Jensen - Ch. 17 Exam Questions with Correct Answers Latest Update

Jensen - Ch. 17 Exam Questions with Correct Answers Latest Update A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source? - Answers Cardiac When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? - Answers S1 A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? - Answers Orthopnea How should a nurse assess a client for pulse rate deficit? - Answers Assess for a difference between the apical and radial pulse In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? - Answers left midclavicular line at the fifth intercostal space A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? - Answers No current medications or treatments A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse? - Answers Ask the client to assume the left lateral position A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? - Answers Inflammation of the pericardial sac A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? - Answers Orthopnea A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client? - Answers Smoking increases the heart's workload and contributes to atherosclerosis. A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? - Answers Bradycardia A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? - Answers Inflammation of the pericardial sac A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following? - Answers Myocardium While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings? - Answers Pericardial friction rub The nurse is integrating health promotion education into the assessment of a client's heart and neck vessels. What teaching point addresses the most significant risk factor for coronary artery disease? - Answers "Your risk for heart disease will drop greatly if you're able to stop smoking." The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply. - Answers Smoking Blood pressure Cholesterol The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of - Answers increased central venous pressure. A community health nurse is planning a screening day for blood pressure and cholesterol. What kind of prevention would this be? - Answers Secondary A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority? - Answers Patient C The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first? - Answers "Do you have any pain or discomfort in your chest?" 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? - Answers Pericardial friction rub After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following? - Answers Ventricles A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? - Answers Pacemaker Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? - Answers Increased urination at rest may indicate heart failure. The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? - Answers Fifth intercostal space, left midclavicular line The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? - Answers Palpate each artery individually to compare The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? - Answers Bruits When evaluating the jugular venous pressure in a patient with known coronary artery disease, the nurse explains to the patient that the JVP measures the pressure in the - Answers right atrium While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate? - Answers Shortness of breath Which of the following interventions can the nurse use to help a client modify risk factors associated with with hypertension? (Select all that apply). - Answers Ask the client to keep a "typical day" record of daily food intake Ask the client to keep an activity log Provide information about aids to promote smoking cessation During the health history interview with a 40-year-old man, the nurse uses the genogram to