Health Ch. 21 PrepU
When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?
Accentuated
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?
Blood pressure
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?
Bradycardia
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 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?"
A client with heart disease is a current cigarette smoker. What should the nurse include when caring for this client? Select all that apply.
*Advise to quit *Arrange for follow-up *Assess willingness to quit *Assist with finding resources
What are the components of S1? (Mark all that apply.)
*An earlier mitral sound *A later tricuspid sound
The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply.
*Increased cardiac output *Increased blood pressure *Increased heart rate
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 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 nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.)
*examining the face *examining the neck *inspecting and palpating the precordium *inspecting the hands and lower legs
When auscultating a client'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?
Aortic and pulmonic
A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?
Ask the client to assume the left lateral position
How should a nurse assess a client for pulse rate deficit?
Assess for a difference between the apical and radial pulse
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 bicuspid, or mitral, valve is located
3rd left rib space
Where is Erb's point located?
3rd left rib space
A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record?
4+
Which client is at greatest risk for the development of coronary heart disease?
65-year-old male with a 5-year history of diabetes mellitus
The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer?
Atrial depolarization
As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?
Atrioventricular (AV) node
Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?
Auscultate to determine the heart rate and if the rhythm is normal
A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure?
Auscultation of an S3 heart sound
A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?
Cardiac cycle
The nurse assesses a client's neck as shown. What is the nurse assessing?
Carotid artery
Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle?
Carotid artery
A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?
Check for pulse inequality between right and left carotid arteries
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
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
To function adequately, the nurse knows that the heart valves need to open simultaneously.
False
A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?
Grade 5
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?
Heart attacks in his father and siblings
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?
Heart failure
The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?
Hypovolemia
A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this?
Increased distance from the apex of the heart to the pre cordium
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?
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.
Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?
Is normally smaller than the male heart
To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment?
Jugular venous pulse
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?
Low-fat, low-cholesterol meals
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?
Mitral
Variations in the presentation of S1 are due to alterations in which heart valve?
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 nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known 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 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?
Orthopnea
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 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
The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound?
Pulmonic
When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest?
Right sternal border, 2nd ICS
When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?
S2
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?
Sinus arrhythmia
A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following?
Stroke volume
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 sternal angle at the right 2nd rib space is also known as what?
The aortic area
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
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.
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible
angina.
During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's
apex of the heart.
What nursing diagnosis would be most appropriate for a client admitted with heart failure?
between the left atrium and the 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
While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of
mitral valve stenosis.
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 notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating?
sinus arrhythmia
The nurse hears a distinctive first heart sound while auscultating a client's heart rate. What does this heart sound represent?
the beginning of systole
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.
