NUR 201 PrepU ch. 17
To function adequately, the nurse knows that the heart valves need to open simultaneously.
false
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 a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?
+4 explanation: The strength of the pulse is evaluated on a scale from 0 to 4 as follows: 0 = Absent; 1+ = Weak; 2+ = Normal; 3+ = Increased; 4+ = Bounding.
The nurse prepares to assess a client's carotid arteries. Which technique should the nurse use during this assessment? Select all that apply.
Auscultate the carotid pulse first Ask to hold the breath during the auscultation explanation: When assessing the carotid arteries, the nurse should ask the client to hold the breath during auscultation and auscultate first before palpating because palpating may change the rate of the pulse. There is no reason for the client to be in the supine or high-Fowler position. The client should be positioned for comfort.
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 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 is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.
Eat foods low in sodium. Walk for at least 30 minutes/day. explanation: Use relaxation techniques to manage stress.Measures to reduce the risk of CHD include eating 3½ ounces equivalent of cocoa such as dark chocolate each day to help lower blood pressure; eating foods low in saturated fats, trans fatty acids, cholesterol, and sodium; participating in an active exercise program such as walking at least 30 minutes per day; limiting alcohol intake to 2 drinks per day for men and 1 drink per day for women; managing stress by reducing personal stress as much as possible, trying muscle relaxation and deep breathing.
Which is true of a third heart sound (S3)?
It is caused by rapid deceleration of blood against the ventricular wall. explanation: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.
The term "base of the heart" refers to which of the following areas of the heart?
Right and left 2nd intercostal spaces, close to the sternum explanation: The site at which the right ventricle narrows as it rises to meet the pulmonary artery at the level of the sternum is called the "base of the heart." It is located at the right and left 2nd intercostal spaces close to the sternum.
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following?
a narrowed vessel explanation: A swishing sound on auscultation is a bruit which is caused by turbulent blood flow through a narrowed vessel. A bruit does not indicate decreased cardiac output. Increased central venous pressure or right heart failure would be indicated by jugular venous distention.
What term is used to describe the degree of vascular resistance to ventricular contraction?
afterload explanation: Afterload refers to the degree of vascular resistance to ventricular contraction.
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible
angina explanation: Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw.
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?
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 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 explanation: The closure of the aortic and pulmonic valves creates the second heart sound, which is heard louder over the 2nd intercostal space right sternal border. The closure of the tricuspid and mitral valves creates the first heart sound. The pulmonic and tricuspid valves do not close together. The mitral and aortic valves do not close together.
The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
aortic stenosis, with pressure overload of the left ventricle explanation: Pressure overload of the left ventricle, as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.
The semilunar valves are located
at the exits of each ventricle at the beginning of the great vessles explanation: 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 explanation: The small P wave indicates atrial depolarization (duration up to 80 msec; PR interval 120 to 200 msec).
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 explanation: If the nurse detects an irregular rhythm, the nurse needs to auscultate for a pulse rate deficit, which may provide further evidence of atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. The client also should be referred for further evaluation because irregular rhythms may predispose the client to decreased cardiac output, heart failure, or emboli. It would not be necessary to inspect for a lift or palpate for a thrill. These would most likely have already been completed. Listening for a ventricular gallop would occur later, when the nurse is auscultating for normal and abnormal heart sounds.
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?
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.
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for
cardiac murmur explanation: A thrill or a pulsation is usually associated with a grade IV or higher murmur.
The nurse assesses a client's neck as shown. What is the nurse assessing?
carotid artery explanation: The carotid arteries are located in the depression between the trachea and sternomastoid muscle in the anterior neck and run parallel to the trachea from clavicle to jaw bilaterally. The internal jugular vein is deeper and nearer the carotid artery. Because of its location, it usually is not visible; because it is a vein, it is not palpable. The external jugular vein is visible in the depression above the middle of the clavicle. It is lateral instead of anterior to the sternomastoid muscle and travels from the clavicle up to the jaw line. The thyroid gland is located anteriorly over the trachea.
