Chapter 21- Assessing Heart and Neck Vessels

The nurse assesses a patients carotid pulse and finds it to be of normal amplitude. The nurse would document this as... ?

2+

the difference between stable and unstable angina is that stable lasts ____ minutes, and unstable lasts longer than that. Unstable has no relation to _____

20, activity

The nurse is reviewing patients cardiac output. what is the normal cardiac output ranges

5-8

The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the A in this assessment model? A) Do you have any other symptoms together with your chest pain, such as nausea, sweating? B) In your experience, what kinds of activities tend to cause your chest pain? C) Would you describe your chest pain as being acute, or is it chronic? D) What changes do you have to make in order to accommodate your chest pain?.

A) Do you have any other symptoms together with your chest pain, such as nausea, sweating?

The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate? A) Increased jugular venous pressure B) Bradycardia C) Decreased blood pressure D) Dysrhythmias

A) Increased jugular venous pressure

The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.) A. examine face C.inspecting and palpating the pericordium D.examine neck E. the legs F.the hands G. ausculating the lungs

A. examine face C.inspecting and palpating the pericordium D.examine neck G. ausculating the lungs

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? A) 1 B) 2 C) 3 D) 4

B) 2

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? A) 1+ B) 2+ C) 3+ D) 4+

B) 2+

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 which of the following locations? A) Bundle of His B) Purkinje fibers C) Sinoatrial node D) AV node

C) Sinoatrial node

the nurse is preparing to assess a patients carotid arteries. how should she palpate each artery? A) palpate the arteries before ausculating them B) ask the patient to breathe in and out deeply C) use the diaphragm of the stethoscope D) palpate each artery individually to compare

D

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? A) Isometric contraction B) Closure of the semilunar valves C) Beginning of diastole D) Closure of the atrioventricular valves

D) Closure of the atrioventricular valves

A nurse cares for a patient who suffered a myocardial infarction two days ago. a high pitched, scratchy scraping sound is heard that increases with exhalation and when the patient leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? A) inability of the atria to contract B) increased pressure within the ventricle C) incompetent mitral valve D) inflammation of the pericardial sac

D) inflammation of the pericardial sac

points for listening to the heart All, people, enjoy, time, magazine

aortic, pulmonic, erb's point, tricuspid, mitral

what occurs during systole

closing AV valves, opening semilunar

what occurs during diastole

closing semilunar valve, opening AV valves

what is responsible for the inspiratory splitting of s2

closure of aortic then pulmonic valves

areas of chest wall are visiably pulsating

heaves

what are two examples of atrioventricular valves

tricuspid and mitral

When performing an adult cardiac examination and listening to the S1 and S2, the nurse may ... (2 answers)

use the diaphragm of the stethoscope, use the bell of the stethoscope pressed firmly on the chest

what are two examples of semilunar valves

pulmonic and aoritc

During the auscultation of a patients heart sounds, the nurse hears a fixed s2 split. what does this heart sound indicate to the nurse

right ventricular failure

what is the function of the atrioventricular valve

separates atria from ventricles

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 this layer as which of the following? A) Myocardium B) Epicardium C) Endocardium D) Pericardium

A) Myocardium

A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. Which of the following should the nurse do next? A) Inspect for a lift. B) Palpate for a thrill. C) Auscultate for pulse rate deficit. D) Listen for a ventricular gallop.

A) Palpate each artery individually to compare.

The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate? A) Palpate each artery individually to compare. B) Palpate the arteries before auscultating them. C) Use the diaphragm of the stethoscope. D) Ask the client to breathe in and out deeply.

A) Palpate each artery individually to compare.

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. The nurse should document which of the following? A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click

A) Pericardial friction rub

A group of nurses is reviewing several ecg's the student demonstrates understanding of waveforms when they identify which component as indicating ventricular repolarization? A) T wave B) ST segment C) QRS complex D) P wave

A) T wave

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? A) The client's ventricles are not contracting simultaneously. B) The client's aortic valve is incompetent. C) The client has left ventricular hypertrophy. D) The client's atria are not synchronized with the ventricles.

A) The client's ventricles are not contracting simultaneously.

