Heart and Neck Vessels Assessment Flashcards
Meet the Client: Mr. Tomas Depodi
Mr. Tomas Depodi is a 58-year-old male who moved to the area from India 20 years ago. He is admitted directly to the cardiac telemetry unit from his physician’s office with a history of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort.
Info
Priority Data Collection
During the admission assessment, the nurse first measures Mr. Depodi’s vital signs and oxygen saturation. The vital signs and oxygen saturation are within normal parameters, although the radial pulse rhythm is irregular.
1.
Based on Mr. Depodi’s report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next?
Ask the client to stand and then recheck the blood pressure.
Place the client in a supine position and observe for orthopnea.
Measure the apical and radial pulse rates at the same time.
Determine if the client is currently experiencing any angina.
Determine if the client is currently experiencing any angina.
Because the client has a history of chest discomfort, the nurse should first determine if the client is currently experiencing angina. Angina should be treated immediately to reduce the risk for myocardial damage.
Mr. Depodi denies any current symptoms, including angina.
2.
After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client’s heart rate?
Palpate both radial pulses simultaneously.
Auscultate the apical pulse for 1 minute.
Compare the ulnar pulse to the radial pulse.
Ask the client if he experiences palpitations.
Auscultate the apical pulse for 1 minute.
Auscultation of the apical pulse is the most accurate method to determine heart rate and rhythm because the nurse is listening directly over the heart, rather than depending on the transmission of the pulse to a distal site, such as the radial pulse site.
Client Interview
The client’s apical rate is 92 and irregular, consistent with the radial pulse. The nurse implements cardiac telemetry monitoring, obtains oxygen for PRN use, and begins treatment for Mr. Depodi’s irregular heart rhythm as prescribed.
After gathering the initial priority data, the nurse interviews Mr. Depodi to gather subjective data related to his cardiac function. During the interview, Mr. Depodi asks the nurse to call him Tomas.
3.
To gather data about Tomas’ history of chest pain, how should the nurse begin?
Encourage the client to describe his chest discomfort.
Determine if the chest pain has radiated to other sites.
Question the client about the frequency of his symptoms.
Ask the client to rate his chest pain on a numeric scale.
Encourage the client to describe his chest discomfort.
Because chest pain can manifest in a number of different ways, the nurse should begin by obtaining information related to any type of chest discomfort, so that further responses by the client include information related to any type of chest discomfort he has experienced.
Client Interview
Tomas reports feeling “pressure” on his chest sometimes, stating that it stops when he sits down and rests.
Tomas also tells the nurse that he feels “tired a lot lately.” He states, “I guess that’s part of growing older.”
4.
To obtain information that will help distinguish whether the client’s fatigue is cardiac in nature, what question should the nurse ask the client?
Why do you feel your fatigue is related to your age?
Can you describe the quality of your fatigue?
What do you do when you feel tired?
At what time of day do you feel most fatigued?
At what time of day do you feel most fatigued?
Fatigue related to stress or depression may be worse in the morning, or be present all day, while fatigue related to decreased cardiac output may worsen in the evening.
Tomas tells the nurse that he gets progressively more fatigued throughout the day.
Related Assessment: Spiritual Assessment
While interviewing Tomas, the nurse learns that the client is Hindu.
5.
Before developing the client’s plan of care, what information is most important for the nurse to obtain regarding the client’s spirituality?
Whether the client participates in formal religious services regularly.
How the client’s spiritual beliefs impact his health care expectations.
What beliefs the client holds regarding the existence of a higher power.
The role played by a spiritual advisor within the client’s faith tradition.
How the client’s spiritual beliefs impact his health care expectations.
In planning care, the nurse should try to determine how the client’s spiritual and cultural beliefs impact the expectations for care in the healthcare setting.
6. It is most important for the nurse to obtain further information related to which aspect of the client’s care? Hygiene practices. Sleep patterns. Exercise habits. Dietary needs.
Dietary needs.
While there are few commonly held beliefs in Hinduism, many Hindus are vegetarians, so the nurse should assess the client’s dietary needs.
