HESI Case Study: Heart and Neck
Assessment Exam Questions and
Answers 100% Pass
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
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,c. Measure the apical and radial pulse rates at the same time
d. Determine if the client is currently experiencing any angina - ANSWER-
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 - ANSWER-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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 2
, 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. - ANSWER-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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 3
Assessment Exam Questions and
Answers 100% Pass
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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 1
,c. Measure the apical and radial pulse rates at the same time
d. Determine if the client is currently experiencing any angina - ANSWER-
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 - ANSWER-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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 2
, 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. - ANSWER-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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 3