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? A) The jugular venous pulse is not visible when the client is sitting upright. B) The jugular veins are fully distended when the client is in a high Fowler's position. C) The jugular veins are distended when the client sits at 45 degrees. D) The jugular venous pulse is visible when the client lies supine.

A) The jugular venous pulse is not visible when the client is sitting upright

During the auscultation of a patients heart sounds, the nurse asks the patient to turn onto the left side. why is this position used during the examination? A) accentuates mitral stenosis B) accentuates the first heart sound C) accentuates aortic murmurs D) accentuates atrial repolarization

A) accentuates mitral stenosis

A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take during the remainder of the physical assessment of the carotid arteries? A) perform palpation lightly B) perform only ausculation C) make patient sit upright D) avoid frequent repositioning

A) perform palpation lightly

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? A) sinus arrhythmia B) atrial fibrillation C) premature ventricular contractions D) premature atrial contractions

A) sinus arrhythmia

a patient is diagnosed with coronary heart disease and hypertension. what can the nurse instruct this patient to help reduce the modifiable risk factors for both of these disorders (select all) A) the need to increase physical activity B) importance of weight reduction C) necessity of smoking cessation D) reducing alcohol consumption E) having kidney function checked each year

A) the need to increase physical activity B) importance of weight reduction C) necessity of smoking cessation

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? A) ventricles B) chordae tendineae C) percordium D) semilunar valves

A) ventricles

what is the function of the semilunar valve

separates ventricles from great vessels

The nurse is assessing a client with mitral insufficiency. Which characteristic of the first heart sound should the nurse expect to hear? A) Split B) Diminished C) Accentuated D) Varying

B) Diminished

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations should the nurse include as appropriate for reducing a person's risk? Select all that apply. A) Avoid eating carbohydrates. B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. D) Limit alcohol intake to 3 drinks per day. E) Use relaxation techniques to manage stress.

B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. E) Use relaxation techniques to manage stress.

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 assessments should focus on the signs and symptoms of what health problem? A) Myocardial infarction B) Heart failure C) Atherosclerosis D) Heart block

B) 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, which information would the nurse include? A) Caucasians usually possess greater lifestyle risks for CAD than African Americans. B) Hypertension is more prevalent in African Americans than among Caucasians. C) Hypertension is seen more in white women than in African-American women. D) Hispanic Americans have a higher rate of CAD than white Americans.

B) Hypertension is more prevalent in African Americans than among Caucasians.

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? A) Assess the client's heart sounds while preventing shortness of breath. B) Identify heart sounds that may be inaudible in other positions. C) Assess the impact of the client's heart disease on his mobility. D) Differentiate heart sounds from breath sounds.

B) Identify heart sounds that may be inaudible in other positions.

A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2. Which of the following would be most appropriate for the nurse to do? A) Use the bell of the stethoscope to help distinguish the sounds. B) Palpate the carotid pulse while auscultating the heart. C) Determine the pulse deficit. D) Palpate the apical impulse.

B) Palpate the carotid pulse while auscultating the heart.

The nurse is assessing a client with a cardiac condition who complains of not sleeping well and of having to get up frequently at night to urinate. The nurse should recognize what implication of this statement? A) The client may have developed a cardiac conduction problem. B) The client may be experiencing symptoms of heart failure. C) The client's cardiac problem is being adequately compensated for. D) The client may be at increased risk for myocardial infarction.

B) The client may be experiencing symptoms of heart failure.

After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? A) Fifth intercostal space near the left midclavicular line B) Third to fifth intercostal space at the left sternal border C) Second intercostal space at the right sternal border D) Second or third intercostal space at the left sternal border

B) Third to fifth intercostal space at the left sternal border

When auscultating a patient'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? A) mitral and aortic B) aortic and pulmonic C) tricuspid and mitral D) pulmonic and tricuspid

B) aortic and pulmonic

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? A) isometric contraction B) closure of the semilunar valves C) ventricular contraction D) closure of the atrioventricular valves

B) closure of the semilunar valves

A nurse assesses a client's jugular venous pulse to gather information about which of the following? A) left ventricular diastole filling B) hemodynamic of the right side of the heart C) left arterial pressure D) right ventricular pressure

