Chapter 21 N303 PrepU
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 or discomfort in your chest?" "Is the pain worse on exertion?" "Do you have cramping pain?' "Is the pain worse when you are lying down?"
"Do you have any pain or discomfort in your chest?" The first question the nurse asks should be broad as this will encourage the client to share more detail regarding the source of the pain. Chest pain is one of the most serious and important symptoms often signaling coronary artery disease, potentially leading to myocardial infarction. All of the other options are more specific; these questions should only be asked when the nurse needs to narrow the focus of the cardiovascular examination.
A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A thrill A thrust A heave A normal finding
A thrill Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.
Which client is at greatest risk for the development of coronary heart disease? 45-year-old female with a total cholesterol level of 20 0mg/dL 65-year-old male with a 5-year history of diabetes mellitus 35-year-old male who smokes ½-pack of cigarettes daily 55-year-old female with a family history of heart attack after the age of 65 years
65-year-old male with a 5-year history of diabetes mellitus The client with the greatest risk is the older male with diabetes because he has three risk factors-advancing age, male gender, and diabetes. The other clients have 1-2 risk factors present.
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? Stenotic aortic valve Atherosclerotic pulmonic valve Atherosclerotic stenotic carotid arteries Congenital stenotic carotid arteries
Atherosclerotic stenotic carotid arteries If the carotid artery pulse is diminished unilaterally or bilaterally (often associated with a systolic bruit), the cause may be carotid stenosis from atherosclerosis. These signs would not indicate anything valvular; the client's age would negate the likely existence of a congenital problem.
A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do? Assess for a difference between the apical and radial pulses Check for pulse inequality between right and left carotid arteries Auscultate for split S1 at the base and apex Observe for a decrease in jugular venous pressure
Check for pulse inequality between right and left carotid arteries 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.
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 an increased chest diameter Heart rate is irregular Respiratory rate is too fast Heart enlargement is present
Client has an increased chest diameter The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.
What is responsible for the inspiratory splitting of S2? Closure of aortic then pulmonic valves Closure of mitral then tricuspid valves Closure of aortic then tricuspid valves Closure of mitral then pulmonic valves
Closure of aortic then pulmonic valves 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 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.
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? Depression Severe muscular exertion Decreased cardiac output Upper respiratory infection
Decreased cardiac output Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day. Severe muscular exertion and an upper respiratory infection may be associated with fatigue, but not the pattern mentioned in the scenario.
The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds? Aortic Mitral Erb point Pulmonic
Erb point Erb's point is auscultated at the 3rd intercostal space at the left sternal border. The aortic area is located at the second intercostal space at the right sternal border. The mitral area is located at the fifth intercostal space near the left mid-clavicular line. The pulmonic area is located at the 2nd or 3rd intercostal space at the left sternal border.
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 Turn the client on the right side; if the rub persists, it is pericardial Auscultate the base of the heart; if a rub is present, it is pericardial Auscultate the upper back; if a rub is present, it is pleural
Have the client hold his or her breath; if the rub persists, it is pericardial Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.
The finding of a fourth heart sound (S4) is considered benign under which of the following conditions? Healthy adolescence Healthy older adulthood Adult male with atrial fibrillation Adult female in the third trimester of pregnancy
Healthy older adulthood Healthy older adults and trained athletes may exhibit a 4th heart sound that does not denote a pathological process. This would not be the case in an adolescent, a pregnant woman, or a client with a dysrhythmia.
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? Hypertension in his grandparents Weight patterns within his family Diabetes mellitus in his extended family Heart attacks in his father and siblings
Heart attacks in his father and siblings Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem? Venous thromboembolism Heart failure Peripheral arterial disease (PAD) Myocardial infarction
Heart failure 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 clients with elevated JVD have heart failure.
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? Temperature Respiratory rate Heart rate Blood pressure
Heart rate 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.
Where is the sinoatrial node located?
In the upper wall of the right atrium
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? Increased pressure within the ventricles Inability of the atria to contract Inflammation of the pericardial sac Incompetent mitral valve
Inflammation of the pericardial sac A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a pericardial friction rub. This is caused by inflammation of the pericardial sac. Increased pressure within the ventricles may cause a decrease in cardiac output. Inability of the atria to contract can be caused by any problem that causes the sinoatrial node not to fire. An incompetent mitral valve would cause a systolic murmur.
