of clients with elevated JVD have heart failure.
Over a 24-hour period there is a striking variation in blood pressure levels. What can cause these variations? (Mark all that apply.) Time of day Size of meals Sugar ingestion Noise Environmental temperature
Time of day Noise Environmental temperature Explanation: Blood pressure levels fluctuate strikingly throughout any 24-hour period, varying with physical activity; emotional state; pain; noise; environmental temperature; use of coffee, tobacco, and other drugs; and even time of day.
The bicuspid, or mitral, valve is located: between the right atrium and the right ventricle. at the beginning of the ascending aorta. between the left atrium and the left ventricle. at the exit of each ventricle near the great vessels.
between the left atrium and the left ventricle. Explanation: The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.
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: pulmonary emphysema. increased central venous pressure. patent ductus arteriosus. diastolic murmurs.
increased central venous pressure. Explanation: The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.
In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the fifth intercostal space right of the midclavicular line at the third intercostal space left midclavicular line at the third intercostal space right of midclavicular line at the fifth intercostal space
left midclavicular line at the fifth intercostal space Explanation: The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.
The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the: fourth or fifth intercostal space at the left lower sternal border. third to fifth intercostal space at the left sternal border. apex of the heart near the midclavicular line (MCL). second intercostal space at the right sternal border.
third to fifth intercostal space at the left sternal border. Explanation: Erb's point: Third to fifth intercostal space at the left sternal border.
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? Tenesmus Orthopnea Hematochezia Abdominal pain
Orthopnea Explanation: Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.
A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? Purkinje fibers Bundle of His Pacemaker Conduction system
Pacemaker Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles. All these structures make up the conduction system of the heart.
A nurse is having difficulty determining a client's heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do? Use the bell of the stethoscope to help distinguish the sounds Palpate the carotid pulse while auscultating the heart Determine the pulse deficit Palpate the apical impulse
Palpate the carotid pulse while auscultating the heart Explanation: If a nurse is having difficulty differentiating S1 from S2, the nurse should palpate the carotid pulse while auscultating the heart. The harsh sound that occurs with the carotid pulse is the S1 sound. The nurse should use the diaphragm of the stethoscope to auscultate S1 and S2 heart sounds. A pulse deficit is determined if the heart rhythm is found to be irregular. Palpating the apical impulse wouldn't provide any help in differentiating S1 and S2 sounds.
The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique? Palpating carotid pulses simultaneously. Auscultating all heart sounds with the bell and diaphragm. Inspecting bilateral jugular veins. Palpation of the point of maximum impulse on the chest.
Palpating carotid pulses simultaneously. Explanation: Carotid pulse palpation should be conducted by feeling one side at a time; otherwise the client my become dizzy or lightheaded. All other assessment techniques are correct.
While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings? Aortic ejection click Mid-systolic click Summation gallop Pericardial friction rub
Pericardial friction rub Explanation: A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A mid-systolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.
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? Aortic ejection click Midsystolic click Summation gallop Pericardial friction rub
Pericardial friction rub Explanation: A pericardial friction rub is best heard in the third intercostal space at the left sternal border and is associated with a high-pitched, scratchy sound caused by inflammation of the pericardial sac. A midsystolic click is heard in middle or late systole over the mitral or apical area. A summation gallop is the simultaneous occurrence of S3 and S4 sounds. An aortic ejection click is heard during early systole at the second right intercostal space and apex.
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 decreases the contractility of the myocardium and contributes to valvular disorders. Smoking damages the cardiac conduction system, resulting in dysrhythmias that are entirely preventable. Smoking increases the heart's workload and contributes to atherosclerosis. Smoking is a central component of metabolic syndrome.
Smoking increases the heart's workload and contributes to atherosclerosis. Explanation: Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome.
A client with heart disease is concerned about the safety of engaging in sexual intercourse with his spouse. He says that he can walk a block or two without feeling any symptoms, but cannot handle any strenuous exercise. How should the nurse respond? Advise him to avoid sexual intercourse Recommend that he assume the missionary position while engaging in intercourse Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Encourage him to take his blood pressure immediately before engaging in sexual intercourse
Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Explanation: Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart. Taking his blood pressure immediately before sex is not necessary.
