HESI Case Study: Heart and Neck vessels

Mr. Thomas Depodi is a 58 year old male who moved to the area from India 20 years ago. He is admitted directly into the cardiac telemetry unit from his physicians office with a history of dyspnea, dizziness, and chest discomfort.

During the admission assessment the nurse measures Mr. Depodi’s vital signs and oxygen saturation. They are within normal parameters although the radial pulse rhythm is irregular.

Based on Mr. Depodi’s reports of increasingly frequent periods of dyspnea, dizziness, and mild chest discomfort, what assessment does the nurse perform next?
A. Ask the client to stand and recheck his blood pressure
B. Place the client in a supine position and observe for orthopnea
C. measure the apical and radial pulse rates at the same time
D. Determine if the client is currently experiencing any angina

D. Determine if the client is currently experiencing any angina

With his history of chest discomfort the nurse should determine if the client is currently experiencing angina, angina should be treated immediately to reduce the risk of myocardial damage.

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?

A.Palpate both radial pulses simultaneously
B. Auscultate the apical pulse for 1 minute
C. Compare the ulnar pulse to the radial pulse
D. Ask the client if he experiences palpitations

B. Auscultate the apical pulse for one minute

this is the most accurate method to determine heart rate

the clients apical pulse rate is 92 and irregular consistent with the radial pulse the nurse implements cardiac telemetry monitoring, obtains oxygen PRN use and begins treatment for Mr. Depodi’s irregular heart rhythm as prescribed. After gathering the initial priority data the nurse interview mr depodi to gather subjective data related to his cardiac function during the interview mr depodi asks the nurse to call him tomas.

To gather data about Tomas’s history of chest pain how should the nurse begin?

A. Encourage the client to describe his chest discomfort
B. Determine if chest pain has radiated to the other side
C. Question the client about the frequency of his symptoms
D. Ask the client to rate his chest pain on a numeric scale

A. Encourage the client to describe his chest discomfort

because chest pain can manifest in different ways the nurse should begin by obtaining information related to the type of chest discomfort

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 that he thinks this is from growing older

To help determine if the client’s fatigue is of a cardiac nature what question should the nurse ask the client?

A. Why do you feel your fatigue is related to your age?
B. Can you describe the quality of your fatigue?
C. What do you do when you feel tired?
D. At what time of day do you feel the most fatigued?

D. At what time of day do you feel the most fatigued?

fatigue related to decreased cardiac output worsens in the evening while fatigue related to stress or depression may worsen in the morning

While interviewing tomas the nurse learns that the client is Hindu. Before developing the client’s plan of care, what information is important to obtain regarding the client’s spirituality?

A. Whether the client participates in religious services regularly
B. How the clients spiritual beliefs impact his health care expectations
C. What beliefs the client holds regarding the existence of a higher power
D. The role played by the spiritual adviser within the client’s faith tradition

B. How the clients 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

It is most important for the nurse to obtain further information related to which aspect of the client’s care?
A. Hygiene practices
B. Sleep patterns
C. Exercise habits
D. Dietary needs
E. Herbs or purgatives used
D. Dietary needs
E. Herbs or purgatives used

How should the nurse prepare for the inspection of the precordium?

A. assist the client to a left side lying position with his chest and back exposed
B. Open the back of the client’s gown while he sits on the side of the bed
C. Help the client to a supine position on the bed with his chest exposed
D. Loosen the clients gown and ask him to lean forward in the bedside chair

C. Help the client to a supine position on the bed with his chest exposed

After preparing the client the nurse visually inspects the precordium by first observing for an apical impulse. The nurse is unable to observe for an apical impulse. The nurse next assesses for a left ventricular heave.

The nurse should observe the force of the impulse at what location?
A. Left midclavicular line, second intercostal space
B. Left sternal boarder fourth intercostal space
C. Right sternal boarder second intercostal space
D. Left midclavicular line 5th intercostal space

D. Left midclavicular line 5th intercostal space

The nurse uses the palmer aspect of her hand to palpate across the precordium

to begin palpitation at the base of the heart where should the nurse palpate first?
A. Right sternal boarder second intercostal space
B. Right sternal boarder 4th intercostal space
C. Left sternal boarder 5th intercostal space
D. left midclavicular line 5th intercostal space

A. Right sternal boarder second intercostal space

this is the location of the aortic site the aortic and pulmonic site are found at the base of the heart

Before attempting to palpate again what instruction should the nurse give the client?

