Nokea
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
- A. Heart failure
- B. Hypertensive heart disease
- C. Normal functioning
- D. Pericarditis
Correct Answer: A
Rationale: A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
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In which client does the nurse consider the presence of an S3 heart sound to be normal?
- A. In a client who is in elementary school
- B. In a client who is an older adult
- C. In a client with an indwelling pacemaker
- D. In a client who is diagnosed with heart failure
Correct Answer: A
Rationale: A heart sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. Although an abnormal finding for many clients, this finding is considered normal in many pediatric clients, including a school-age client. In adults, the presence of S3 may signify heart failure, so this is not considered normal. Additionally, S3 is not considered normal for older adult clients nor for a client who has an indwelling pacemaker.
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
- A. Fluoroscopy
- B. Nuclear cardiology
- C. Serum blood work
- D. Chest radiography
Correct Answer: B
Rationale: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.
The nurse provides care for a dying client following a massive myocardial infarction (MI). The nurse notes the client is experiencing dyspnea and has a barely palpable pulse. Which documentation of pulse quality by the nurse is appropriate?
- A. The client's pulse is full.
- B. The client is exhibiting a thready pulse.
- C. The client is experiencing a pulse deficit.
- D. The client's pulse indicates a regular rhythm.
Correct Answer: B
Rationale: When taking a client's pulse, the nurse notes its rate, rhythm, and quality. The pulse quality refers to its palpated volume. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. Documentation that the client's pulse is full is inaccurate. The nurse also determines any pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Documenting that the client's pulse indicates a regular rhythm is inaccurate because the documentation in this scenario focuses on the quality, not rhythm.
The nurse is caring for a client with right-sided heart failure. When assessing the respiratory rate of this client, what is an indication that the client is having difficulty breathing?
- A. Not using the abdominal muscles during breathing
- B. Using accessory muscles during respiration
- C. Barely palpable, thready pulse volume
- D. Combination of noisy and quiet respiration
Correct Answer: B
Rationale: When assessing the respiratory rate of a client with a cardiovascular disorder, the nurse observes the character of the respirations, noting whether the client's breathing is easy, labored, or dyspneic; deep or shallow; and noisy or quiet. The use of accessory muscles such as neck or abdominal muscles during respiration is an indication that the client is having difficulty breathing. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable.
One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
- A. Distention of the jugular vein
- B. Effort to lie down to breathe
- C. Right-sided heart failure
- D. Blood congestion in neck veins
Correct Answer: C
Rationale: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.