3016 CH 17 (prepU + review Qs)

For me when reviewing, im gonna go thru all flashcards once, star the ones I get wrong/hesitated on. Then im gonna only practice the flashcards i starred.

Ch.17; #1

Which of the following statements describes the cardiovascular system most accurately?

A. It is a double pump circulating out to the lungs and body.

B. It has a heart with six chambers, great vessels, and valves

C. It includes concepts of precontractility, postcontractility, and load.

D. It functions with a conduction system that starts in the ventricles.

A. It is a double pump circulating out to the lungs and body.

Rationale: The heart is a double pump with four chambers, four valves, and a conduction system that has a pacemaker originating in the atrium (SA node). Concepts of preload, after load, and contractility are used when considering the effectiveness of the pumping.

Ch.17; #2

In a healthy patient, the myocardial cells in the ventricle depolarize and contract during _____.

A. prediastole

B. diastole

C. systole

D. postsystole

C. Systole

Rationale: The SA node depolarizes and the atria contract, which appears as the P wave on an ECG. After a brief pause at the AV junction, the impulse travels through the bundle of His, bundle branches, and Purkinje fibers. The muscle cells depolarize and contract, appearing as the QRS complex on the ECG. The end result is ventricular systole and ejection of blood to the lungs and body, producing the heartbeat.

Ch.17; #3

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is _____.

A. S1 greater than S2

B. S1 is equal to S2

C. S2 is greater than S1

D. No Si is heard

A. S1 greater than S2

Rationale: Closure of the mitral and tricuspid valves at the beginning of systole produces the S1. This closure prevents back flow of blood from the ventricles into the atria. S1 is loudest over these valves, located in the 5th left ICS at the sternal border (tricuspid) and the 5th left ICS at the MCL (mitral).

Ch.17; #4

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following?

A. The bilateral carotid pulse

B. The presence of bruits

C. The highest level of jugular venous pulsation

D. The strength of the jugular veins

C. The highest level of jugular venous pulsation

Rationale: The nurse looks for fluid volume overload in the patient with congestive heart failure (CHF). An elevated jugular venous pulsation reflects fluid volume overload in the right heart. The bilateral carotid pulse is never palpated, because doing so may obstruct the circulation to the brain and cause carotids for the presence of narrowing that may lead to stroke; the carotids, not the jugular veins, are also palpated for arterial pulse strength.

Ch.17; #5

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?

A. Auscultate heart sounds

B. Inspect the precordium

C. Percuss the left border

D. Obtain pulse and blood pressure

D. Obtain pulse and blood pressure

Rationale: Blood pressure serves as an indicator of hemodynamic stability in this acute situation. Evaluating the pulse and blood pressure indicates if the patent has an effective pulse. Although heart sounds will be auscultated, the highest priority is identifying the consequences of chest pain and cardiac ischemia. Abnormal heart sounds may or may not reflect ischemia.

Ch.17; #6

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when preforming patient teaching?

A. Teach the patient the most serious information

B. Give the patient brochures to review before the next visit

C. Discuss risk factors that the patient is interested in modifying

D. Describe consequences of risk factors to motivate the patient

C. Discuss risk factors that the patient is interested in modifying.

Rationale: Because multiple risk factors are apparent, the most effective strategy may be for the patient to identify those items that he or she would like to change. Presentation of many brochures is likely to overwhelm the patient; it is better to focus attention on one of two things that the patient is interested in modifying..

Ch.17; #7

Which of the following clusters of symptoms are common in women preceding an MI?

A. Chest pain, nausea, diaphoresis

B. Weight gain, edema, nocturia

C. Dizziness, palpitations, low pulse

D. Fatigue, difficulty sleeping, dyspnea

D. Fatigue, difficulty sleeping, dyspnea

Rationale: Men typically have chest pain, nausea, and diaphoresis. Weight gain, edema, and nocturne are typically symptoms of CHF. Dizziness, palpations, and low pulse are common with arrhythmias. Fatigue is a common presenting symptom in women.

Ch.17; #8

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following?

A. Grade III systolic murmur

B. Grade I systolic murmur

C. Grade V diastolic murmur

D. Grade II diastole murmur

A. Grade III systolic murmur

Rationale: A medium loud murmur is graded III or IV on a I to VI scale. Murmurs between S1 and S2 are systolic; those between S2 and S1 are diastolic.

Ch.17; #9

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heart best at the apex. Which of the following does the nurse report?