A. lift his left arm above his head
B. Turn onto his right side
C. Externally rotate his right shoulder
D. Roll halfway to his left side

D. Roll halfway to his left side

moving this way moves the apex of the closer to the chest wall so its easier to palpate

The nurse is able to palpate the apical impulse after turning Tomas on his side. The nurse considers whether to percuss the client’s precordium Tomas’s medical record contains the results of several diagnostic tests completed prior to his admission to the hospital.

Which test can the nurse review to obtain the same information that might be obtained during precordial percussion?

A. creatine phosphokinase (CPK)
B. Carotid ultrasound
C. Serum liver enzymes
D. Chest X ray
E. echocardiogram

D. Chest x ray

chest percussion helps outline the boarder of the heart to detect enlargement

E. echocardiogram

The nurse uses a stethoscope for auscultation of the client’s heart and plans to begin auscultation of the aortic area.

How should the nurse plan to continue auscultation from that site?

A. Move the stethoscope back and forth across the sternum
B. Slide the stethoscope over and up in an X pattern
C. Lift the stethoscope from one valve area to the next
D. Inch the stethoscope across and down in a Z pattern

D. Inch the stethoscope across and down in a Z pattern

Inching the stethoscope across the chest using a systematic pattern ensures that all sounds produced by the valve will be heard

The nurse places the diaphragm of the stethoscope at the second right interspace

In listening at this site what should the nurse attempt to distinguish first?

A. S1 and S2 heart sounds
B. Diastolic heart murmur
C. S3 and S4 sounds
D. systolic heart murmur

A. S1 and S2 heart sounds

The nurse should begin with listening to the normal heart sounds S1, S2 before attempting to distinguish abnormal heart sounds

During auscultation the nurse has trouble distinguishing S1 from S2 because of the client’s irregular heart rhythm

While continuing to listen at the aortic site, what action should the nurse take?

A. Observe for P wave on telemetry monitor
B. Watch the client’s inhalation and exhalation
C. Palpate the carotid artery pulse
D. Check for a pulse deficit

C. Palpate the carotid artery pulse

S1 occurs simultaneously with carotid artery pulsation, by gently palpating the carotid artery the nurse can distinguish S1 as the sound that occurs with pulsation

The nurse is able to distinguish LUB-dup sequence of S1 and S2 from the assessment. After inching the diaphragm of the stethoscope to the left second intercostal space the nurse hears a split S2 during the client’s inspiration.

What action should the nurse take in response to this finding?

A. Document this normal finding on the initial assessment record
B. Confirming the finding on the bedside cardiac telemetry monitor
C. Assess for changes in the client’s oxygen saturation reading
D. Contact the healthcare provider to report the assessment finding

A. Document this normal finding on the initial assessment record

A split S2 is a normal finding that can be heard in some people as the result of the slightly asynchronous closing of the aortic and pulmonic valves. A split S2 is heard best heard during inspiration at the pulmonic site, the second left intercostal space.

The nurse hears a swooshing sound that coincides with S1 while listening to the diaphragm of the stethoscope How should the nurse identify this sound?

A. Diastolic murmur
B. Systolic murmur
C. S4 heart sound
D. S3 heart sound

B. Systolic murmur

murmurs are often heard as a swooshing sound, systolic murmurs coincide with the S1 heart sound.

The nurse assesses the murmur more completely.

To determine the grade of the murmur what action should the nurse take?

A. listen in surrounding areas for the extent of radiation of the sound
B. Assess for a change in the murmur during a change in the murmur during a change in the client’s position
C. Determine the location on the client’s chest where the murmur is best heard
D. Note how easily the murmur is heard by gradually lifting the stethoscope

D. Note how easily the murmur is heard by gradually lifting the stethoscope

murmurs are graded based on the intensity of the sound, ranging from grade 1 murmur which is barely audible, to grade 6 murmur which can be heard with a stethoscope lifted off the chest wall

The nurse hears a grade 3 systolic murmur at the apical site but does not hear an S3 or S4 heart sound.

