Health Assessment Chapter 19
17. The nurse is performing a cardiovascular assessment and wants to identify the client's risk factors for cardiovascular disease. Which questions will help the nurse assess the client's risk? Select all that apply. a. "Do you use recreational drugs?" b. "Tell me about your exercise routine." c. "Do you know your cholesterol numbers?" d. "Do you smoke?" e. "Are you married or do you have a significant other?"
"Do you use recreational drugs?" "Tell me about your exercise routine." "Do you know your cholesterol numbers?" "Do you smoke?" The use of recreational drugs, especially cocaine can cause spasm of the coronary arteries leading to myocardial ischemia or injury of the myocardium. The benefits of exercise on the heart are well documented. Elevated cholesterol and triglyceride levels are associated with cardiovascular disease. Smoking has been linked to hypertension hypertension is closely linked to coronary artery disease. The client's relationship status is not a risk factor for cardiovascular disease.
A client has an S3 heart sound. The nurse knows: a. An S3 heart sound is indicative of heart disease in almost all individuals. b. An S3 heart sound is a systolic sound. c. A physiologic S3 is common in children and young adults. d. The presence of an S3 heart sound is an expected and normal finding in the elderly client.
A physiologic S3 is common in children and young adults. An S3 heart sound, also called a ventricular gallop, occurs early in diastole when blood is flowing from the atria into the ventricles and causes vibrations. S3 is a physiologic heart sound in children, young adults, and pregnant females in their third trimester. The presence of an S3 heart sound may be associated with pathologic conditions such as myocardial infarction (MI) or heart failure however it is not indicative of heart disease in the majority of individuals. The S3 heart sound is an early diastolic sound. The presence of an S3 sound is not an expected sound in an elderly adult and may signify the presence of heart failure or a previous MI.
The nurse is preparing an educational session for a group of older adults regarding risk factors for cardiovascular disease. Which group would the nurse note as having the highest incidence of hypertension? a. African Americans b. Asians c. Whites d. Native Americans
African Americans Hypertension is a risk factor for cardiovascular disease. Hypertension occurs more frequently in African Americans and Hispanics than in other groups. Hypertension does not occur as frequently in Asians, Caucasians, and Native Americans.
The nurse is auscultating across the precordial surface and is focusing on the second heart sound (S2). Which heart valves produce this sound? a. Mitral and tricuspid b. Aortic and pulmonic c. Mitral and pulmonic d. Aortic and tricuspid
Aortic and pulmonic The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves. Closure of the aortic and pulmonic valves produces the first heart sound. Closure of the mitral and tricuspid valves produces the first heart sound. The mitral and pulmonic valves do not close at the same time to produce a heart sound. The aortic and tricuspid valves do not close at the same time to produce a heart sound.
The nurse is educating a group of women about heart attacks and explains that women may experience symptoms differently than men. Which symptoms should the nurse highlight as ones that tend to be more common in women having heart attacks? Select all that apply. a. Chest pain radiating to the jaw b. Nausea and vomiting c. Extreme fatigue d. Diaphoresis e. Indigestion
Nausea and vomiting Extreme fatigue Indigestion During myocardial infarction (heart attack), women may experience nausea and vomiting, indigestion, or extreme fatigue in the absence of chest pain. Men often experience prolonged, dull chest pain radiating to the jaw or shoulder accompanied by diaphoresis, shortness of breath, and nausea. Both men and women may experience shortness of breath.
A nurse explaining the cardiac circulation to cardiac rehabilitation clients, wants to include the oxygenation of the heart muscle. Which structure carries deoxygenated blood to the lungs? a. Pulmonary artery b. Pulmonary vein c. Great cardiac vein d. Anterior cardiac vein,
Pulmonary artery The pulmonary artery is the only artery in the body to carry deoxygenated blood. Deoxygenated blood flows into the right atrium. It is ejected through the tricuspid valve into the right ventricle and passes through the pulmonic valve into the pulmonary artery and pulmonary circulation. Oxygenated blood is then returned to the left atrium via the pulmonary veins, which are the only veins to carry oxygenated blood. The great cardiac vein carries deoxygenated blood to the coronary sinus. The anterior cardiac vein carries deoxygenated blood to the great cardiac vein, which then empties into the coronary sinus.
The nurse is calculating the cardiac output for a client with a heart rate of 88 beats per minute. What other measurements does the nurse need to complete this calculation? a. Cardiac index b. Blood pressure c. Mean arterial pressure d. Stroke volume
Stroke volume To calculate the cardiac output, the stroke volume (amount of blood that is ejected with each heartbeat) is multiplied by the heart rate. Cardiac output = stroke volume × heart rate for 1 minute. Cardiac index takes into account the client's weight, which is not used in calculating the cardiac output. Blood pressure is not used when calculating the cardiac output. Mean arterial pressure is not used in cardiac output calculation. Mean arterial pressure is the difference between systolic and diastolic blood pressure.
During the cardiac assessment the nurse finds that a client has jugular vein distention. What does this finding suggest? a. The client could have fluid overload. b. The client is dehydrated. c. The client has an infection. d. This is an expected finding for the jugular veins.,
The client could have fluid overload. Distention of the neck veins indicates elevated central venous pressure commonly seen with heart failure, fluid overload, or pressure on the superior vena cava. With dehydration, the neck veins would be flat, not distended. Infection would not impact the jugular veins. Distention of the jugular veins is not a normal finding.