B) hemodynamic of the right side of the heart

Which technique would be most appropriate to use when examining the jugular venous pulse A) Perform the exam with the patient in supine position B) inspect the suprasternal notch or around the clavicles C) have the patient look straight ahead with chin slightly lifted D) have the patient sit up at a 90 degree angle

B) inspect the suprasternal notch or around the clavicles

Which is true of splitting of the second heart sound? A) it is best heart over the apex B) it is best heard over the pulmonic area with the bell of the stethoscope C) it normally increases with exhalation D) it does not vary with respiration

B) it is best heard over the pulmonic area with the bell of the stethoscope

A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse? A) opening snap B) midsystolic click C) ventricular gallop D) venous hum

B) midsystolic click

Which of the following statements most accurately describes preload? A) the amount of resistance that must be overcome prior to systole B) the amount of blood in the ventricles at the end of diastole C) the amount of muscle contractility possessed by the myocardium D) the blood volume in the atria that must be overcome by the ventricles

B) the amount of blood in the ventricles at the end of diastole

A patient complains of palpations and a feeling of anxiety. which of the following would be most appropriate for the nurse to keep in mind A) the heart is responding to increased renal perfusion B) the heart is attempting to increase cardiac output C) this is the body's response to an increase in cardiac output D) this is the normal response by the hearts conduction system

B) the heart is attempting to increase cardiac output

The nurse is preparing to conduct a physical examination of a patient's cardiovascular system. What should the nurse instruct the patient in preparation for this examination? (Select all that apply.) A) the patient will stand during the exam B) wear the gown with opening in front C) explain that gloves will be worn during the exam D) a sheet will be draped over the patient for comfort E) the nurse will be conducting the exam from the left side

B) wear the gown with opening in front C) explain that gloves will be worn during the exam D) a sheet will be draped over the patient for comfort E) the nurse will be conducting the exam from the left side

The nurse has assessed a client's neck vessels and is now preparing to auscultate the client's heart sounds. What action should the nurse perform during this phase of assessment? A) Rapidly auscultate all areas of the precordium and then repeat the assessments in greater detail. B) Stand on the client's left side, nearest the heart. C) Elevate the head of the client's bed to 30 degrees. D) Begin by auscultating the entire precordium with the bell of the stethoscope.

C) Elevate the head of the client's bed to 30 degrees.

When ausculating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting? A) Increased central venous pressure B) decreased cardiac output C) a narrowed vessel D) right ventricular failure

C) a narrowed vessel

Which of the following events occurs at the start of diastole? A) the first heart sound (s1) is produced B) closure of the tricuspid valve C) closure of the aortic valve D) opening of the pulmonic valve

C) closure of the aortic valve

The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? A) beginning of diastole B) isometric contraction C) closure of the atrioventricular valves D) closure of the semilunar valves

C) closure of the atrioventricular valves

Where is the point of maximal impulse (PMI) normally located? A) in the left 5th intercostal space 10-12 cm lateral to the sternum B) in the left 5th intercostal space in the anterior axillary line C) in the left 5th intercostal space 7 to 9 cm lateral to the sternum

C) in the left 5th intercostal space 7 to 9 cm lateral to the sternum

A nurse performs an initial health history on a patient admitted for new onset of chest pain. Which data is considered subjective ? A) apical heart rate 70 beats per minute B) no edema of extremities noted C) no current medications or treatments D) apical impulse palpated at 5 intercostal space

C) no current medications or treatments

What is the most important physical sign of acute pericarditis? A) intense pain B) elevated white cell count C) pericardial friction rub D) murmur heard over the left sternal border

C) pericardial friction rub

When auscultating a patients heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be A) crescendo B) decrescendo C) plateau D) crescendo-decrescendo

C) plateau

During auscultation of the heart, a nurse hears an extra sound immediately after s2 at the second left intercostal space. what should the nurse do to further assess this finding A) ask the client to lean forward to bring the left ventricle closer to the chest wall B) observe the jugular vein for distension at 30, 60 and 90 degrees of head elevation C) watch the patients respirations while listening for effect on heart sounds

C) watch the patients respirations while listening for effect on heart sounds

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line

D) Fifth intercostal space, left midclavicular line

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse? A) Perform the exam with the client in a supine position. B) Have the client look straight ahead with chin slightly lifted. C) Have the client sit up at a 90-degree angle. D) Inspect the suprasternal notch or around the clavicles.