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. Ensure that the client lies flat for the examination. Palpate the carotid pulse. Assess for thrills.
Inspect for dependent edema. Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of nocturia results from the redistribution of fluid at night, forcing the client to get up to void more frequently. The client should only be told to lie flat for the physical examination if the client is hypovolemic and the neck veins need to be visualized. Palpation of the carotid pulse is useful for determining whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.
Across the lifespan, a nurse knows what characteristic of the female heart is consistently true? Is normally smaller than the male heart Weighs more than a male heart Is normally larger than a male heart Normally beats more slowly than a male heart
Is normally smaller than the male heart The total size of the heart is approximately that of a clenched adult fist. The female heart is normally smaller and weighs less than the male heart across all age groups. The female heart does not consistently beat more slowly than a male heart.
Which is true of a third heart sound (S3)? It marks atrial contraction. It reflects normal compliance of the left ventricle. It is caused by rapid deceleration of blood against the ventricular wall. It is not heard in atrial fibrillation.
It is caused by rapid deceleration of blood against the ventricular wall. 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 nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client? High-protein, low-fat meals Low-fat, low-cholesterol meals High-protein, low-carbohydrate meals Low-cholesterol, low-carbohydrate meals
Low-fat, low-cholesterol meals This client should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the client to eat high-protein or low-carbohydrate meals since they are not the focus of the management of elevated cholesterol levels.
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 Tricuspid Aortic Pulmonic
Mitral Mitral valve sounds are usually heard best at and around the cardiac apex.
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? Aortic Pulmonic Mitral Tricuspid
Mitral 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.
Suzanne is a 20-year-old college student who complains of chest pain. The pain is intermittent and located to the left of her sternum. There are no associated symptoms. Examination reveals a short, high-pitched sound in systole, followed by a murmur that increases in intensity until S2. It is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis? Mitral stenosis Mitral insufficiency Mitral valve prolapse Mitral valve papillary muscle ischemia
Mitral valve prolapse The description above is classic for mitral valve prolapse. The extra sound is a mid-systolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, low-pitched rumbling murmur that is difficult to hear unless the bell is used in the left lateral decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? Assess for a difference between the apical and radial pulse Check for pulse inequality between right and left carotid arteries Auscultate for split S1 at the base and apex Observe for a decrease in jugular venous pressure
Observe for a decrease in jugular venous pressure 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).
The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse? Palpable Soft, rapid, undulating quality Pulsation eliminated by light pressure on the vessel Level of pulsation changes with changes in position
Palpable The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.
What instructions should the nursing instructor stress when teaching the students how to optimally position the client to best assess venous pulses? (Select all that apply.) Place a pillow behind the client head and neck. Encourage the client to flex the neck to improve vein exposure. Emphasize the shadows of the pulsations with a bright penlight. Place the head of the bed 30° to 45°. Have the client turn the head away from the side being examined.
Place the head of the bed 30° to 45°. Have the client turn the head away from the side being examined. Positioning of the client would be with the head of the bed at 30° to 45° to promote visibility of the pulsation. The nurse would remove the pillow to avoid flexing the neck and to improve vein exposure. The right side is easiest to see; it may help for the client to turn the head away from the side being examined. The nurse would use lighting that emphasizes the shadows of the pulsations versus a bright light.
The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound? Pulmonic Aortic Left ventricular Right ventricular
Pulmonic The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum.
The nurse assesses the apical pulse while conducting a cardiovascular exam. The nurse notes the client has an irregular pulse. Which of the following chambers of the heart should be further assessed? Right ventricle Left ventricle Right atrium Left atrium
Right atrium The sinus node is a group of specialized cardiac cells located in the right atrium near the junction of the vena cava. The sinus node acts as the cardiac pacemaker and automatically discharges an impulse about 60 to 100 times a minute. In the client with an irregular pulse, this area of the heart needs to be further assessed. Impulse generation for the heart does not originate in the right or left ventricle or the left atrium.
When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? S1 S2 Preload Afterload
S2 Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators.
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? Chest pain Shortness of breath Palpitations Edema
Shortness of breath Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect.
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 Family history Age
Smoking Blood pressure Cholesterol Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors.