What action should the nurse take next?

A. Document the findings and report the murmur to the charge nurse
B. Repeat auscultation across the chest using the bell of the stethoscope
C. Continue the assessment of heart sounds across the client’s posterior thorax.
D. Plan to repeat the assessment in one hour after the client rests

B. Repeat auscultation across the chest using the bell of the stethoscope

after completing the assessment with the diaphragm of the stethoscope the nurse should repeat the sequence using the bell of the stethoscope. The bell of the stethoscope is used to listen for relatively lower pitched sounds of the diaphragm.

While listening to the client’s heart sounds at the apical site, the nurse now hears a dull soft sound following S2

What action will help the nurse confirm the presence of this sound?

A. Move the diaphragm of the stethoscope to the base of the heart
B. Use the bell of the stethoscope to continue listening at the apical site
C. Palpate the apical impulse while listening at the base of the heart
D. Place the stethoscope at the right sternal border at the third interspace

B. Use the bell of the stethoscope to continue listening at the apical site

a soft dull sound heard after S2 is an abnormal heart sound, this S3 sound is low pitched and is heard best at the apex with the bell of the stethoscope

The nurse’s further assessment confirms the finding of an S3 sound.

After determining that the client has developed an S3 heart sound the nurse re-assess the client.

What assessment should the nurse include?

A. Check for jugular vein distention
B. Note the onset of nail bed clubbing
C. Check for diminished skin elasticity
D. Assess for orthostatic hypotension

A. Check for jugular vein distention

An S3 heart sound may be an early indicator of the onset of heart failure, so the nurse should assess for other signs of heart failure including jugular vein distention

The nurse places Tomas supine in a Semi-Fowlers position

To inspect for JVD what actions should the nurse take?
Select all that apply

A. Place the client in a Semi-Fowler’s position with his head straight
B. Lower the head of the bed while observing the neck veins
C. Remove the client’s pillow and turn his head away slightly
D. Assist the client to lean forward at a 30-45 degree angle
E. Place client in a semi-fowlers position

C. Remove the client’s pillow and turn his head away slightly

E. Place client in a semi-fowlers position

The nurse observes a pulsation low and laterally on the neck at the area of the left internal jugular vein but is unable to palpate the pulsation

What action should the nurse take?

A. Use a stethoscope to auscultate the pulsation
B. Palpate the pulsation again using less pressure
C. Re position the client’s head and attempt the palpate again
D. Document the level at which the pulsation is observed

D. Document the level at which the pulsation is observed

venous pulsations are not palpable, the nurse should document the level at which the pulsations are observed

How should the nurse begin the carotid artery assessment?

A. palpate one artery while listening to the other side with a stethoscope
B. palpate one artery and then palpate the artery on the opposite side
C. Gently compress both arteries simultaneously to compare volume
D. Avoid palpation’s and only use a stethoscope to listen to each artery

B. palpate one artery and then palpate the artery on the opposite side

The nurse does not hear a bruit. What should the nurse do next?

A. Reassure the client that his right artery sounds “clear” and listen to the left side.
B. Listen at the base of the neck again, this time using the diaphragm of the stethoscope
C. Move the bell of the stethoscope up the right side to the mid cervical area
D. Press the bell of the stethoscope more firmly against the base of the neck and listen again

C. Move the bell of the stethoscope up the right side to the mid cervical area

The nurse documents the findings and prepares to report the findings to the healthcare provider. Which assessment data is important to the nurse to report to the physician?

A. Presence of S1 and S2 heart sounds
B. Onset of S3 heard
C. Observed jugular vein distention
D. Noted absence of carotid bruit
E. Client’s subjective report of dyspnea

B. Onset of S3 heard
C. Observed jugular vein distention
E.Client’s subjective report of dyspnea

The nurse uses the SBAR method when communicating with the primary care providor. Which are components of the SBAR method? Select all that apply.

A. assessment
B. Response
C. recommendation
D. Action
E. Situation

A. assessment
C. recommendation
E. Situation