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The nurse is assessing an underweight older-adult patient and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?
- A. Notify the hospital rapid response team.
- B. Instruct the patient to remain on bed rest.
- C. Teach the patient about aortic aneurysms.
- D. Document the finding in the patient chart.
Correct Answer: D
Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and the nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
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The nurse is providing teaching to a patient being evaluated for rhythm disturbances with a Holter monitor. Which of the following information should the nurse include in the teaching plan?
- A. Exercise more than usual while the monitor is in place.
- B. Remove the electrodes when taking a shower or tub bath.
- C. Keep a diary of daily activities while the monitor is worn.
- D. Connect the recorder to a telephone transmitter once daily.
Correct Answer: C
Rationale: The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.
The nurse is assessing the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which of the following laboratory results is most important for the nurse to review?
- A. LDL cholesterol
- B. Troponins T and I
- C. C-reactive protein
- D. Creatine kinase-MB (CK-MB)
Correct Answer: B
Rationale: Cardiac troponins start to elevate hours (average 4-6 hours) after myocardial injury and are specific to myocardium. Creatine kinase-MB (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction.
The nurse is reviewing the 12-lead electrocardiogram (ECG) of a healthy older-adult patient who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?
- A. The heart rate is 43 beats/minute.
- B. The PR interval is 0.21 seconds.
- C. There is a right bundle-branch block.
- D. The QRS duration is 0.13 seconds.
Correct Answer: A
Rationale: The resting supine HR is not markedly affected with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, the bundle of His, and the bundle branches.
The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left 5th intercostal space and midclavicular line. How should the nurse record this information?
- A. Systolic murmur heard at mitral area.
- B. Diastolic murmur heard at aortic area.
- C. Systolic murmur heard at Erb's point.
- D. Diastolic murmur heard at tricuspid area.
Correct Answer: A
Rationale: The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left 5th intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest or during the diastolic phase of the cardiac cycle.
To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?
- A. Use the bell of the stethoscope with the patient in the left lateral position.
- B. Use the bell of the stethoscope with the patient sitting and leaning forward.
- C. Use the diaphragm of the stethoscope with the patient in a reclining position.
- D. Use the diaphragm of the stethoscope with the patient lying flat on the left side.
Correct Answer: A
Rationale: Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.