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 explanations: The nurse should check for pulse inequality between the right and left carotid arteries, because differences in the amplitude or rate of the carotid pulse may indicate stenosis. Pulse deficit is detected by assessing the difference in the apical and radial pulses. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume.
Which of the following events occurs at the start of diastole?
closure of the aortic valve explanation: At the beginning of diastole, the valves that allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).
The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?
closure of the atrioventricular valves explanation: The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action?
closure of the atrioventrucular valves explanation: The first heart sound is the result of closure of the atrioventricular valves. The second heart sound is the result of closure of the semilunar valves. Ventricular contraction is isometric when all four valves are closed during systole. Diastole occurs when the AV valves are open and the ventricles are relaxed.
A nurse understands that the cardiac event that cycles the beginning of systole is what?
closure of the mitral and tricuspid valves explanation: The beginning of systole occurs when the pressure in the ventricles exceeds the pressure in the atrium causing the mitral and tricuspid valves to close. This closure produces the first heart sound (S1). The ventricles contract and empty of the blood volume which causes the pressure to drop and the aortic and pulmonic valves close. This produces the second heart sound (S2). Relaxation and contraction of the ventricles do not produce heart sounds.
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?
closure of the semilunar valves explanation: Closure of the semilunar valves, which are the aortic and pulmonic valves, cause the second heart sound of S2. The closure of these valves signals the end of systole. Isometric contraction occurs when all valves are closed, which occurs just before systole in which no sound is produced. Closure of the atrioventricular valves produces the S1 heart sound, which is the beginning of systole. Ventricular contraction is the occurrence of systole, which produces not sound but causes ejection of blood from the ventricles.
The P-wave phase of an electrocardiogram (ECG) represents
conduction of the impulse throughout the atria explanation: The P wave indicates atrial depolarization; conduction of the impulse throughout the atria.
A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?
grade 5 explanation: A very loud murmur that can be heard with the stethoscope partly off the chest is graded as Grade 5. A Grade 1 is very faint and a Grade 6 can be heard with the stethoscope entirely off the chest. A Grade 2 is quiet but heard immediately on placing the stethoscope on the chest.
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?
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.
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 III/VI systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?
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 is not enough criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective health Maintenance.
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 explanation: The jugular venous pulse is important for determining the hemodynamics of the right side of the heart. The level of the jugular venous pressure reflects right atrial (central venous) pressures, and usually right ventricular diastolic filling pressure. The carotid artery pulse is a centrally located pulse on both sides of the neck that supply blood and oxygen to the neck and head. The apical pulse is located on chest in the mitral valve area and is the result of left ventricle movement during systole. Heart sounds, such as S1 and S2, are produced by the closure of the valves and are auscultated over the entire precordium.
A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position?
leaning forwards while in a sitting postion explanation: For best results, the nurse would use the diaphragm of the stethoscope and have the client sit up, lean forward, exhale, and hold his or her breath. The left lateral position may be used to hear an S3 or S4 heart sound or a murmur of mitral stenosis that was not detected in the supine position.
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 explanation: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If the examiner does not listen in a quiet room to the heart in this position with both the diaphragm and bell, it is possible to miss significant murmurs such as mitral stenosis.
Variations in the presentation of S1 are due to alterations in which heart valve?
mitral explanation: The sound of S1 is produced at the onset of systole, which is the closure of the mitral and tricuspid valves. The variations in the intensity of S1 are due to the position of the mitral valve at the start of systole and can cause the sound to be accentuated, diminished, or variable. The tricuspid valve is involved when there is a split S1, which causes the ventricles to contract at different times. The aortic and pulmonic valve closures produce the sound of S2.
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following?
mitral stenosis explanation: An accentuated S1 sound is louder than an S2 sound. This occurs when the mitral valve is wide open and closes quickly such as in hyperkinetic states (e.g., fever, anemia, hyperthyroidism) or mitral stenosis. A heart murmur reflects turbulent blood flow.
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 valve explanation: Mitral valve sounds are usually heard best at and around the cardiac apex.
While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of
mitral valve stenosis explanation: Opening snaps occur early in diastole and indicate mitral valve stenosis.
