PrepU ch. 17

The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action?

Closure of the atrioventricular valves

The nurse positions the client for auscultation of heart sounds. What does the nurse do first?

Clean the stethoscope

A client has engorged jugular veins. What should this finding suggest to the nurse?

right atrial pressure

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 integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease?

"Your risk for heart disease will drop greatly if you're able to stop smoking."

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

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

Angina

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

Apical impulse

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.

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

Bruits

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

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 places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

Erb point

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

Flat neck veins

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

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

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?

Heart failure

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 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

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

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.

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

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 group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying it as which of the following?

Myocardium

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 medications 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 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 preparing to assess a client's carotid arteries. Which of the following would be most appropriate?

Palpate each artery individually to compare

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

Patient C

What is the most important physical sign of acute pericarditis?

Pericardial friction rub

A community health nurse is planning a screening day for blood pressure andcholesterol. What kind of prevention would this be?

Secondary

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 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

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.

Smoking Blood Pressure Cholesterol

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.

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?

Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

The client may be experiencing symptoms of heart failure.

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

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.

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes.

The bicuspid, or mitral, valve is located

between left atrium and 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

increased central 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

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

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

right atrium

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 at the left sternal border.