D) Inspect the suprasternal notch or around the clavicles.

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? A) Palpate the client's left and right carotid arteries simultaneously. B) Palpate the client's carotid arteries prior to auscultation. C) Instruct the client to inhale and exhale forcefully during auscultation. D) Palpate the client's carotid arteries gently if an occlusion is audible.

D) Palpate the client's carotid arteries gently if an occlusion is audible.

The nurse's auscultation of a 22-year-old client's apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding? A) Make a referral to the client's primary care provider promptly. B) Perform a focused respiratory assessment. C) Recognize this as an early sign of left-sided heart failure. D) Recognize this as a normal assessment finding in this client.

D) Recognize this as a normal assessment finding in this client.

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment? A) Start by auscultating the client's breath sounds. B) Auscultate prior to inspection and palpation. C) Use the bell rather than the diaphragm. D) Systematically listen to the entire precordium.

D) Systematically listen to the entire precordium.

A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which component as indicating ventricular repolarization? A) P wave B) QRS complex C) ST segment D) T wave

D) T wave

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? A) If you can eliminate red meat from your diet, your risk of heart disease will drop significantly. B) Try to ensure that you're screened for heart disease at least once every six months. C) Anything that you can do to reduce stress in your life will benefit your heart health. D) Your risk for heart disease will drop greatly if you're able to stop smoking.

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

A nurse is demonstrating the technique for auscultating heart sounds. which of the following is most important for the nurse to emphasize? A) start at the apex B) listen over each chamber of the heart C) use both the bell and diaphragm D) cover the entire pericordium

D) cover the entire pericordium

A patient is admitted to the health care facility with reports of chest pain, elevated bp, sob 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. A) ineffective health maintenance B) impaired breathing pattern C) activity tolerance D) ineffective tissue perfusion

D) ineffective tissue perfusion

Which is true of the third heart sound (s3) A) it is not heard in atrial fibrillation B) it reflects normal compliance of the left ventricle C) it marks atrial contraction D) it is caused by rapid deceleration of blood against the ventricular wall

D) it is caused by rapid deceleration of blood against the ventricular wall

The nurse hears a murmur in a patient with known mitral valve prolapse. The murmur most likely occurs in: A) early diastole B) mid-systole C) middiastole D) late systole

D) late systole

A nurse suspects that a patient may have a pericardial friction rub. To ensure that the nurse hears this the nurse would place the patient in which position? A) flat, left lateral B) sitting upright in a straight back chair C) supine with head of bed elevated 30 degrees D) leaning forward while in a sitting position

D) leaning forward while in a sitting position

Which area of the heart should be further assessed in patient with irregular pulse A) right ventricle B) left atrium C) left ventricle D) left atrium

D) left atrium

A nurse is having difficulty determining a client's heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do? A) palpate the apical impulse B) use the bell of the stethoscope to help distinguish sounds C) determine the pulse deficit D) palpate the carotid pulse while ausculating the heart

D) palpate the carotid pulse while ausculating the heart

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 patient leaning forward. The nurse would document which of the following? A) midsystolic click B) aortic ejection click C) summation gallop D) pericardial friction rub

D) pericardial friction rub

During the auscultation of a patient's heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse? A) Left bundle branch block B) right bundle branch block C) pulmonic stenosis D) right ventricular failure

D) right ventricular failure

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 A) s3 B) s4 C) s2 D) s1

D) s1

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? A) premature ventricular contractions B) atrial fibrillation C) premature atrial contractions D) sinus arrhythmias

D) sinus arrhythmias

A group of students is reviewing information about the different types of murmurs. which of the following would they identify as an example of midsystolic murmur

innocent

Upon assessment of a patients pulse, a nurse notices that the amplitude of the pulse varies between beats. which other finding should the nurse assess for the patient?

presence of an s3