Question 1

A patient comes to the health clinic asking for advice on lowering her risk of heart disease. What is the nurse's best response to this request?

Accepted Answer

Conducting a health history and physical exam is the best approach to determine the patient's areas of risk and use these findings to educate the patient on how to lower her risk of heart disease. The nurse can then provide specific recommendations based on the patient's individual health history and physical exam findings. Options A, B, and C do not provide enough individualized information to provide the patient with tailored advice.

Question 2

The patient presents to the emergency department (ED) complaining of chest pain, fatigue, and dyspnea. What is the nurse's priority assessment?

Accepted Answer

Chest pain, fatigue, and dyspnea are all symptoms that could indicate a potentially serious cardiovascular or respiratory issue. Therefore, the nurse's priority assessment should be to check the patient's airway and oxygen status to ensure they are stable and provide any necessary interventions to improve those vital signs.

Question 3

During admission assessment for evaluation of chest pain, the patient reports an allergy to sulfa drugs. Which nursing statements are indicated?. Select all that apply.

Accepted Answer

The nurse should ask the patient about the type of reaction they have had to sulfa drugs and when they first found out about the allergy to determine the potential severity and whether it is a true allergy. Option A may not be accurate as some cardiac patients may receive sulfa-containing medications. Option B is incorrect as any sensitivity or adverse reaction to sulfa drugs should be considered significant. Option E may not be appropriate as antihistamines may not be effective for severe allergic reactions.

Question 4

A patient is being evaluated for intermittent chest pain. The nurse's concern about a cardiac origin for this pain would be increased if the patient reports his mother had a myocardial infarction at the age of ______ years or younger.

Accepted Answer

The answer of A patient is being evaluated for intermittent...

Question 5

A patient has a split S2 heart sound. Where would the nurse auscultate to best hear this sound?

Accepted Answer

The split S2 heart sound is best heard at the pulmonic area, which is located at the 2nd intercostal space left of the sternum.

Question 6

A patient has a split S1 heart sound. How should the nurse explain this finding to the patient?

Accepted Answer

A split S1 heart sound occurs when the mitral and tricuspid valves do not close simultaneously, leading to the perception of two separate sounds.

Question 7

A patient presents with complaints of intermittent chest pain. The nurse assesses that the patient holds a high-stress job and is a Type A personality. How can the nurse best explain the importance of reducing cardiac risk factors?

Accepted Answer

The exposure to chronic stress increases the workload for the heart, which can increase the risk for cardiovascular disease. Managing stress in a healthy manner is important for reducing cardiac risk factors. Option A is incorrect because constant chest pain is not a healthy sign for the heart. Option B is incorrect because resting frequently may not always be feasible for some individuals. Option C is incorrect because seeking a different type of job may not always be an option for the patient.

Question 8

While completing the health history of a patient with a suspected cardiac disorder, the nurse would ask about which childhood illnesses?

Accepted Answer

Rheumatic fever and strep throat infections are childhood illnesses that may lead to cardiac complications later in life.

Question 9

During the physical assessment of a patient on admission, the nurse auscultates a grade II midsystolic heart murmur. The nurse would conduct additional assessment for which condition?

Accepted Answer

A grade II midsystolic heart murmur is most commonly associated with aortic stenosis, which is a narrowing of the aortic valve. Additional assessment would include checking for symptoms such as chest pain, shortness of breath, and dizziness, as well as ordering an echocardiogram to confirm the diagnosis. The other options, mitral stenosis, aortic regurgitation, and mitral regurgitation, are associated with different types of murmurs.

Question 10

The nurse is completing a physical assessment on a clinic patient who has been complaining of fatigue and intermittent chest pain over the last several weeks. Upon auscultation of the chest, the nurse hears an S₁, S₂, and S₃. Because of these findings, the nurse's priority will be to assess for which other finding?

Accepted Answer

The presence of crackles in lung sounds can indicate heart failure, which could be related to the patient's symptoms of fatigue and intermittent chest pain. Crackles are a sign of fluid accumulation in the lungs, a common finding in heart failure.

Question 11

The S1 heart sound corresponds to which physiological event?