A. S3 gallop

B. S4 gallop

C. Systolic ejection click

D. Split S2

A. S3 gallop

Rationale: Because of the clinical situation, the nurse is concerned about the pump function with loss of muscle from the MI. The S3 gallop results from a forceful atrial contraction during presystole that ejects blood into a ventricle that cannot expand further. The S4 gallop immediately precedes S1, and the S3 gallop follows S2.

Ch.17; #10

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis?

A. Ineffective cardiac tissue perfusion

B. Decreased cardiac output

C. Impaired gas exchange

D. Excess fluid volume

D. Excess fluid volume

Rationale: Ineffective cardiac tissue perfusion describes the lack of blood being supplied to the myocardium and relates to cardiac ischemia and chest pain. Impaired gas exchange, a respiratory diagnosis, focuses on the exchange of oxygen and carbon dioxide at the alveolar level. Decreased cardiac output relates to CHF and reduced circulation. Dyspnea from fluid in the lungs and edema and weight gain from fluid accumulation in the body support the most accurate labeling of excess fluid volume.

A client has sought care with reports of increasing swelling in their feet and ankles, and the nurse's assessment confirms the presence of bilateral edema. The nurse's subsequent assessment should focus on the signs and symptoms of what health problem?

• Myocardial infarction

• Heart failure

• Atherosclerosis

• Heart block

• Heart failure

 Explanation:

Edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart causing blood returning to the heart to back up in the organs and dependent areas of the body. Edema is not associated with MI, heart block, or atherosclerosis.

A nurse is assessing a client with decreased left ventricular compliance who is exhibiting fatigue and reduced exercise tolerance. Which cardiac parameter will the nurse evaluate to determine the effectiveness of the heart’s contractions?

• central venous pressure (CVP)

• stroke volume

• pulmonary vascular resistance (PVR)

• mean arterial pressure (MAP)

• stroke volume

 Explanation:

Stroke volume measures the amount of blood ejected by the left ventricle with each contraction. Decreased ventricular compliance can impair filling and reduce stroke volume, making this the most relevant parameter to assess the heart’s pumping effectiveness. Pulmonary vascular resistance (PVR) reflects the resistance the right ventricle must overcome to pump blood into the pulmonary circulation. It is not a direct indicator of left ventricular function. Mean arterial pressure (MAP) reflects overall perfusion pressure in the arteries but can be maintained temporarily even with declining cardiac output, making it a less specific measure of left ventricular effectiveness. Central venous pressure (CVP) is effective in determining preload along with right atrial pressure.

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

• Tricuspid and mitral

• Pulmonic and tricuspid

• Mitral and aortic

• Aortic and pulmonic

The nurse is assessing a client with isolated decompensated right-sided heart failure. Which assessment does the nurse associate with right-sided heart failure?

• increased jugular venous pressure

• bradycardia

• crackles in lung bases bilaterally

• bounding peripheral pulses

increased jugular venous pressure

Explanation:

In isolated decompensated right-sided heart failure, the heart is unable to effectively pump blood into the pulmonary circulation. This results in elevated right atrial pressure, which is reflected as increased jugular venous pressure. Bounding peripheral pulses are not characteristic of right-sided failure and may suggest an increase in cardiac output, such as in pregnancy or compensation for anemia. Crackles in the lungs would suggest pulmonary edema, which is associated with left-sided heart failure due to increased pulmonary capillary pressures. Isolated right-sided heart failure will not cause pulmonary edema. Bradycardia is not an expected finding in right-sided heart failure. 

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

• Acknowledge dependence

• Assist with finding resources

a b c e

The nurse assesses a hospitalized adult client and observes that the client’s jugular veins are fully extended. The nurse contacts the client’s health care provider because the client’s signs are indicative of

• pulmonary emphysema.

• diastolic murmurs.

• patent ductus arteriosus.

• increased central venous pressure.

increased central venous pressure.

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

• Chest pain

• Diaphoresis

• Dyspnea

• Fatigue

• Hypotension

a b c d

During the health history interview with a 40-year-old male client, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

• Hypertension in their grandparents

• Weight patterns within their family

• Diabetes mellitus in their extended family

• Heart attacks in parents and siblings

Heart attacks in parents and siblings

A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in what location?

• Bundle of His

• Purkinje fibers

• Sinoatrial node

• AV node

Sinoatrial node

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

• Flat neck veins

• Round neck veins

• Distended neck veins

• Invisible neck veins

• Flat neck veins

 Explanation:

A client with dehydration or volume depletion have barely visible neck veins, even when lying flat. These are described as flat neck veins. Distended neck veins are used to describe engorged neck veins found in clients with fluid volume overload. Round and invisible are not descriptions of veins found in dehydrated clients.

Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client?

• Presence of an S3

• Diminished heart sounds

• Changes on expiration

• Split S2 on inspiration

• Presence of an S3

 Explanation:

Changes in the amplitude (or strength) of a client's pulse from beat to beat is called pulsus alternans. This is usually seen in heart failure. The nurse should assess the client for the presence of an S₃ and an S₄ which indicate a noncompliant ventricle. Diminished heart sounds can be present in an obese client or with hypovolemia, shock, or decreased cardiac output. A pulse that changes with respirations is called a paradoxical pulse & seen in cardiac tamponade or obstructive lung disease. A split S₂ does not change the amplitude of a client's pulse.

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.

• Avoid eating dark chocolate.

• Eat foods low in sodium.

• Walk for at least 30 minutes/day.

• Limit alcohol intake to 3 drinks per day.

• Use relaxation techniques to manage stress.

b c e

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

• Diminished

• Normal split

• Wide split

• Accentuated

 Explanation:

An accentuated S₂ means that the S₂ is louder than the S₁. This occurs in conditions in which the aortic or pulmonic valve has a higher closing pressure. A diminished S₂ means that the S₂ is softer than the S₁. This occurs in conditions in which the aortic or pulmonic valves have decreased mobility. Normal split S₂ can be heard over the second or third left intercostal space; it is usually heard best during inspiration and disappears during expiration. Wide split S₂ is an increase in the usual splitting that persists throughout the entire respiratory cycle, and widens on expiration.

The nurse is assessing a client with a cardiac condition who reports fatigue and nocturia. The nurse should recognize what implication of this statement?

• The client may have developed a cardiac conduction problem.

• The client may be experiencing symptoms of heart failure.

• The client's cardiac problem is being adequately compensated for.

• The client may be at increased risk for myocardial infarction.

• The client may be experiencing symptoms of heart failure.

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.

• Consume two to three glasses of red wine daily.

• Increase consumption of dairy products.

a b c

The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?

• Second intercostal space, left sternal border

• Third intercostal space, left axillary line

• Fourth intercostal space, left sternal border

• Fifth intercostal space, left midclavicular line

Fifth intercostal space, left midclavicular line

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.

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

• Bruits

• Murmurs

• Normal findings

• Gallops

• Bruits

 Explanation:

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.

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?

• Increased pressure within the ventricle

• Inability of the atria to contract

• Inflammation of the pericardial sac

• Incompetent mitral valve

• Inflammation of the pericardial sac

 Explanation:

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.

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?

• Abdominal pain

• Orthopnea

• Hematochezia

• Tenesmus

• Orthopnea

 Explanation:

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.

The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?

• The client's ventricles are not contracting simultaneously.

• The client's aortic valve is incompetent.

• The client has left ventricular hypertrophy.

• The client's atria are not synchronized with the ventricles.

• The client's ventricles are not contracting simultaneously.

 Explanation:

A split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction).

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.

The nurse is assessing a client's heart and neck vessels. Which technique would be most appropriate to use when examining the client's jugular venous pulse?

• Lie the client flat in the supine position with the head turned to the left.

• Position the client in semi-Fowler position with the chin tilted upward.

• Sit the client at 90 degrees, and instruct them to keep the head midline.

• Position at 30 to 40 degrees with the head turned slightly to the left.

Position at 30 to 40 degrees with the head turned slightly to the left.

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?

• Bundle of His

• Purkinje fibers

• Pacemaker

• Conduction system

• Pacemaker

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?

• “If you can eliminate red meat from your diet, your risk of heart disease will drop significantly.”

• “Try to ensure that you're screened for heart disease at least once every six months.”

• “Anything that you can do to reduce stress in your life will benefit your heart health.”

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

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

The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client’s electronic medical record?

• 1+

• 2+

• 3+

• 4+

2+

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

• The mediastinum, between the lungs above the diaphragm

• The mediastinum, between the lungs below the diaphragm

• The peritoneum, above the diaphragm

• The peritoneum, below the diaphragm

The mediastinum, between the lungs above the diaphragm

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.

 Explanation:

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.

A 52-year-old client is skeptical about the potentially harmful effect of their smoking on their heart, citing the fact that a parent and a grandparent both 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.

 Explanation:

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.

When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following?