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. Smoking decreases the contractility of the myocardium and contributes to valvular disorders. Smoking damages the cardiac conduction system, resulting in dysrhythmias that are entirely preventable. Smoking is a central component of metabolic syndrome.
Smoking increases the heart's workload and contributes to atherosclerosis. Smoking increases cardiac workload and contributes to hypertension, plaque build-up, and blood clots. It does not directly affect contractility or cardiac conduction, and it is not a component of metabolic syndrome.
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? Advise him to avoid sexual intercourse Recommend that he assume the missionary position while engaging in intercourse Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Encourage him to take his blood pressure immediately before engaging in sexual intercourse
Suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart. Taking his blood pressure immediately before sex is not necessary.
When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as? Summation gallop Atrial kick Ejection clicks Diastolic clicks
Summation gallop 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.
Which of the following assessment findings would signal a pathophysiological finding to the nurse? S1 is softer than S2 when the nurse listens at the base of the client's heart. Auscultation at the client's apex reveals that S1 is louder than S2. The intensity of the client's S1 varies between beats. S2 is split when the nurse asks the client to inhale deeply but is not split on exhalation.
The intensity of the client's S1 varies between beats. S1 is usually louder than S2 at the apex, while the opposite can be true when listening at the base of the heart. Normal physiological splitting of S2 is accentuated on inspiration and disappears on exhalation. Varying intensity of S1 is associated with a heart block or arrhythmia.
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 spread of depolarization in the atria The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle The spread of depolarization and sodium release in the ventricles to cause ventricular contraction Relaxation of the ventricles and repolarization of the cells
The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle 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).
The nurse on the cardiac unit is caring for a client who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this client, 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 more than double the risk of cardiac disease. They have no direct correlation with increased risk of cardiac disease. They are both sensitive and specific to heart failure. They are clinical proof that the client had a coronary event.
They more than double the risk of cardiac disease. The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.
The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client's heart sounds? Arrhythmia An opening snap Wide splitting S3 sound
Wide splitting Wide splitting occurs when a bundle branch block delays activation of the right ventricle. It also can happen when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle. The nurse would not expect to auscultate an arrhythmia since it is a reflection of heart rate. An opening snap indicates that the mitral valve is mobile and "snaps" during early diastole from high atrial pressure, such as with mitral stenosis. Blood rushes into ventricles abnormally resistant to filling, distending the ventricular walls and causing vibration that results in a S3 sound.
The semilunar valves are located between the left atrium and the left ventricle. between the right atrium and the right ventricle. at the exit of each ventricle at the beginning of the great vessels. at the beginning of the ascending aorta.
at the exit of each ventricle at the beginning of the great vessels. The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels.
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 a normal sound heard in adult clients. a wheezing sound. associated with occlusive arterial disease. heard when the artery is almost totally occluded.
associated with occlusive arterial disease. A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease.
The bicuspid, or mitral, valve is located between the left atrium and the left ventricle. between the right atrium and the right ventricle. at the beginning of the ascending aorta. at the exit of each ventricle near the great vessels.
between the left atrium and the left ventricle.
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 level of low-density lipoproteins. low-carbohydrate diets. high serum level of high-density lipoproteins. diets that are high in antioxidant vitamins.
high serum level of low-density lipoproteins. Dyslipidemia presents the greatest risk for the developing coronary artery disease. Elevated cholesterol levels have been linked to the development of atherosclerosis.
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 pulmonary emphysema. diastolic murmurs. patent ductus arteriosus. increased central venous pressure.
increased central venous pressure. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.
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 palpitations hypertension dextrocardia
left-sided heart failure Left-sided heart failure can cause fluid to leak into the lungs, and as a result fine crackles can be heard from the movement of fluid in the lungs on air exchange. Auscultation of fine crackles is not a typical finding associated with clients experiencing palpitations or hypertension. Dextrocardia is a condition in which the heart is situated on the right side. Fine crackles are not a characteristic feature of dextrocardia.
A client has engorged jugular veins. What should this finding suggest to the nurse? right atrial pressure integrity of the aorta patency of carotid arteries closure of the tricuspid valves
right atrial pressure 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.
The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the second intercostal space at the right sternal border. third to fifth intercostal space at the left sternal border. apex of the heart near the midclavicular line (MCL). fourth or fifth intercostal space at the left lower sternal border.
third to fifth intercostal space at the left sternal border.