Accepted Answer

The S1 heart sound corresponds to the closure of the AV valves (the mitral and tricuspid valves), which occurs at the beginning of ventricular systole (when the ventricles contract and begin to empty). This produces the "lub" sound of the heartbeat.

Question 12

A patient is admitted to the telemetry unit. Which nursing assessment has the highest priority for further investigation?

Accepted Answer

The patient complaining of intermittent chest pain during mild exercise could be a symptom of cardiovascular disease and requires immediate investigation. It could indicate a potential heart attack or angina, which requires prompt medical attention. A history of urinary retention, fatigue and dyspnea after exercise, and a family history of smoking are also important considerations, but they do not require immediate attention as potential chest pain.

Question 13

When palpating a thrill on the precordium, the nurse recognizes that this sign is associated with which cardiac condition?

Accepted Answer

A thrill on the precordium (an abnormal vibration felt on the chest wall) is commonly associated with severe valve stenosis, specifically aortic or pulmonic valve stenosis. This is due to the turbulent flow of blood through the narrowed valve. Cardiomyopathy, stenosis of the carotid arteries, and aortic aneurysms may have their own unique symptoms and signs, but a thrill is not typically associated with these conditions.

Question 14

When assessing the adult heart, the nurse expects to hear which heart sounds?

Accepted Answer

The normal sequence of heart sounds in adults is S1 (first heart sound), followed by S2 (second heart sound). S3 and S4 may be heard in certain pathological conditions but are not typically present in healthy adults. S2 is heard before S1 because it is produced by the closure of the aortic and pulmonic valves during ventricular diastole, whereas S1 is produced by the closure of the mitral and tricuspid valves during ventricular systole.

Question 15

When auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI), the nurse hears an S3 heart sound immediately following S₂. Because of these findings, the nurse would assess for which other condition?

Accepted Answer

An S3 heart sound heard in a patient post-MI is often indicative of heart failure, as it suggests decreased left ventricular compliance and/or increased end-diastolic pressure. The presence of an S3 sound can help clinicians identify early stages of heart failure and initiate interventions to improve the patient's outcomes. Extension of the MI or renal/liver failure is not necessarily indicated by the presence of an S3 sound.

Question 16

The nurse is assessing a patient's heart and believes a pericardial friction rub is present, but it is very faint. Which technique might help the nurse hear this sound more clearly?

Accepted Answer

Leaning forward or having the patient lean on the overbed table can bring the heart closer to the chest wall, making it easier to hear pericardial friction rubs.

Question 17

A patient presents to the medical-surgical unit confused and with a blood pressure of 90/

Accepted Answer

Prolonged capillary refill and diminished peripheral pulses are signs of poor perfusion, which is a manifestation of low cardiac output.

Question 18

While auscultating the patient's heart sounds, the nurse hears an additional sound immediately following S₂. The nurse would conduct further assessment for which condition?

Accepted Answer

An additional heart sound immediately following S1 (the first heart sound) suggests a problem with ventricular filling, which is often due to ventricular volume overload. This condition can cause the ventricles to stretch and fill more than normal, leading to the production of abnormal heart sounds.

Question 19

A review of the medical record reveals that a patient has been diagnosed with paroxysmal nocturnal dyspnea (PND). Which questions would the nurse ask to assess the status of this condition?. Select all that apply.

Accepted Answer

These questions assess the frequency, severity, and duration of the patient's PND symptoms.

Question 20

The nurse is conducting a physical examination of a patient's heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?

Accepted Answer

The S1 heart sound, often termed the "lub" sound, is best heard at the mitral area, which is located at the left midclavicular line at the fifth intercostal space. This location is closest to the mitral valve, where the S1 sound originates.

Quiz 29: Nursing Assessment of the Patient With Cardiovascular Disorders

A patient comes to the health clinic asking for advice on lowering her risk of heart disease. What is the nurse's best response to this request?

The patient presents to the emergency department (ED) complaining of chest pain, fatigue, and dyspnea. What is the nurse's priority assessment?

During admission assessment for evaluation of chest pain, the patient reports an allergy to sulfa drugs. Which nursing statements are indicated?. Select all that apply.

A patient is being evaluated for intermittent chest pain. The nurse's concern about a cardiac origin for this pain would be increased if the patient reports his mother had a myocardial infarction at the age of ______ years or younger.

