Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 18 Cardiovascular System

1. The nurse educator is teaching a group of nursing students to assess heart sounds. Which response by a student indicates appropriate understanding of how S2 heart sounds are produced?

1. "It results from the closure of the mitral valve."

2. "It is a result from the closure of the semilunar valves."

3. "It results from the closure of the tricuspid valve."

4. "It is caused by atrial contraction and ejection of blood into the ventricles in late diastole."

Page Ref: 356

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

1. The nurse is reviewing the function of the right side of the heart with a client. Which statement made by the client indicates further teaching is required?

1. "The right atrium receives blood that is deoxygenated."

2. "The mitral valve separates the right atrium from the right ventricle."

3. "The right atrium pumps blood to the right ventricle."

4. "The right atrium relaxes during diastole."

Page Ref: 363, 364

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.1: Describe the anatomy and physiology of the cardiovascular system.

MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

1. The client's stroke volume is 72 ml/beat. The client's heart rate is 82 beats per minute. What is the client's cardiac output? Record the response using a whole number.

Page Ref: 376

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.1: Describe the anatomy and physiology of the cardiovascular system.

MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

1. The nurse prepares to assess a client's point of maximal impulse (PMI). Which location should the nurse assess?

1. Second intercostal space, left sternal border.

2. Fifth intercostal space at the midclavicular line.

3. Second intercostal space, right sternal boarder.

4. Fourth intercostal space, left sternal boarder.

Page Ref: 387

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

1. The nurse is preparing to assess a client for heaves. Which location should the nurse palpate?

1. Fifth intercostal space, midaxillary line.

2. Second intercostal space, left sternal border.

3. Fourth intercostal space, left sternal border.

4. Second intercostal space, right sternal border.

Page Ref: 387

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

1. The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

1. "I have been stressed out since my divorce last year."

2. "I have cut back on my smoking."

3. "I have gained 25 pounds over the past year."

4. "I have cut back on fat and switched to a vegetarian diet."

5. "I have an occasional glass of wine."

Page Ref: 377

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.

1. The nurse is assessing a client for risk factors of developing cardiovascular disease. Which statement made by the client places the client at risk?

1. "I was diagnosed with hypothyroidism about 5 years ago."

2. "My doctor always tells me when I come in that my blood pressure is low."

3. "I know my grandmother had diabetes, but every time it has been checked mine has been normal."

4. "My total cholesterol has been around 180."

Page Ref: 380

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.

1. The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. Which statement made by the client is generally unrelated to a myocardial infarction in males?

1. "I couldn't catch my breath."

2. "I did not feel any chest pain."

3. "I started sweating profusely."

4. "I got so sick to my stomach."

Page Ref: 380

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.

MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.

1. The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the coronary arteries. Which question by the nurse is the priority when determining risk factors for this condition?

1. "Can you please tell me about the vitamins or supplements that you take?"

2. "Have you ever been diagnosed with rheumatic fever?"

3. "Do you smoke or are you exposed to secondhand smoke?"

4. "Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or echocardiogram, or a surgical procedure for a cardiovascular problem?"

Page Ref: 378

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.3: Determine which questions about the cardiovascular system to use for the focused interview.

MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.

1. The nurse is preparing to assess the female client's cardiovascular system during a routine health assessment visit. Which items should the nurse have available in the room in order to complete the examination? Select all that apply.

1. Ruler (metric).

2. Stethoscope.

3. Reflex hammer.

4. Client gown and a drape.

5. An ultrasound machine.

Page Ref: 383

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse is preparing to assess the client's cardiovascular system. Which client positions will the nurse use when conducting this assessment? Select all that apply.

1. Dorsal recumbent.

2. Leaning forward.

3. Right lateral position.

4. Left lateral position.

5. Sitting upright.

Page Ref: 384-391

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse is preparing to auscultate heart sounds after repositioning the client on the left side. Which sounds should the nurse anticipate evaluating the client for?

1. S3 and S4 sounds.

2. S1 and S2 sounds.

3. Pulmonic valve murmurs.

4. Tricuspid valve murmurs.

Page Ref: 391

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse is assessing the client's cardiovascular system. Which techniques are appropriate for the nurse to use during this assessment? Select all that apply.

1. Continuing the exam when the client complains of discomfort when lying flat.

2. Auscultating the apical impulse at the fifth intercostal space at the midclavicular line.

3. Examining the client's legs and noting the distribution pattern of the client's hair

4. Palpating the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate.

5. Examining the client's hands and fingers.

Page Ref: 384-387

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The client has a history of rheumatic fever. Which layer of the heart is at the greatest risk for damage due to infection?

1. Epicardium.

2. Myocardium.

3. Endocardium.

4. Pericardium.

Page Ref: 392

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is preparing to assess the central venous pressure of a client with a ruler. Which techniques should the nurse include in the assessment?

1. Place the client in 45-degree angle.

2. Measure the distention on both sides.

3. Place the ruler horizontally at the angle of Lois and the second at a 45-degree angle.

4. Place the ruler at the substernal notch and the end of the juggler vein on the lateral aspect of the neck.

Page Ref: 386

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse is performing a cardiac assessment on an older adult client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. Which conclusion by the nurse is appropriate based on this data?