• Crescendo

• Decrescendo

• Crescendo-decrescendo

• Plateau

• Crescendo-decrescendo

 Explanation:

A crescendo-decrescendo murmur is one that grows louder and then grows softer. A crescendo murmur is one that grows louder while a decrescendo murmur is one that grows softer. A plateau murmur stays the same throughout.

A client reports 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.

• Tends to occur after meals

• Worsens with activity

• Is relieved with antacids

• May occur at any time

• Radiates to left shoulder and down the left arm

• Has a squeezing sensation around the heart

b d e f

In order for the nurse to observe the jugular venous pulse, the client should be in which of the following positions?

• Trendelenburg's position

• semi-Fowler's position

• high-Fowler's position

• prone position

• semi-Fowler's position

A client reports difficulty sleeping, stating they have to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

• Orthopnea

• Tachypnea

• Pneumonia

• Sleep apnea

• Orthopnea

 Explanation:

A client with heart failure may have fluid in their lungs, making it difficult to breathe when lying flat (orthopnea). An increased respiratory rate is tachypnea. Sleep apnea is a condition where the client has periods of not breathing while sleeping. Pneumonia does not present as described in the question.

A 20-year-old college student reports chest pain. The pain is intermittent and located to the left of the 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 the client 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

 Explanation:

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.

The nurse hears a distinctive first heart sound while auscultating a client’s heart rate. What does this heart sound represent?

• the ending of diastole

• the beginning of systole

• opening of the mitral valve

• closure of the aortic valve

the beginning of systole

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Client A has an arrhythmia diagnosed as atrial fibrillation; Client B is in chronic congestive heart failure; Client C is assessed and found to have a probable pulmonary embolism; Client D reports of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

• Client A

• Client B

• Client C

• Client D

• Client C

 Explanation:

Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?

• Isometric contraction

• Closure of the semilunar valves

• Beginning of diastole

• Closure of the atrioventricular valves

Closure of the atrioventricular valves

The client asks the nurse what the small P wave on their ECG indicates. What would the nurse answer?

• Atrial depolarization

• Ventricular depolarization

• Atrial repolarization

• Ventricular repolarization

• Atrial depolarization

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client’s

• base of the heart.

• pulmonic valve area.

• apex of the heart.

• second left interspace.

apex of the heart.

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.

• Use the diaphragm of the stethoscope to listen over the right sternal border.

• With the client leaning forward, listen over the left carotid artery.

• With the client supine, place the bell of the stethoscope on the 2nd left intercostal space.

• Place the bell of the stethoscope over the apex with client on left side.

 Explanation:

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 client 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.

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

 Explanation:

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.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

• left midclavicular line at the third intercostal space

• right of the midclavicular line at the third intercostal space

• left midclavicular line at the fifth intercostal space

• right of midclavicular line at the fifth intercostal space

left midclavicular line at the fifth intercostal space

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

 Explanation:

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 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?

• atrial fibrillation

• sinus arrhythmia

• premature atrial contractions

• premature ventricular contractions

• sinus arrhythmia

 Explanation:

In a sinus arrhythmia the heart varies cyclically, usually speeding up with inspiration and slowing down with expiration. In atrial fibrillation the ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may seem regular. In premature atrial contractions a beat of atrial origin comes earlier than the next expected normal beat. A pause follows, and then the rhythm resumes. In premature ventricular contractions a beat of ventricular origin comes earlier than the next expected normal beat. A pause follows, and the rhythm resumes.

The nurse is assessing a client who has a complex cardiac history. The nurse has asked the client to lean forward while in a sitting position. This position will allow the nurse to do which of the following?

• Assess the client's heart sounds while preventing shortness of breath.

• Identify heart sounds that may be inaudible in other positions.

• Assess the impact of the client's heart disease on their mobility.

• Differentiate heart sounds from breath sounds.

Identify heart sounds that may be inaudible in other positions.

The nurse is reviewing dietary changes for a client with hypertension in order to manage the condition. What should the nurse include in the teaching? Select all that apply.

• Consume 2,300 mg sodium per day.

• Use alcohol in moderation.

• Have a dietary intake of more than 3,500 mg of potassium per day.

• Include more fruits and vegetables in meals.

• Use low-fat dairy products with reduced saturated and total fat.

b c d e

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?

• Premature ventricular contractions

• Atrial fibrillation

• Sinus arrhythmia

• Premature atrial contractions

• Sinus arrhythmia

 Explanation:

A heart rate that speeds with inspiration and slows with exhalation is termed sinus arrhythmia. This is often a normal rhythm in young children and well-conditioned athletes. Premature ventricular contractions and premature atrial contractions occur earlier than expected. Atrial fibrillation causes the ventricles to beat irregularly.