A patient has a split S2 heart sound. Where would the nurse auscultate to best hear this sound?

A patient has a split S1 heart sound. How should the nurse explain this finding to the patient?

A patient presents with complaints of intermittent chest pain. The nurse assesses that the patient holds a high-stress job and is a Type A personality. How can the nurse best explain the importance of reducing cardiac risk factors?

While completing the health history of a patient with a suspected cardiac disorder, the nurse would ask about which childhood illnesses?

During the physical assessment of a patient on admission, the nurse auscultates a grade II midsystolic heart murmur. The nurse would conduct additional assessment for which condition?

The S1 heart sound corresponds to which physiological event?

A patient is admitted to the telemetry unit. Which nursing assessment has the highest priority for further investigation?

When palpating a thrill on the precordium, the nurse recognizes that this sign is associated with which cardiac condition?

When assessing the adult heart, the nurse expects to hear which heart sounds?

When auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI) , the nurse hears an S3 heart sound immediately following S₂. Because of these findings, the nurse would assess for which other condition?

The nurse is assessing a patient's heart and believes a pericardial friction rub is present, but it is very faint. Which technique might help the nurse hear this sound more clearly?

A patient presents to the medical-surgical unit confused and with a blood pressure of 90/

While auscultating the patient's heart sounds, the nurse hears an additional sound immediately following S₂. The nurse would conduct further assessment for which condition?

A review of the medical record reveals that a patient has been diagnosed with paroxysmal nocturnal dyspnea (PND) . Which questions would the nurse ask to assess the status of this condition?. Select all that apply.

The nurse is conducting a physical examination of a patient's heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?

Quiz 29: Nursing Assessment of the Patient With Cardiovascular Disorders

A patient comes to the health clinic asking for advice on lowering her risk of heart disease. What is the nurse's best response to this request?

The patient presents to the emergency department (ED) complaining of chest pain, fatigue, and dyspnea. What is the nurse's priority assessment?

During admission assessment for evaluation of chest pain, the patient reports an allergy to sulfa drugs. Which nursing statements are indicated?. Select all that apply.

A patient is being evaluated for intermittent chest pain. The nurse's concern about a cardiac origin for this pain would be increased if the patient reports his mother had a myocardial infarction at the age of ______ years or younger.

A patient has a split S2 heart sound. Where would the nurse auscultate to best hear this sound?

A patient has a split S1 heart sound. How should the nurse explain this finding to the patient?

A patient presents with complaints of intermittent chest pain. The nurse assesses that the patient holds a high-stress job and is a Type A personality. How can the nurse best explain the importance of reducing cardiac risk factors?

While completing the health history of a patient with a suspected cardiac disorder, the nurse would ask about which childhood illnesses?

During the physical assessment of a patient on admission, the nurse auscultates a grade II midsystolic heart murmur. The nurse would conduct additional assessment for which condition?

The S1 heart sound corresponds to which physiological event?

A patient is admitted to the telemetry unit. Which nursing assessment has the highest priority for further investigation?

When palpating a thrill on the precordium, the nurse recognizes that this sign is associated with which cardiac condition?

When assessing the adult heart, the nurse expects to hear which heart sounds?

When auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI) , the nurse hears an S3 heart sound immediately following S2. Because of these findings, the nurse would assess for which other condition?

The nurse is assessing a patient's heart and believes a pericardial friction rub is present, but it is very faint. Which technique might help the nurse hear this sound more clearly?

A patient presents to the medical-surgical unit confused and with a blood pressure of 90/

While auscultating the patient's heart sounds, the nurse hears an additional sound immediately following S2. The nurse would conduct further assessment for which condition?

A review of the medical record reveals that a patient has been diagnosed with paroxysmal nocturnal dyspnea (PND) . Which questions would the nurse ask to assess the status of this condition?. Select all that apply.

The nurse is conducting a physical examination of a patient's heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?

When auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI) , the nurse hears an S3 heart sound immediately following S₂. Because of these findings, the nurse would assess for which other condition?

While auscultating the patient's heart sounds, the nurse hears an additional sound immediately following S₂. The nurse would conduct further assessment for which condition?