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
observe for a decrease in jugular veinous pressure explanation: Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume, so the nurse should observe for a decrease in jugular venous pressure. Assessing the difference in the apical and radial pulses would help the nurse assess for pulse deficit. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction).
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?
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.
What is the most important physical sign of acute pericarditis?
pericardial friction rub explanation: A pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the patient is upright and leaning forward. Acute pericarditis, elevated white cell count, and a murmur heard over the left sternal border would not be the primary physical sign of the condition.
When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?
summation gallop explanation: Presence of both S3 and S4 is referred to as a "summation gallop." Atrial kick is the additional flow of blood from the atrium to the ventricles as the atrium contract. Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the S1 sound. Diastolic clicks can be found in clients with mitral valve prolapse as the valve does not close properly.
A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?
systematically listen to the entire pre-cordium explanation: When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apex or from the apex to the base. Both the diaphragm and bell are used. Inspection and palpation usually precede auscultation. It is not necessary to begin with breath sounds.
A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?
systematically listen to the entire precordium explanation: When auscultating heart sounds, the nurse would need to emphasize the need to cover the entire precordium, using a systematic approach moving the stethoscope from left to right across the entire heart area from the base to the apex or from the apex to the base. Both the diaphragm and bell are used. Inspection and palpation usually precede auscultation. It is not necessary to begin with breath sounds.
The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be normal in a healthy client?
the jugular venous pulse is not visible when the patient is sitting upright explanation: The jugular venous pulse is not normally visible with the client sitting upright. Jugular venous distention and a visible jugular venous pulse in a supine position are pathologic findings.
The nurse on the cardiac unit is caring for a patient who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this patient, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein?
they are more than double the risk of cardiac disease explanation: The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.
The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?
6 explanation: Normal cardiac out put ranges from 5-8 L/min.
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 explanation: The beginning of systole occurs when the pressure in the ventricles exceeds the pressure in the atrium, causing the mitral and tricuspid valves to close. This closure produces the first heart sound (S1). The ventricles contract and empty of the blood volume, which causes the pressure to drop and the aortic and pulmonic valves close. This produces the second heart sound (S2). Relaxation and contraction of the ventricles do not produce heart sounds.
A nurse receives a client from the cardiac catheterization laboratory. The client is on bed rest and has a weight on the puncture site of the right groin. What must the nurse assess for frequently? Select all that apply.
Hematoma at the puncture site Bleeding at the puncture site Increased blood pressure, which could cause excess bleeding or hematoma explanation: Left-sided heart catheterization involves placing a catheter through the femoral artery to the coronary arteries where dye is used for visualization. Following the procedure, the client is on bed rest and the puncture site and distal circulation must be monitored frequently. Nursing staff also monitor blood pressure and cardiac rhythm.
A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization?
T wave explanation: The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?
The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle explanation: PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction).
A client complains of chest pain. The nurse understands that chest pain can have causes other than cardiac pain, thus follows up with the client regarding the timing and quality of this pain. Which of the following would indicate cardiac pain as opposed to other types? Select all that apply.
Worsens with activity May occur at any time Radiates to left shoulder and down the left arm Has a squeezing sensation around the heart explanation: Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity. Gastrointestinal pain may occur after meals and is relieved with antacids.
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 explanation: S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).
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 lateral left position explanation: If unable to locate the apical impulse, ask the client to turn to the left lateral position. This displaces the heart towards the left chest wall and relocates the apical impulse farther to the left. Using one finger is appropriate after locating the pulse for a more accurate palpation. Coughing will not assist in location of the apical impulse. The nurse should locate the apical impulse by palpation before auscultating heart sounds.
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 explanation: A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease.
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?
fifth intercostal space, mid-clavicular line explanation: The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line.
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?
blood pressure explanation: With decreased cardiac output, the heart pumps inadequate blood to meet the body's metabolic demands. The blood pressure is most important to assess frequently.
