Florida University: NUR 3125 prep u chapter 17 Heart and Neck Vessels Assessment ,100% CORRECT

Florida University: NUR 3125 prep u chapter 17 Heart and Neck Vessels Assessment Question 1 See full question After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following? You Selected: • Ventricles Correct response: • Ventricles Explanation: Blood flows from the atria into the ventricles via the atrioventricular valves. The chordate tendineae are collagen fibers that anchor the AV valve flaps to the papillary muscle within the ventricles. The semilunar valves are located at the exit of each ventricle at the beginning of the great vessels. The precordium is the anterior chest area that overlies the heart and great vessels. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 456. Chapter 17: Heart and Neck Vessels Assessment - Page 456 Question 2 See full question 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? You Selected: • Pacemaker Correct response: • Pacemaker Explanation: The sinoatrial node is often called the pacemaker of the heart because it generates impulses that are conducted through the heart. The impulse is conduced across the atria to the AV node, which then relays the impulse to the AV bundle or bundle of His. From here the impulse travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles. All these structures make up the conduction system of the heart. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 456. Chapter 17: Heart and Neck Vessels Assessment - Page 456 Question 3 See full question Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? You Selected: • Increased urination at rest may indicate heart failure. Correct response: • Increased urination at rest may indicate heart failure. Explanation: With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. Nocturia does not indicate that the heart is working efficiently. Depending on the client's fatigue level from not sleeping well, as well as other complaints, the client's ability to perform activities of daily living may be affected. If the client is experiencing dyspnea at night, he or she will likely be sleeping on more than one pillow at night. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 462, p. 465. Chapter 17: Heart and Neck Vessels Assessment - Page 465 Question 4 See full question A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include? You Selected: • Hypertension is more prevalent in African Americans. Correct response: • Hypertension is more prevalent in African Americans. Explanation: Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 459. Chapter 17: Heart and Neck Vessels Assessment - Page 459 Question 5 See full question After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which location as Erb's point? You Selected: • Third intercostal space at the left sternal border Correct response: • Third intercostal space at the left sternal border Explanation: Erb's point is found at the third intercostal space at the left sternal border. The mitral (apical) area is located at the fifth intercostal space near the left midclavicular line. The aortic area is located at the second intercostal space at the right sternal border. The pulmonic area is located at the second or third intercostal space at the left sternal border. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 472. Chapter 17: Heart and Neck Vessels Assessment - Page 472 Question 6 See full question 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? You Selected: • 2+ Correct response: • 2+ Explanation: A normal pulse amplitude would be recorded as 2+. A weak pulse amplitude would be documented as 1+; increased as 3+; bounding as 4+. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 471. Chapter 17: Heart and Neck Vessels Assessment - Page 471 Question 7 See full question When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? You Selected: • S1 Correct response: • S1 Explanation: The S1 heart sound is associated with systole, while the S2, S3, and S4 heart sounds are associated with diastole. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p.456. Question 8 See full question The nurse positions the client for auscultation of heart sounds. What does the nurse do first? You Selected: • Clean the stethoscope Correct response: • Clean the stethoscope Explanation: A stethoscope can transmit bacteria among clients. Thus, before beginning, the nurse should clean the diaphragm of the stethoscope with the alcohol swab before bringing the diaphragm into contact with the client. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 468. Chapter 17: Heart and Neck Vessels Assessment - Page 468 Question 9 See full question When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply. You Selected: • Exercise regularly • Undergo regular cholesterol screening • Quit or do not start smoking Correct response: • Quit or do not start smoking • Exercise regularly • Undergo regular cholesterol screening • Undergo regular screening for diabetes Explanation: Important healthy habits to emphasize include following a low-fat diet, regularly exercising, undergoing regular screening for diabetes and cholesterol, and quitting (or continuing not) smoking. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, pp. 460-462. Chapter 17: Heart and Neck Vessels Assessment - Page 460-462 Question 10 See full question 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? You Selected: • Orthopnea Correct response: • 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. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 463. Chapter 17: Heart and Neck Vessels Assessment - Page 463 Question 11 See full question 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? You Selected: • Smoking increases the heart's workload and contributes to atherosclerosis. Correct response: • 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. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, pp. 461-462. Chapter 17: Heart and Neck Vessels Assessment - Page 461-462 Question 12 See full question 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? You Selected: • Client has an increased chest diameter Correct response: • 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. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 471. Chapter 17: Heart and Neck Vessels Assessment - Page 471 Question 13 See full question The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement? You Selected: • The client may be experiencing symptoms of heart failure. Correct response: • The client may be experiencing symptoms of heart failure. Explanation: With heart failure, increased renal perfusion during periods of rest or recumbency may cause nocturia. This does not signal CAD, a conduction problem, or adequate compensation. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 464, p. 465. Chapter 17: Heart and Neck Vessels Assessment - Page 465 Question 14 See full question The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location? You Selected: • Fifth intercostal space, left midclavicular line Correct response: • Fifth intercostal space, left midclavicular line Explanation: The apical impulse is palpated at the fourth or fifth intercostal space at the left midclavicular line. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 471. Chapter 17: Heart and Neck Vessels Assessment - Page 471 Question 15 See full question 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? You Selected: • Hypertension is more prevalent in African Americans than among Caucasians. Correct response: • Hypertension is more prevalent in African Americans than among Caucasians. Explanation: Ethnicity plays a role in developing coronary heart disease. African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans have a higher risk of heart disease thought to be due to more severe hypertension and higher rates of obesity and diabetes in these populations. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 460. Chapter 17: Heart and Neck Vessels Assessment - Page 460 Question 16 See full question The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. You Selected: • Increased cardiac output • Increased blood pressure • Increased heart rate Correct response: • Increased cardiac output • Increased blood pressure • Increased heart rate Explanation: When the sympathetic nervous system is stimulated, epinephrine and norepinephrine are released which causes an increased heart rate and cardiac output and and increase in the blood pressure. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, pg. 457. Question 17 See full question When a patient is obese or has a thick chest wall, what is difficult to palpate? You Selected: • Apical impulse Correct response: • Apical impulse Explanation: Obesity or a thick chest wall makes palpation of the apical impulse difficult. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 473. Chapter 17: Heart and Neck Vessels Assessment - Page 473 Question 18 See full question 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? You Selected: • Cardiac cycle Correct response: • Cardiac cycle Explanation: The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 456. Chapter 17: Heart and Neck Vessels Assessment - Page 456 Question 19 See full question 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. You Selected: • Use a low sodium seasoning to flavor food. • Walk briskly 30 minutes per day. • Consume two to three glasses of red wine daily. Correct response: • Walk briskly 30 minutes per day. • Use a low sodium seasoning to flavor food. • Choose foods like bananas and sweet potatoes. Explanation: Encouraging physical activity, decreasing dietary intake of sodium, and increasing dietary intake of potassium, such as in bananas and sweet potato, are lifestyle modifications that can promote sustaining a healthy blood pressure. Excess alcohol consumption is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for hypertension should avoid increasing consumption of these foods. Reference: • Jensen, S., Nursing Health Assessment, 2nd ed., Philadelphia, Wolters Kluwer, 2015, Chapter 17: Heart and Neck Vessels Assessment. Question 20 See full question The nurse begins auscultating a client’s heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? You Selected: • 2nd intercostal space left sternal border Correct response: • 2nd intercostal space left sternal border Explanation: Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 472. Chapter 17: Heart and Neck Vessels Assessment - Page 472 Question 1 See full question The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? You Selected: • Palpate each artery individually to compare Correct response: • Palpate each artery individually to compare Explanation: When assessing a client's carotid arteries, the nurse should palpate each artery individually because bilateral palpation could result in reduced cerebral blood flow. Auscultation should be done before palpation because palpation may increase or slow the heart rate, changing the strength of the carotid pulse heard. The nurse should use the bell of the stethoscope to auscultate the arteries and have the client hold his or her breath for a moment so breath sounds do not conceal any vascular sounds. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 470. Chapter 17: Heart and Neck Vessels Assessment - Page 470 Question 2 See full question A nurse is having difficulty determining a client's heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do? You Selected: • Palpate the carotid pulse while auscultating the heart Correct response: • Palpate the carotid pulse while auscultating the heart Explanation: If a nurse is having difficulty differentiating S1 from S2, the nurse should palpate the carotid pulse while auscultating the heart. The harsh sound that occurs with the carotid pulse is the S1 sound. The nurse should use the diaphragm of the stethoscope to auscultate S1 and S2 heart sounds. A pulse deficit is determined if the heart rhythm is found to be irregular. Palpating the apical impulse wouldn't provide any help in differentiating S1 and S2 sounds. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 470. Chapter 17: Heart and Neck Vessels Assessment - Page 470 Question 3 See full question A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what? You Selected: • Flat neck veins Correct response: • 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 neck veins are distracters to the question. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 468. Chapter 17: Heart and Neck Vessels Assessment - Page 468 Question 4 See full question How does the nurse differentiate a pleural friction rub from a pericardial friction rub? You Selected: • Have the client hold his or her breath; if the rub persists, it is pericardial Correct response: • Have the client hold his or her breath; if the rub persists, it is pericardial Explanation: 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. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 477. Chapter 17: Heart and Neck Vessels Assessment - Page 477 Question 5 See full question 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? You Selected: • Accentuated Correct response: • 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. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 486. Chapter 17: Heart and Neck Vessels Assessment - Page 486 Question 6 See full question A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be irregular. What would the nurse do next? You Selected: • Auscultate for pulse rate deficit. Correct response: • Auscultate for pulse rate deficit. Explanation: If the nurse detects an irregular rhythm, the nurse needs to auscultate for a pulse rate deficit, which may provide further evidence of atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. The client also should be referred for further evaluation because irregular rhythms may predispose the client to decreased cardiac output, heart failure, or emboli. It would not be necessary to inspect for a lift or palpate for a thrill. These would most likely have already been completed. Listening for a ventricular gallop would occur later, when the nurse is auscultating for normal and abnormal heart sounds. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 473. Chapter 17: Heart and Neck Vessels Assessment - Page 473 Question 7 See full question 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? You Selected: • “Your risk for heart disease will drop greatly if you're able to stop smoking.” Correct response: • “Your risk for heart disease will drop greatly if you're able to stop smoking.” Explanation: Smoking is among the most significant risk factors for heart disease. Screening does not need to be performed on a twice yearly basis. Stress reduction is beneficial, but smoking is a greater risk factor than stress. Dietary fat is a risk factor, but for most clients there is not a need to wholly eliminate red meat from the diet. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 462. Chapter 17: Heart and Neck Vessels Assessment - Page 462 Question 8 See full question 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. You Selected: • Cholesterol • Smoking • Blood pressure Correct response: • Smoking • Blood pressure • Cholesterol Explanation: Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, pg. 462. Question 9 See full question The bicuspid, or mitral, valve is located You Selected: • between the left atrium and the left ventricle. Correct response: • between the left atrium and the left ventricle. Explanation: The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 455. Chapter 17: Heart and Neck Vessels Assessment - Page 455 Question 10 See full question The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the You Selected: • third to fifth intercostal space at the left sternal border. Correct response: • third to fifth intercostal space at the left sternal border. Explanation: Erb’s point: Third to fifth intercostal space at the left sternal border. Reference: • Jensen, S. Nursing Health Assessment, 2nd ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 17: Heart and Neck Vessels Assessment, p. 472. Chapter 17: Heart and Neck Vessels Assessment - Page 472