During the examination of an 8-month-pregnant client the nurse measures the blood pressure at 160/98 and notes bilateral edema of the ankles. What do these findings suggest to the nurse? a. This is a normal finding during the eighth month of pregnancy. b. The client may have a prolapsed mitral valve. c. The client may go into early labor. d. The client may be exhibiting signs of preeclampsia.,
The client may be exhibiting signs of preeclampsia. Hypertension and edema are symptoms of preeclampsia and can place the mother and infant at risk if not treated. This is not a normal finding at any stage of pregnancy. Elevated blood pressure and edema are not related to a prolapsed mitral valve. Hypertension and edema do not indicate early labor
The nurse is instructing a client about high cholesterol level and wants to include behavioral considerations. What should the nurse include in this instruction? a. The need for an annual cholesterol panel b. The need for annual flu inoculation c. The need to stop smoking d. The need to reduce stress
The need to stop smoking Behavioral considerations to include in this instruction include smoking cessation, diet, and the need for regular exercise. Behavioral considerations include factors that the client can modify. The client may need an annual cholesterol panel, but it is not related to behavioral modification. Influenza immunization is not related to high cholesterol. Stress may be related to the onset of chest pain but not elevated cholesterol.
During cardiac auscultation the nurse hears a split S2 heart sound. Which is true regarding this physiologic sound? a. The aortic valve is closing slightly before the tricuspid valve. b. The pulmonic valve is closing slightly after the aortic valve. c. This is an abnormal finding. d. The mitral valve closes slightly before the tricuspid valve.,
The pulmonic valve is closing slightly after the aortic valve. A split S2 is heard during inspiration in many individuals. It is the result of the semilunar valves closing at slightly different times. The aortic valve closes slightly faster than the pulmonic valve due to changes in intrathoracic pressure caused by inspiration. A split S2 during inspiration is a normal (physiologic) sound and doesn't signify cardiac pathology. The mitral valve closes slightly before the tricuspid valve and is responsible for the S1 heart sound, not a split S2.
8. The nurse is palpating the precordial surface of an adult and notes a mild pulsation in the fifth intercostal space at the midclavicular line. What does this finding suggest to the nurse? a. The client may have had a myocardial infarction. b. This is an abnormal finding related to emphysema. c. This is a normal finding and the location of the point of maximum impulse (PMI)/apical impulse. d. The client likely has a heart murmur.
This is a normal finding and the location of the point of maximum impulse (PMI)/apical impulse. The presence of a palpable pulsation in this location identifies the point of maximum impulse (PMI) or apical impulse. This is a normal and expected finding. This doesn't signify that the client has had an MI. It is a normal, not an abnormal, finding and not related to the presence of emphysema. Heart sounds should not be altered based on this normal finding.
During the assessment of the precordial surface of an adult client the nurse inspects and palpates a heave at the apex of the heart with each heartbeat. What does this finding suggest to the nurse? a. This is a normal finding in an athletic adult. b. This is an abnormal finding possibly due to left ventricular hypertrophy. c. The client is likely having a myocardial infarction. d. The client likely has a history of a heart murmur.,
This is an abnormal finding possibly due to left ventricular hypertrophy. The presence of a heave is considered abnormal over any location on the precordial surface. In this case, it may be indicative of hypertrophy of the left ventricle. The presence of a heave is an abnormal finding regardless of the age or athletic condition of the client. The presence of a lift is not associated with a current MI, nor is it indicative of the presence of a heart murmur.
A client has been diagnosed with a myocardial infarction that has damaged a part of the right atrium. The nurse monitors this client for: a. shortness of breath b. increase in collateral circulation c. onset of aortic regurgitation d. a change in the rate and rhythm of the client's heartbeat
a change in the rate and rhythm of the client's heartbeat The sinoatrial node, which initiates the electrical impulse, is called the pacemaker of the heart and has a rate of 60-100 per minute. This node is located at the junction of the superior vena cava and the right atrium. Shortness of breath would be seen with left-sided heart failure. A myocardial infarction would not cause an increase in the collateral circulation. Aortic regurgitation would be seen with abnormalities of the aortic valve, which is located in the left side of the heart, not the right atrium.
The nurse identifies a heart sound heard during the interval between the first heart sound (S1) and the second sound (S2) as: a. a systolic sound b. a diastolic sound c. an atrial filling sound d. a ventricular contraction sound
a systolic sound The period between S1 and S2 is systole. Any sound heard after S1 and before S2 would be called a systolic sound. The period between S2 and the next S1 is diastole. Any sound heard during this would be called a diastolic sound. Filling of the atria does not produce a sound. The ventricles do not produce a sound when contracting.
During the cardiac assessment the nurse learns that a client had rheumatic fever as a child. The nurse should carefully assess this client for: a. chest pain b. mitral valve prolapse c. mitral stenosis d. pulmonic stenosis,
mitral stenosis Mitral stenosis, the narrowing of the mitral valve, can be caused by rheumatic fever or another cardiac infection. Mitral stenosis produces a diastolic murmur heard best at the apex of the heart. Rheumatic fever does not cause chest pain. Mitral valve prolapse has unknown etiology. Pulmonic stenosis is congenital in origin and not related to rheumatic fever.
The nurse understands that the pericardial space is formed by the: a. parietal and visceral layers b. myocardium and the endocardium c. pericardium and the mediastinal space d. myocardium and the epicardium
parietal and visceral layers The pericardial space is between the parietal and visceral pericardial layers. The parietal layer is the outer layer. The visceral layer is the inner layer, which lines the surface of the heart. This is the location where infection or inflammation can occur and lead to pericarditis. The myocardium is the thick, muscular layer of the heart, and the innermost layer is the endocardium. The pericardium surrounds the heart. The area between the lungs and above the diaphragm is called the mediastinal space.
