Exam 1-Holistic Health Assessment Questions With
Complete Solutions Graded To Pass!!
While auscultating the heart at the third intercostal space, left sternal border, the
nurse notes a high-pitched, scratchy sound that increases with exhalation with
the client leaning forward. The nurse would document which of the following?
Pericardial friction rub
A client with dehydration or volume depletion has barely visible neck veins, even
when lying flat. These are described as what?
Flat Neck Veins
A nurse auscultates the heart of a client with hypertension for the past ten (10)
years. With the client in the left lateral position, the nurse hears a heart sound
that occurs just before S1. The nurse recognizes this sound as what pathological
process?
Atrial contractions heard as vibrations against stiff walled ventricles
During a cardiac examination, the nurse can best hear the S1 heart sound by
placing the stethoscope at the client's
apex of the heart.
In order to palpate an apical pulse when performing a cardiac assessment, where
should the nurse place the fingers?
left midclavicular line at the fifth intercostal space
Across the lifespan, a nurse knows what characteristic of the female heart is
consistently true?
Is normally smaller than the male heart
The nurse hears high-pitched swooshing sounds over the carotid artery on the
right side. What is this sound indicative of?
Bruits
The nurse begins auscultating a client's heart sounds at the 2nd intercostal space
right sternal border. Which location should the nurse assess next?
2nd intercostal space left sternal border
The nurse is preparing to assess a client's apical impulse. The nurse should
palpate at which location?
Fifth intercostal space, left midclavicular line
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?
Accentuated
A client is admitted to the health care facility with reports of chest pain, elevated
blood pressure, and shortness of breath with activity. The nurse palpates the
carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic
murmur is auscultated. Which nursing diagnosis can the nurse confirm based on
this data?
Ineffective Tissue Perfusion
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
, The nurse is preparing to assess a client's carotid arteries. Which of the following
would be most appropriate?
Palpate each artery individually to compare
How does the nurse differentiate a pleural friction rub from a pericardial friction
rub?
Have the client hold his or her breath; if the rub persists, it is pericardial
The nurse is caring for a client who has an elevated cholesterol level. To reduce
the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol
levels, what diet should the nurse discuss with the client?
Low-fat, low-cholesterol meals
Where is the point of maximal impulse (PMI) normally located?
In the left 5th intercostal space 7 to 9 cm lateral to the sternum
Which of the following are clinical identifiers of metabolic syndrome?
A man with a BP of 144/88
A nurse auscultates a very loud murmur that occurs throughout systole and can
be heard with the stethoscope partly off the chest. How should the nurse grade
this murmur?
Grade 5
A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be
irregular. What would the nurse do next?
Auscultate for pulse rate deficit.
A client has engorged jugular veins. What should this finding suggest to the
nurse?
right atrial pressure
The nurse is having difficulty locating a client's point of maximum impulse. What
should the nurse do to facilitate this assessment?
assist the client into a left lateral decubitus position
The nurse notes that a client's heart rate increases with inspiration and slows
down with expiration. How should the nurse document this finding?
Sinus arrhythmia
The nurse assesses a client's neck as shown. What is the nurse assessing?
Carotid artery
When auscultating the heart, the nurse is most likely to hear a diastolic murmur
after which heart sound?
S2
When auscultating a client's heart, the nurse hears both S3 and S4. What is this
known as?
Summation gallop
Which anterior neck structure is found in the depression between the trachea and
the sternomastoid muscle?
Carotid artery
An older adult client has come to the clinic for a routine checkup. The nurse
practitioner notes that the carotid artery pulse is diminished bilaterally and a
systolic bruit is auscultated bilaterally. What would the nurse practitioner want to
have this client assessed for by a cardiologist?
Atherosclerotic stenotic carotid arteries
Complete Solutions Graded To Pass!!
While auscultating the heart at the third intercostal space, left sternal border, the
nurse notes a high-pitched, scratchy sound that increases with exhalation with
the client leaning forward. The nurse would document which of the following?
Pericardial friction rub
A client with dehydration or volume depletion has barely visible neck veins, even
when lying flat. These are described as what?
Flat Neck Veins
A nurse auscultates the heart of a client with hypertension for the past ten (10)
years. With the client in the left lateral position, the nurse hears a heart sound
that occurs just before S1. The nurse recognizes this sound as what pathological
process?
Atrial contractions heard as vibrations against stiff walled ventricles
During a cardiac examination, the nurse can best hear the S1 heart sound by
placing the stethoscope at the client's
apex of the heart.
In order to palpate an apical pulse when performing a cardiac assessment, where
should the nurse place the fingers?
left midclavicular line at the fifth intercostal space
Across the lifespan, a nurse knows what characteristic of the female heart is
consistently true?
Is normally smaller than the male heart
The nurse hears high-pitched swooshing sounds over the carotid artery on the
right side. What is this sound indicative of?
Bruits
The nurse begins auscultating a client's heart sounds at the 2nd intercostal space
right sternal border. Which location should the nurse assess next?
2nd intercostal space left sternal border
The nurse is preparing to assess a client's apical impulse. The nurse should
palpate at which location?
Fifth intercostal space, left midclavicular line
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?
Accentuated
A client is admitted to the health care facility with reports of chest pain, elevated
blood pressure, and shortness of breath with activity. The nurse palpates the
carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic
murmur is auscultated. Which nursing diagnosis can the nurse confirm based on
this data?
Ineffective Tissue Perfusion
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
, The nurse is preparing to assess a client's carotid arteries. Which of the following
would be most appropriate?
Palpate each artery individually to compare
How does the nurse differentiate a pleural friction rub from a pericardial friction
rub?
Have the client hold his or her breath; if the rub persists, it is pericardial
The nurse is caring for a client who has an elevated cholesterol level. To reduce
the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol
levels, what diet should the nurse discuss with the client?
Low-fat, low-cholesterol meals
Where is the point of maximal impulse (PMI) normally located?
In the left 5th intercostal space 7 to 9 cm lateral to the sternum
Which of the following are clinical identifiers of metabolic syndrome?
A man with a BP of 144/88
A nurse auscultates a very loud murmur that occurs throughout systole and can
be heard with the stethoscope partly off the chest. How should the nurse grade
this murmur?
Grade 5
A nurse auscultates a client's heart rate and rhythm and finds the rhythm to be
irregular. What would the nurse do next?
Auscultate for pulse rate deficit.
A client has engorged jugular veins. What should this finding suggest to the
nurse?
right atrial pressure
The nurse is having difficulty locating a client's point of maximum impulse. What
should the nurse do to facilitate this assessment?
assist the client into a left lateral decubitus position
The nurse notes that a client's heart rate increases with inspiration and slows
down with expiration. How should the nurse document this finding?
Sinus arrhythmia
The nurse assesses a client's neck as shown. What is the nurse assessing?
Carotid artery
When auscultating the heart, the nurse is most likely to hear a diastolic murmur
after which heart sound?
S2
When auscultating a client's heart, the nurse hears both S3 and S4. What is this
known as?
Summation gallop
Which anterior neck structure is found in the depression between the trachea and
the sternomastoid muscle?
Carotid artery
An older adult client has come to the clinic for a routine checkup. The nurse
practitioner notes that the carotid artery pulse is diminished bilaterally and a
systolic bruit is auscultated bilaterally. What would the nurse practitioner want to
have this client assessed for by a cardiologist?
Atherosclerotic stenotic carotid arteries
