ATI Health Assess 2.0: Cardiovascular

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck." Rationale: Focused lighting, such as from a penlight, will enhance visualization of the blood vessels in the neck to check for pulsations and distention.

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds Rationale: Capillary refill should be less than or equal to 2 seconds. This finding should be reported to the provider for further evaluation.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?

Limit sodium intake to less than 3,000 mg/day. Rationale: A heart-healthy diet aims to reduce the client's sodium intake to no more than 2 to 3 g/day. Excess sodium can lead to hypertension, which is a risk factor for cardiovascular disease.

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.)

Rationale: "I am going to start walking several times a week" is correct. The Centers for Disease Control and Prevention (CDC) recommend that adults engage in at least 150 min per week of activity of moderate physical intensity. "I plan to join a support group to help me stop smoking" is correct. Smoking increases the risk for developing cardiovascular disease due to increased oxygen demands, increased clotting, and adverse effects on lipid profiles. "I will be sure to have my blood pressure checked at least every year" is correct. Monitoring blood pressure is a component of screening for cardiovascular health issues. Untreated high blood pressure can increase the risk of developing cardiovascular disease.

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.)

Rationale: Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct. A full and bounding pulse in the carotid arteries upon palpation is an unexpected finding and should be reported to the provider. This may indicate fluid overload or heart failure. Distention of the jugular vein on one side of the neck is correct. A distention of one or both jugular veins is not expected and may be an indicator of right-sided heart failure or an obstruction in the blood vessel. This finding should be reported to the provider. The left carotid artery pulse is weak is correct. This is an unexpected finding and should be reported to the provider. The carotid arteries should be moderate in strength bilaterally. A weak pulse can indicate a blockage or narrowing of the artery.

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply.)

Rationale: Instruct the client to sit with their legs uncrossed is correct. The nurse should instruct the client to avoid crossing their legs and wearing constructive clothing to prevent decreasing circulation. Encourage the client to avoid tobacco products is correct. The chemicals in tobacco cause vasoconstriction and decrease blood flow to the extremities. Instruct the client to cleanse the area with mild soap is correct. Cleansing the area with a mild soap and lukewarm water promotes wound healing. Instruct the client to wear shoes when ambulating is correct. Wearing shoes when ambulating provides protection from further injury.

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report?

A forceful chest movement at the midclavicular line in the fourth intercostal space Rationale: A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is termed a heave or lift. This finding is associated with an enlarged left ventricle. This is an unexpected finding and should be reported to the provider.

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

An adolescent who has an s3 heart sound Rationale: In children and young adults, it is an expected variation to hear the S3 heart sound, which is a vibration that results from rapid filling of the ventricles.

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated

D Rationale: D is correct. The nurse should auscultate in this area for 1 min to determine the rate, rhythm, and pitch of the apical pulse. This area, at the apex of the heart, is where sounds generated by the mitral valve between the left atrium and ventricle are best heard and is termed the apical impulse or point of maximal impulse. The mitral heart sound is located at the fifth intercostal space in the left midclavicular area.

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client Rationale: The nurse can provide the client with information about meditation, which is a stress-reduction activity. The nurse may also discuss other stress-reduction activities, such as yoga, guided imagery, or hobbies.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of the bed at a 45° angle. Rationale: Having the client positioned supine with the head of their bed at a 35° to 45° angle assists the nurse in visualizing the pulsation of the carotid arteries and the jugular vein.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?

Palpable dorsalis pedal pulse Rationale: The pedal pulses remain present in clients who have peripheral venous disease. Absent pedal pulses are consistent with arterial insufficiency.

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

Rationale: Auscultate the apical pulse is correct. Auscultating the rate and rhythm of the apical pulse is included in an assessment of the cardiovascular system. Ask the client if they experience shortness of breath is correct. Shortness of breath can be an indication of alterations in the cardiovascular system that result in fluid accumulation in the lungs. Check the color of the client's skin is correct. The nurse should inspect the color of the client's skin during a cardiovascular assessment. The presence of pallor, cyanosis, or a grey color can indicate an alteration in the cardiovascular system. Inspect the extremities for the presence of edema is correct. The nurse should inspect for the presence of edema during a cardiovascular assessment. Alterations in the efficiency of the cardiovascular system can result in the presence of edema in the lower portion of the body.

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rationale: Elevate the head of the bed 30° and instruct the client to breath normally is the first step. The nurse should instruct the client to breath normally and explain to them that they'll be listening to the heart in several places. The nurse should then position the client supine with the head of the bed elevated to a 30° angle. Visualize the anatomy of the heart is the second step. The nurse should visualize the anatomy of the heart as they auscultate to ensure they are listening in the correct area. Place the stethoscope to the right sternal border at the second intercostal space is the third step. The nurse should place the stethoscope to the right sternal border at the second intercostal space to begin auscultation of the aortic valve. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. This is the location for auscultation of the tricuspid valve. Auscultate the apical pulse for 1 min is the fifth step. The last heart sound is the mitral heart sound. This is where the apical pulse is heard and should be auscultated for 1 min to note rate, rhythm, and presence of the S1 heart sound.

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?

Sibling who has hypertension Rationale: Hypertension can have a negative impact on cardiovascular health. An immediate family member, such as a sibling, who has hypertension increases the likelihood that the client will develop hypertension due to genetics.