Exam 20: Heart and Neck Vessels

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S₂ heart sound. Which of these findings can be explained by the expected hemodynamic changes r/t age?

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What should the nurse do?

When listening to heart sounds, which valve closures are heard best at the base of the heart?

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. What does the nurse suspect?

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?

The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath." Which is the best response by the nurse?

While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S₃, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?

The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching?

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. How should the nurse interpret this finding?

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What does this finding indicate?

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short-time hungry again. What other information would the nurse want to have?

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

During the precordial assessment of a patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. What does this finding indicate?

During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. What does this finding indicate?