What is responsible for the inspiratory splitting of S2?
closure of aortic and then pulmonic valves explanation: During inspiration, the closures of the aortic valve and pulmonic valves separate slightly, and this may be heard as two audible components instead of as a single sound. Current explanations of inspiratory splitting include increased capacitance(electrical charge) in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, the examiner may not hear it away from the left second intercostal space. Because it is a low-pitched sound, the examiner may not hear it without use of the bell of the stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?
closure of the semilunar valves explanation: Closure of the semilunar valves, which are the aortic and pulmonic valves, causes the second heart sound, S2. The closure of these valves signals the end of systole. Isometric contraction occurs when all valves are closed, which occurs just before systole, in which no sound is produced. Closure of the AV valves produces the S1 heart sound, which is the beginning of systole. Ventricular contraction is the occurrence of systole, which produces not sound but causes ejection of blood from the ventricles.
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency?
diminished explanation: A client with mitral insufficiency would most likely exhibit a diminished S1 sound. A split S1 sound would be heard with conduction delays and ventricular ectopy. An accentuated S1 sound would be heard in hyperkinetic states and mitral stenosis. Varying S1 sound would be heard with atrial fibrillation.
After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel?
femoral artery explanation: The large veins and arteries leading directly to and away from the heart are the great vessels and include the superior and inferior vena cava, the pulmonary artery and vein, and the aorta. The femoral artery is a distracter for the question.
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?
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 patients with elevated JVD have heart failure.
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 levels of low-density lipoproteins explanations: Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis.
The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following?
identify heart sounds that may be inaudible in other positions explanation: Otherwise undetectable heart sounds may be revealed with alternative positioning. These positions are not adopted primarily to relieve shortness of breath or to assess mobility.
A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this?
increased distance from the apex of the heart to the precordium explanation: In addition, it may be difficult to palpate the apical impulse in clients who are obese or barrel chested because these conditions increase the distance from the apex of the heart to the pre cordium. The other answers are not likely reasons for the nurse's inability to find the apical pulse.
The nursing instructor explains to a group of students that what can shorten diastole?
increased heart rate explanation: As the heart rate increases, the length of diastole is shortened. The respiratory rate, blood pressure and filling pressures do not shorten diastole.
This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the patient turned to the left. The carotid arteries are auscultated one at a time for bruits. The 2nd left intercostal space is the location to hear pulmonic valve conditions.
place the bell of the stethoscope over the apex with client on left side explanation: This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the patient turned to the left. The carotid arteries are auscultated one at a time for bruits. The 2nd left intercostal space is the location to hear pulmonic valve conditions.
A client has engorged jugular veins. What should this finding suggest to the nurse?
right atrial pressure explanation: Jugular venous pressure (JVP) reflects right atrial pressure. Engorged jugular veins are seen in right or left heart failure, pulmonary hypertension, tricuspid stenosis, and pericardial compression or tamponade. The jugular veins are not used to estimate the integrity of the aorta, patency of carotid arteries, or the closure of the tricuspid valves.
When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest?
right sternal border, 2nd ICS explanation: Aortic Stenosis is a midsystolic ejection murmur begins after S1, crescendos, and then decrescendos before S2. It radiates upward to the right second ICS and into the neck. It is soft to loud, with a medium pitch and harsh quality. It is associated with ejection click, split S2. It's best heard over the 2nd or 3rd right intercostal space.
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 arrhythmia explanation: A heart rate that speeds with inspiration and slows with exhalation is termed Sinus Arrhythmia. This is often a normal rhythm in young children and well conditioned athletes. Premature Ventricular Contractions and Premature Atrial Contractions occur earlier than expected. Atrial Fibrillation causes the ventricles to beat irregularly.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization?
t wave explanation: The T wave indicates ventricular repolarization, when the ventricles return to a resting state. The P wave indicates atrial depolarization and conduction of the impulse throughout the atria. The QRS complex indicates ventricular depolarization with conduction of the impulse throughout the ventricles. The ST segment indicates the period between ventricular depolarization and the beginning of ventricular repolarization.
The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?
the clients ventricles are not contracting simultaneously explanation: A split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction). This finding is not associated with an incompetent aortic valve, left ventricular hypertrophy, or lack of synchronicity between the atria and ventricles.