7.
How should the nurse prepare the client for inspection of the precordium?
Assist the client to a left side-lying position with his chest and back exposed.
Open the back of the client’s gown while he sits on the side of the bed.
Help the client to a supine position on the bed with his chest exposed.
Loosen the client’s gown and ask him to lean forward in the bedside chair.
Help the client to a supine position on the bed with his chest exposed.
A supine position with the chest exposed provides the best exposure for inspection of the precordium.
Inspection of the Precordium
The nurse begins the physical assessment by inspecting the client’s precordium.
After preparing the client, the nurse visually inspects the precordium by first observing for an apical impulse. The nurse is unable to observe the apical impulse.
The nurse next assesses for a left ventricular heave.
8.
The nurse should observe the force of the impulse at what location?
Left midclavicular line, 2nd intercostal space.
Left sternal border, 4th intercostal space.
Right sternal border, 2nd intercostal space.
Left midclavicular line, 5th intercostal space.
Left midclavicular line, 5th intercostal space.
A left ventricular heave is seen at the apex, located at the left midclavicular line, 5th intercostal space. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle.
Palpation of the Precordium
The nurse uses the palmar aspects of the fingers to palpate across the precordium.
9.
To begin palpation at the base of the heart, where should the nurse palpate first?
Right sternal border, 2nd intercostal space.
Right sternal border, 4th intercostal space.
Left sternal border, 5th intercostal space.
Left midclavicular line, 5th intercostal space.
Right sternal border, 2nd intercostal space.
This is the location of the aortic site. The aortic and pulmonic sites are found at the base of the heart.
10. Before attempting to palpate again, what instruction should the nurse give the client? Lift his left arm above his head. Turn onto his right side. Externally rotate his right shoulder. Roll half-way to his left side.
Roll half-way to his left side. Correct
Turning half-way to the left side moves the apex of the heart closer to the chest wall, so it is easier to palpate.
Palpation of the Precordium
The nurse is able to palpate the apical impulse after Tomas turns midway to his left side.
The nurse considers whether to percuss the client’s precordium. Tomas’ medical record contains the results of several diagnostic tests completed prior to his admission to the hospital.
11. Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? (Select all that apply.) Creatine phosphokinase (CPK). Carotid ultrasound. Serum liver enzymes. Chest x-ray. Echocardiogram.
Chest x-ray.
Chest percussion helps outline the borders of the heart to detect enlargement. Enlargement of the heart is more accurately detected with a chest x-ray.
Echocardiogram.
Chest percussion helps outline the borders of the heart to detect enlargement. Enlargement of the heart is more accurately detected using an echocardiogram.
Auscultation of the Precordium
The nurse uses a stethoscope for auscultation of the client’s heart and plans to begin auscultation at the aortic area.
12.
How should the nurse plan to continue auscultation from that site?
Move the stethoscope back and forth across the sternum.
Slide the stethoscope over and up in an “X” pattern.
Lift the stethoscope from one valve area to the next.
Inch the stethoscope across and down in a “Z” pattern.
Inch the stethoscope across and down in a “Z” pattern.
Inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard.
The nurse places the diaphragm of the stethoscope at the second right interspace.
13.
In listening at this site, what should the nurse attempt to distinguish first?
S1 and S2 heart sounds.
Diastolic heart murmur.
S3 and S4 heart sounds.
Systolic heart murmur.
S1 and S2 heart sounds.
The nurse should begin by listening for the normal heart sounds, S1 and S2, before attempting to distinguish abnormal heart sounds, such as S3 and S4 or heart murmurs.
Auscultation of the Precordium
During auscultation, the nurse has difficulty distinguishing S1 from S2 because of the client’s irregular heart rhythm.
14.
While continuing to listen at the aortic site, what action should the nurse take?
Observe the P wave on the telemetry monitor.
Watch the client’s inhalation and exhalation.
Palpate the carotid artery pulse.
Check for a pulse deficit.
Palpate the carotid artery pulse.
S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, the nurse can distinguish S1 as the sound that occurs with each pulsation.
