PrepU Heart and Neck Assessment

The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?

6

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe this heart sound? S2 is:

Accentuated

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

Closure of the semilunar valves

The nurse is preparing to assess a client's carotid arteries. Which of the following actions would be most appropriate?

Palpate each artery individually to compare.

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?

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

When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following?

A narrowed vessel

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action?

Administer prescribed diuretic

What term is used to describe the degree of vascular resistance to ventricular contraction?

Afterload

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 presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source?

Cardiac

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

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.

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

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

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

A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include?

Hypertension is more prevalent in African Americans. Correct.

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 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 pericardium sac

Which is true of a third heart sound (S3)?

It is caused by rapid deceleration of blood against the ventricular wall

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

While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for

Murmur

A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following?

Pacemaker

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.

What is the most important physical sign of acute pericarditis?

Pericardial friction rub

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 client leaning forward. The nurse would document which of the following?

Pericardial friction rub

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

Precordium

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?

Systematically listen to the entire precordium.

The nurse is assessing an older adult client's heart and neck vessels. When attempting to palpate the client's apical impulse, what principle should guide the nurse's actions?

The apical impulse may be more difficult to palpate than in a younger client.

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?

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

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

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

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.

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 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. Correct

Which symptoms would indicate to the nurse the client may be experiencing a cardiac event? Select all that apply.

• Diaphoresis • Chest pain • Fatigue • Dyspnea

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply

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

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 • Radiates to left shoulder and down the left arm • Has a squeezing sensation around the heart

When performing an adult cardiac examination and listening to the S1 and S2, the nurse may (Select all that apply.)

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