prepU ch. 14 nurs 210
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?
Bruits
The nurse assesses a client's chest as shown. What is the nurse assessing?
Apical impulse
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
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 prescribed diuretic.
A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next?
Auscultate for pulse rate deficit.
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
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 evaluating a client's jugular venous pressure. Which of the following findings would tend to indicate obstructive pulmonary disease?
Elevated venous pressure only during expiration
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?
Fifth intercostal space, left midclavicular line
How does the nurse differentiate a pleural friction rub from a pericardial friction rub?
Have the client hold his or her breath; if the rub persists, it is pericardial
During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?
Heart attacks in his father and siblings
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?
Hypertension is more prevalent in African Americans than among Caucasians.
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
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
The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate?
Palpate each artery individually to compare
The nurse is assessing the carotid arteries of a client with a history of heart disease. What action should the nurse perform during this assessment?
Palpate the client's carotid arteries gently if an occlusion is audible.
The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique?
Palpating carotid pulses simultaneously.
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?
Pericardial friction rub
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?
Pericardial friction rub
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1
A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?
Shortness of breath
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?
Sinoatrial node
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.
When, in the cardiac cycle, does blood pressure peak?
Systole
After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following?
Ventricles
The nurse is having difficulty locating a client's point of maximum impulse. What should the nurse do to facilitate this assessment?
assist the client into a left lateral decubitus position
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.