A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?

• White Americans usually possess greater lifestyle risks for CAD.

• Hypertension is more prevalent in African Americans than among White Americans.

• Hypertension is seen more in White American females than in African American females.

• Latin Americans have a higher rate of CAD than many other populations.

• Hypertension is more prevalent in African Americans than among White Americans.

 Explanation:

Ethnicity plays a role in developing coronary heart disease. African American, Mexican American, American Indian, native Hawaiian, and some Asian American populations tend to have a higher risk of heart disease.

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

 Explanation:

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.

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

 Explanation:

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.

The S4 heart sound

• can be heard during systole.

• is often termed ventricular gallop.

• is usually due to a heart murmur.

• can be heard during diastole.

can be heard during diastole.

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 health care provider because this is usually indicative of

• pulmonary hypertension.

• aortic stenosis.

• mitral valve stenosis.

• pulmonary hypotension.

• mitral valve stenosis.

 Explanation:

Opening snaps occur early in diastole and indicate mitral valve stenosis.

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client’s

• base of the heart.

• pulmonic valve area.

• apex of the heart.

• second left interspace.

• apex of the heart.

After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel?

• Aorta

• Pulmonary vein

• Femoral artery

• Inferior vena cava

• Femoral artery

 Explanation:

The large veins and arteries leading directly to and away from the heart are the great vessels and include the superior and inferior vena cava, the pulmonary artery and vein, and the aorta. The femoral artery is a distracter for the question.

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.

 Explanation:

A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease.

The nurse's auscultation of the client's heart sounds reveals the presence of a split S1. What conclusion should the nurse draw from this assessment finding?

• The client's ventricles are not contracting simultaneously.

• The client's aortic valve is incompetent.

• The client has left ventricular hypertrophy.

• The client's atria are not synchronized with the ventricles.

• The client's ventricles are not contracting simultaneously.

 Explanation:

A split S1 occurs when the left and right ventricles contract at different times (asynchronous ventricular contraction). This finding is not associated with an incompetent aortic valve, left ventricular hypertrophy, or lack of synchronicity between the atria and ventricles.

A nursing instructor is teaching nursing students proper techniques of assessment of the heart and neck vessels. Which statements made by the students demonstrate proper understanding? Select all that apply.

• Palpate the carotid arteries one at a time.

• Palpate the carotid arteries before auscultating them.

• Auscultate for a pulse rate deficit if the heart rhythm is irregular.

• Place the client in a left lateral position when palpating apical pulsation.

• If experiencing difficulty differentiating S₁ from S₂, palpate the carotid pulse while listening to the heart.

a c d e

A client has a long history of heart failure. The nurse expects which of the following signs and symptoms of decreased cardiac output? Select all that apply.

• fatigue

• pedal edema

• absent pedal pulses

• lack of hair on lower extremities

• shortness of breath with exertion

a b e

A nurse has been assigned a group of clients. A nurse determines a client is at high risk for cardiac disease when the client states which of the following? Select all that apply.

• “I don’t drink a lot of alcohol, only occasionally.”

• “I smoke two packs of cigarettes a day.”

• “I am mostly a vegetarian.”

• “My job is so stressful.”

• “I am a computer programmer.”

b d e

The nurse notes that a client’s heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding?

• Sinus arrhythmia

• Sinus bradycardia

• Premature atrial contractions

• Premature ventricular contractions

Sinus arrhythmia

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

 Explanation:

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.

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 will be irregular due to normal, age-related physiological changes.

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

• The apical impulse will be found in a more medial location than in a younger client.

• The apical impulse will be easier to palpate if the client is in a standing position.

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

 Explanation:

In older clients, the apical impulse may be difficult to palpate because of increased anteroposterior chest diameter. The apical impulse is not located in a more medial location in older adults. An irregular rhythm is pathologic in clients of all ages. The standing position is not normally used for palpation.

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

• endocardium.

• epicardium.

• myocardium.

• precordium.

precordium.

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

 Explanation:

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.

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.

A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position?

• Supine with head of bed elevated 30 degrees

• Leaning forward while in a sitting position

• Flat, left lateral

• Sitting upright in a straight back chair

• Leaning forward while in a sitting position

 Explanation:

For best results, the nurse would use the diaphragm of the stethoscope and have the client sit up, lean forward, exhale, and hold their breath. The left lateral position may be used to hear an S3 or S4 heart sound or a murmur of mitral stenosis that was not detected in the supine position.