HESI Case Study: Heart and Neck Assessment
Client is a 58 y.o. male. He is admitted directly to the cardiac telemetry unit from his HCP's office
with a hx of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort.
During the admission assessment, the nurse first measures client's VS and oxygen saturation.
The VS and oxygen saturation are within normal parameters, although the radial pulse rhythm is
irregular.
Based on the client's report of increasingly frequent periods of dyspnea, dizziness, and minor
chest discomfort, what assessment should the nurse perform next?
a. Ask the client to stand and then recheck the BP
b. Place the client in a supine position and observe for orthopnea
c. Measure the apical and radial pulse rates at the same time
d. Determine if the client is currently experiencing any angina
Determine if the client is currently experiencing any angina
*Because the client has a hx of chest discomfort, the nurse should first determine if the client is
currently experiencing angina. Angina should be treated immediately to reduce the risk of
myocardial damage
Client denies any angina. After palpating an irregular pulse rhythm at the left radial pulse site,
what action should the nurse take to confirm the client's HR?
a. Palpate both radial pulses simultaneously
b. Auscultate the apical pulse for 1 min
, c. Compare the ulnar pulse to the radial pulse
d. Ask the client if he experiences palpitations
Auscultate the apical pulse for 1 min
*Auscultation of the apical pulse is the most accurate method to determine HR and rhythm
because the nurse is listening directly over the heart, rather than depending on the
transmission of the pulse to a distal site, such as the radial pulse site.
The client's apical rate is 92 and irregular, consistent with the radial pulse. The nurse
implements cardiac telemetry monitoring, obtains oxygen for PRN use, and begins tx for client's
irregular heart rhythm as prescribed. After gathering the initial priority data, the nurse
interviews him to gather subjective data related to his cardiac function.
To gather data about client's hx of chest. pain, how should the nurse begin?
a. Encourage the client to describe his chest discomfort
b. Determine if the chest pain has radiated to other sites
c. Question the client about the frequency of his symptoms
d. Ask the client to rate his chest pain on a numeric scale.
Encourage the client to describe his chest discomfort
*Because chest pain can manifest in a number of ways, the nurse should begin by obtaining
information related to any type of chest discomfort so that further responses by the client
include info related to any type of chest discomfort he has experienced.
Client is a 58 y.o. male. He is admitted directly to the cardiac telemetry unit from his HCP's office
with a hx of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort.
During the admission assessment, the nurse first measures client's VS and oxygen saturation.
The VS and oxygen saturation are within normal parameters, although the radial pulse rhythm is
irregular.
Based on the client's report of increasingly frequent periods of dyspnea, dizziness, and minor
chest discomfort, what assessment should the nurse perform next?
a. Ask the client to stand and then recheck the BP
b. Place the client in a supine position and observe for orthopnea
c. Measure the apical and radial pulse rates at the same time
d. Determine if the client is currently experiencing any angina
Determine if the client is currently experiencing any angina
*Because the client has a hx of chest discomfort, the nurse should first determine if the client is
currently experiencing angina. Angina should be treated immediately to reduce the risk of
myocardial damage
Client denies any angina. After palpating an irregular pulse rhythm at the left radial pulse site,
what action should the nurse take to confirm the client's HR?
a. Palpate both radial pulses simultaneously
b. Auscultate the apical pulse for 1 min
, c. Compare the ulnar pulse to the radial pulse
d. Ask the client if he experiences palpitations
Auscultate the apical pulse for 1 min
*Auscultation of the apical pulse is the most accurate method to determine HR and rhythm
because the nurse is listening directly over the heart, rather than depending on the
transmission of the pulse to a distal site, such as the radial pulse site.
The client's apical rate is 92 and irregular, consistent with the radial pulse. The nurse
implements cardiac telemetry monitoring, obtains oxygen for PRN use, and begins tx for client's
irregular heart rhythm as prescribed. After gathering the initial priority data, the nurse
interviews him to gather subjective data related to his cardiac function.
To gather data about client's hx of chest. pain, how should the nurse begin?
a. Encourage the client to describe his chest discomfort
b. Determine if the chest pain has radiated to other sites
c. Question the client about the frequency of his symptoms
d. Ask the client to rate his chest pain on a numeric scale.
Encourage the client to describe his chest discomfort
*Because chest pain can manifest in a number of ways, the nurse should begin by obtaining
information related to any type of chest discomfort so that further responses by the client
include info related to any type of chest discomfort he has experienced.
