NUR103: Ch. 20

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What does this finding indicate?

• Decreased fluid volume

• Increased cardiac output

• Narrowing of jugular veins

• Elevated pressure r/t heart failure

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. “I’ll be sleeping great, and then I wake up and feel like I can’t get my breath.” Which is the best response by the nurse?

• “When was your last electrocardiogram?”

• “It’s probably because it’s been so hot at night.”

• “Do you have any history of problems with your heart?”

• “Have you had a recent sinus infection or upper respiratory infection?”

In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history?

• Family history, hypertension, stress, and age

• Personality type, high cholesterol, diabetes, and smoking

• Smoking, hypertension, obesity, diabetes, and high cholesterol

• Alcohol consumption, obesity, diabetes, stress, and high cholesterol

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?

• Valvular disorder

• Blood flow turbulence

• Fluid volume overload

• Ventricular hypertrophy

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

• Third left intercostal space at the midclavicular line

• Fourth left intercostal space at the sternal border

• Fourth left intercostal space at the anterior axillary line

• Fifth left intercostal space at the midclavicular line

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

• Listening for all possible sounds at a time at each specified area.

• Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.

• Listening to the sounds only at the site where the apical pulse is felt to be the strongest.

• Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

In assessing for an S₄ heart sound, what part of the stethoscope should the nurse use and in what location?

• Bell of the stethoscope at the base with the patient leaning forward

• Diaphragm of the stethoscope in the aortic area with the patient sitting

• Diaphragm of the stethoscope in the pulmonic area with the patient supine

• Bell of the stethoscope at the apex with the patient in the left lateral position

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S₁. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. Based on these findings and the patient’s history, the nurse should recognize this extra heart sound is most likely what?

• Split S₁

• Atrial gallop

• Diastolic murmur

• Summation sound

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. What does the nurse suspect?

• Another MI

• Increased cardiac output

• Inflammation of the precordium

• Ventricular hypertrophy resulting from muscle damage

During a cardiac assessment on a 38-year-old patient in the hospital for “chest pain,” the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S₃ on auscultation. Which of these conditions best explains the cause of these findings?

• Heart failure

• Fluid overload

• Atrial septal defect

• Myocardial infarction