Question 1

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

Accepted Answer

S1 (lub) is the first heart sound, caused by the closure of the mitral and tricuspid valves, and is followed by S2 (dub) which is caused by the closure of the aortic and pulmonic valves. This is the normal sequence of heart sounds.

Question 2

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 3

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, which is a palpable vibration or buzzing sensation felt over the heart, is often associated with severe valve stenosis. This is because the narrowed valve causes turbulent blood flow, which is felt as a palpable vibration. Cardiomyopathy, carotid artery stenosis, and aortic aneurysm may all have different signs and symptoms.

Question 4

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 5

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 nurse should explain that chronic stress increases the workload for the heart and that managing stress in a healthy manner can decrease the risk factors for cardiovascular disease. Option A is incorrect as any type of chest pain should be investigated rather than waiting for constant pain. Option B is incorrect as resting alone may not be enough to manage stress. Option C is incorrect as it does not address the importance of reducing cardiac risk factors.

Question 6

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 can lead to damage of the heart valves and increase the risk for cardiac disorders later in life. Rubella and chickenpox do not have a direct association with cardiac disorders. Asthma and bronchitis are respiratory illnesses and otitis media and RSV are ear and respiratory infections, respectively, and may not have a direct relationship with cardiac disorders.

Question 7

The S1 heart sound corresponds to which physiological event?

Accepted Answer

The S1 heart sound corresponds to the closure of the AV valves (tricuspid and mitral valves) at the beginning of systole, which signals the start of ventricular contraction and ejection of blood out of the heart.

Question 8

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 commonly associated with aortic stenosis, which is characterized by narrowing of the aortic valve opening. Additional assessment, such as echocardiogram, may be necessary to confirm the diagnosis.

Question 9

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

Accepted Answer

Chest pain during mild exercise is a potential symptom of cardiac ischemia and requires immediate investigation and intervention. The other options are important, but do not indicate an acute or potentially life-threatening condition.

Question 10

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.

Question 11

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

Accepted Answer

The answer of A patient has a split S2 heart...

Question 12

A patient presents to the medical-surgical unit confused and with a blood pressure of 90/50. Which assessment findings would support the nurse's concern that the patient has low cardiac output?

Accepted Answer

Prolonged capillary refill and diminished peripheral pulses are indicative of poor perfusion, which is an indicator of low cardiac output. Skin tenting poor turgor, heart rate of 102, pallor, peripheral edema, bounding peripheral pulses, and low pulse oximeter reading can be attributed to other factors and do not necessarily indicate low cardiac output.

Question 13

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

Accepted Answer

The answer of A patient has a split S1 heart...

Question 14

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A review of the medical record reveals...

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

The presence of an S3 heart sound, particularly after an MI, is indicative of heart failure. This occurs because the left ventricle becomes stiff and cannot relax normally, leading to decreased filling during diastole and an abnormal flow pattern in the heart. This abnormal flow causes the S3 sound. The other options (B, C, and D) are not typically associated with an S3 heart sound.

Question 16

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 an S3 heart sound indicates possible heart failure, which can cause fluid accumulation in the lungs and lead to crackles on auscultation. Therefore, the nurse's priority should be to assess lung sounds for crackles to further evaluate for heart failure. Absence of bowel sounds and sluggish pupil response are not directly related to the patient's cardiac symptoms, and diminished pulses may be a concern but are not as high of a priority as assessing for possible fluid accumulation in the lungs.

Question 17

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

Accepted Answer

Airway and oxygen status are the nurse's priority assessment in this situation as the patient is presenting with symptoms that could suggest respiratory distress. It is crucial to assess the patient's airway patency and oxygen saturation levels to determine the severity of the situation and provide appropriate interventions. Chest pain, activity tolerance, and medications are also important assessments but are not as critical as assessing and ensuring the patient's airway and oxygen status.

Question 18

During admission assessment for evaluation of chest pain, the patient reports an allergy to sulfa drugs. Which nursing statements are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

It is important to gather more information about the patient's allergy to sulfa drugs, including what specifically happens when they take it and when they first found out about the allergy. This information will help the healthcare team determine what medications to avoid or use with caution. Options A and E are incorrect because they provide incorrect or potentially harmful information. Option B is incorrect because it undermines the patient's reported allergy.

Question 19

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 20

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 allows the nurse to determine the patient's areas of risk for heart disease. Using this information, the nurse can then educate the patient on specific steps they can take to lower their risk, such as maintaining a healthy diet, exercising regularly, quitting smoking, and managing stress. Reviewing the patient's previous medical record or discussing their perceived area of health risks may provide some information, but conducting a thorough health history and physical exam is necessary for identifying specific areas of risk and developing an appropriate plan of care.

Quiz 29: Nursing Assessment of the Patient With Cardiovascular Disorders