Nursing 202 Health Assessment: Ch 21

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

1+ pulses

When a patient is obese or has a thick chest wall, what is difficult to palpate?

Apical impulse Obesity or a thick chest wall makes palpation of the apical impulse difficult.

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?

Aortic and pulmonic The closure of the aortic and pulmonic valves creates the second heart sound, which is heard louder over the 2nd intercostal space right sternal border. The closure of the tricuspid and mitral valves creates the first heart sound. The pulmonic and tricuspid valves do not close together. The mitral and aortic valves do not close together. (less)

A nurse is assessing a client for the presence of asynchronous contraction in the heart. Which of the following should the nurse do?

Auscultate for split S1 at the base and apex A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction); thus, the nurse should auscultate for split S1 at the base and apex to detect this condition. Pulse deficit is detected by assessing the difference in the apical and radial pulses. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume. (less)

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

Blood pressure 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.

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

Bruits Distinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. A gallop is a generic term for an additional heart sounds heard besides the normal S1 and S2 sound. (less)

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

What do the oscillations in the internal jugular veins reflect?

Changing pressures within the right atrium The oscillations that you see in the internal jugular veins, and often in the externals, reflect changing pressures within the right atrium.

A nurse is unable to palpate the apical impulse on a 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 apical impulse may not be palpable in clients with increased anterioposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical pulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.

A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?

Closure of the semilunar valves Closure of the semilunar valves, which are the aortic and pulmonic valves, causes the second heart sound, S2. The closure of these valves signals the end of systole. Isometric contraction occurs when all valves are closed, which occurs just before systole, in which no sound is produced. Closure of the AV valves produces the S1 heart sound, which is the beginning of systole. Ventricular contraction is the occurrence of systole, which produces not sound but causes ejection of blood from the ventricles. (less)

A nurse is evaluating a client's jugular venous pressure. Which of the following findings would tend to indicate obstructive pulmonary disease?

Elevated venous pressure only during expiration Clients with obstructive pulmonary disease may have elevated venous pressure only during expiration. An inspiratory increase in venous pressure, called Kussmaul's sign, may occur in clients with severe constrictive pericarditis. Distention, bulging, or protrusion at 45, 60, or 90 degrees may indicate right-sided heart failure. It is normal for the jugular veins to be visible when the client is supine. (less)

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 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. (less)

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?

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 patients with elevated JVD have heart failure. (less)

A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur?

Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). The examiner can further hear this soft murmur by having the client hold his or her breath in exhalation. (less)

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia A weak pulse can indicate hypovolemia, shock or decreased cardiac output. Pulse inequality may indicate a constriction or occlusion. Hypervolemia would be manifested by bounding pulses. (less)

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 In addition, it may be difficult to palpate the apical impulse in clients who are obese or barrel chested because these conditions increase the distance from the apex of the heart to the pre cordium. The other answers are not likely reasons for the nurse's inability to find the apical pulse. (less)

The nursing instructor explains to a group of students that what can shorten diastole?

Increased heart rate As the heart rate increases, the length of diastole is shortened. The respiratory rate, blood pressure and filling pressures do not shorten diastole.

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders (less)

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase 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 A high pitched, scratchy, scraping sound is heard that increase 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. (less)

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 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. (less)

Which is true of splitting of the second heart sound?

It is best heard over the pulmonic area with the bell of the stethoscope. S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low pressure system. The bell is best used because it is a low pitched sound. S2 splitting normally increases with inhalation. (less)

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 Mitral valve sounds are usually heard best at and around the cardiac apex.

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, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure. (less)

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 Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium. (less)

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 The myocardium is the thickest layer of the heart and is made up of contractile cardiac muscle cells. The pericardium is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. A serous membrane lining, the parietal pericardium, secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This same type of serous membrane covers the outer surface of the heart and is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels. (less)

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?

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). (less)

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 A client with heart failure may have fluid in their lungs, making it difficult to breathe when lying flat (

The nurse manager on a cardiac unit should immediately intervenen when observing which staff nurse's assessment technique?

Palpating carotid pulses simultaneously. Caroid pulse palpation should be conducted by feeling one side at a time; otherwise the client my become dizzy or lightheaded. All other assessment techniques are correct.

what raises Jugular venous pressure?

Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure.

What is the most important physical sign of acute pericarditis?

Pericardial friction rub A pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the patient is upright and leaning forward. Acute pericarditis, elevated white cell count, and a murmur heard over the left sternal border would not be the primary physical sign of the condition. (less)

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?

Place the bell of the stethoscope over the apex with client on left side. This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the patient turned to the left. The carotid arteries are auscultated one at a time for bruits. The 2nd left intercostal space is the location to hear pulmonic valve conditions. (less)

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?

S2 The "lub" sound of S1 signals the beginning of ventricular systole, whereas the "dub" sound of S2 signals the end of systole and beginning of diastole. Systole occurs between S1 and S2, whereas diastole occurs between S2 and the next S1. 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. (less)

The nurse on the cardiac unit is caring for a patient who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this patient, 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. The risk of a cardiovascular event more than doubles with an elevated cholesterol and C-reactive protein level.

What finding upon assessment would indicate the client is experiencing shock?

Systolic blood pressure 50 A systolic blood pressure of 50 would indicate the client is experiencing shock. All other vital signs, while elevated do not indicate shock

Cardiac cycle is

The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.

Where are the heart and great vessels located in the human body?

The mediastinum, between the lungs above the diaphragm

A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?

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. (less)

Angina (cardiac chest pain) is usually described as

a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity

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

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.

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. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. (less)

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. S1 may be heard over the entire precordium but is heard best at the apex (left MCL, fifth ICS).

The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to

ask the client to hold her breath. Place the bell of the stethoscope over the carotid artery and ask the client to hold his or her breath for a moment so that breath sounds do not conceal any vascular sounds.

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle. The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.

Chest pain can be ...

cardiac, pulmonary, muscular, or gastrointestinal in origin

The P-wave phase of an electrocardiogram (ECG) represents

conduction of the impulse throughout the atria. The P wave indicates atrial depolarization; conduction of the impulse throughout the atria.

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. 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

increased central venous pressure. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic filling pressure.

The anterior chest area that overlies the heart and great vessels is called the

precordium The anterior chest area that overlies the heart and great vessels is called the precordium.

A client complains of chest pain. The nurse understands that chest pain can have causes other than cardiac pain, thus follows up with the client regarding the timing and quality of this pain. Which of the following would indicate cardiac pain as opposed to other types? Select all that apply.

• Worsens with activity • May occur at any time • Has a squeezing sensation around the heart • Radiates to left shoulder and down the left arm