HA Cardiovascular Assessment

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

1+ pules

The nurse assesses the client's pulses to be normal. These would be documented how?

2+

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

3rd to 5th ICS at the left sternal border

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

4+

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

While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is

Associated with occlusive arterial disease

An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist?

Atherosclerotic stenotic carotid arteries

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

Atrial depolarization

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

Bruits

A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?

Check for pulse inequality between right and left carotid arteries

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply.

Choose foods like bananas and sweet potatoes, use a low sodium seasoning to flavor food, walk briskly 30 min. a day

A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what?

Closure of the mitral and tricuspid valves

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

Do you have any pain/discomfort in your chest?

The nurse is participating in a health fair and performing cholesterol screens. One person has hypercholesterolemia. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease?

Gender

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

Ineffective tissue perfusion

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

What is the most important physical sign of acute pericarditis?

Pericardial Friction Rub

When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the

Right atrium

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?

Sinus Arrythmia

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

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's

apex of the heart

The nurse assesses a client's chest as shown. What is the nurse assessing?

apical impluse

The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's

apical pulse

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

apical pulse

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

assess for a difference between the apical and radial pulse

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle

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 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

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, smoking, blood pressure

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 increased chest diameter

What is responsible for the inspiratory splitting of S2?

closure of aortic then pulmonic 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

After conducting a physical examination of a client, the nurse suspects hypertrophy of the left ventricle. What is a characteristic of the apical impulse that is useful in confirming this suspicion?

duration

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

have the client hold his/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

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

The nursing instructor explains to a group of students that what can shorten diastole?

increased heart rate

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

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

inspect for dependent edema

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

is normally smaller than the male heart

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

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem?

left sided heart failure

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

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 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?

myocardium

Which of the following would the nurse consider to be an urgent situation?

new onset chest pain

A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?

no current medication or treatments

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?

orthopnea

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

palpating the carotid pulses simultaneously

What is the most important lifestyle changes a client can make to improve cardiovascular health?

quitting smoking

The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should

recgonize that this finding is normal in adolescents

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?

severe sepsis

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

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?

summation gallop

What finding upon assessment would indicate the client is experiencing shock?

systolic blood pressure 50

The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output?

tachypnea; hypotension