1. Left ventricular hypertrophy.

2. Aortic stenosis.

3. Right ventricular volume overload.

4. Enlarged left atrium.

Page Ref: 388

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is assessing a client with a history of rheumatic fever. Subjective findings include fatigue and objective findings include a diastolic murmur in the apical area when the client is in the left lateral position. Which diagnosis should the nurse suspect?

1. Tricuspid regurgitation.

2. Mitral regurgitation.

3. Mitral stenosis.

4. Pulmonic stenosis.

Page Ref: 393

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. During the cardiac assessment of a client, the nurse hears a loud rumbling at the left sternal border. Which diagnosis should the nurse suspect?

1. Aortic stenosis.

2. Tricuspid stenosis.

3. Mitral regurgitation.

4. Pulmonic stenosis.

Page Ref: 394

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The intensive care nurse is performing a cardiac assessment on a newly admitted older adult client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45-degree angle, and an enlarged liver. Based on this data, which diagnosis does the nurse suspect?

1. Pulmonary edema.

2. Left-sided heart failure.

3. Myocardial infarction.

4. Right-sided heart failure.

Page Ref: 392

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is assessing a client notes a loud, blowing sound over the right carotid artery. Based on this data, which diagnosis should the nurse anticipate?

1. Mitral stenosis.

2. Aortic regurgitation.

3. Atrial septal defect.

4. Stricture of the carotid.

Page Ref: 390

Cognitive Level: Remembering

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is preparing to listen to a client's mitral valve. Which landmark on the client's chest should the nurse place the bell of the stethoscope?

1. Left sternal boarder, third intercostal space.

2. Left sternal border, fourth intercostal space.

3. Right sternal boarder, second intercostal space.

4. The apex, fifth intercostal space, left midclavicular line.

Page Ref: 390

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse notes that a client has xanthelasma during an assessment. Which cardiovascular condition should the nurse suspect?

1. Liver disease.

2. Diabetes.

3. Elevated cholesterol.

4. Premature atherosclerosis.

Page Ref: 385

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is preparing to care for a client with Paget's disease. Which assessment findings should the nurse monitor the client for? Select all that apply.

1. Dyspnea.

2. Fatigue.

3. Weakness.

4. Flushed skin.

5. Distended jugular veins.

Page Ref: 385

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse observes splinter hemorrhages in a client's nailbeds. Which finding should the nurse suspect the findings are associated with?

1. Polycythemia.

2. Congestive heart failure.

3. Infective endocarditis.

4. Inadequate cardiac perfusion.

Page Ref: 386

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is reviewing the symptoms of an MI with a female client. Which findings should the nurse include?

1. Extreme fatigue.

2. Prolonged dull chest pain.

3. Dyspnea.

4. Indigestion.

5. Nausea and vomiting.

Page Ref: 380

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is reviewing the effects of smoking on the cardiovascular system with a client. Which information should the nurse include in the teaching?

1. Injury to the vessel walls.

2. Decreased workload of the heart.

3. Damage to the cardiac muscle.

4. Damage to cardiac valves.

Page Ref: 381

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is caring for a client that is using cocaine. Which initial cardiovascular effect occurs due to the use of the drug?

1. Congestive heart failure.

2. Coronary artery spasms.

3. Vasodilation.

4. Atherosclerosis.

Page Ref: 381

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse observes that a client's skin is a ruddy color. Which condition should the nurse suspect?

1. Systemic Infection.

2. Polycythemia.

3. Coronary artery disease.

4. Rheumatic heart disease.

Page Ref: 384

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is caring for a client suspected of having a myocardial infarction. Which assessment findings should the nurse recognize are associated with the condition? Select all that apply.

1. Mental confusion.

2. Vomiting.

3. Skin is flushed and warm.

4. Diaphoresis.

5. Jugular venous distension.

Page Ref: 392

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. A client asks the nurse what pulmonary stenosis means. Which information should the nurse provide the client?

1. Narrowing between the pulmonary vein and left atrium.

2. Narrowing between the pulmonary artery and left ventricle.

3. Narrowing between the pulmonary vein and the right atrium.

4. Narrowing between the pulmonary artery and the right ventricle.

Page Ref: 393

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is conducting a cardiovascular focused assessment. Which question should the nurse ask that reflects behavior?

1. "Can you describe your diet?"

2. "Do you take any medications?"

3. "What is your present occupation?"

4. "Have you experienced a change in your weight?"

Page Ref: 381

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.3: Determine which questions about the cardiovascular system to use for the focused interview.

MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.

1. The nurse observes expected findings after assessing a client's conjunctiva. Which description should the nurse anticipate to document?

1. Red.

2. White.

3. Clear.

4. Pink.

Page Ref: 385

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.5: Generate the appropriate documentation to describe the assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.

1. The nurse is auscultating the fifth intercostal space left midclavicular line. Which should the nurse anticipate documenting?

1. Tricuspid sounds.

2. Apical pulse.

3. Pulmonic sounds.

4. Aortic sounds.

Page Ref: 387

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 18.5: Generate the appropriate documentation to describe the assessment of the cardiovascular system.

MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.