ATI Health Assess 2.0: Cardiovascular Test Questions with Answers and Rationales 2023., Exams of Nursing

Download ATI Health Assess 2.0: Cardiovascular Test Questions with Answers and Rationales 2023. and more Exams Nursing in PDF only on Docsity! A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report? - Correct ANS: A forceful chest movement at the midclavicular line in the fourth intercostal space Rationale: A forceful thrusting movement of the chest at the point of maximal impulse (PMI) is termed a heave or lift. This finding is associated with an enlarged left ventricle. This is an unexpected finding and should be reported to the provider. A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress? - Correct ANS: Discuss the benefits of meditation with the client Rationale: The nurse can provide the client with information about meditation, which is a stress-reduction activity. The nurse may also discuss other stress-reduction activities, such as yoga, guided imagery, or hobbies. A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider? - Correct ANS: Capillary refill of 3 seconds Rationale: Capillary refill should be less than or equal to 2 seconds. This finding should be reported to the provider for further evaluation. A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated - Correct ANS: D Rationale: D is correct. The nurse should auscultate in this area for 1 min to determine the rate, rhythm, and pitch of the apical pulse. This area, at the apex of the heart, is where sounds generated by the mitral valve between the left atrium and ventricle are best heard and is termed the apical impulse or point of maximal impulse. The mitral heart sound is located at the fifth intercostal space in the left midclavicular area. A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate Ask the client if they experience shortness of breath is correct. Shortness of breath can be an indication of alterations in the cardiovascular system that result in fluid accumulation in the lungs. Check the color of the client's skin is correct. The nurse should inspect the color of the client's skin during a cardiovascular assessment. The presence of pallor, cyanosis, or a grey color can indicate an alteration in the cardiovascular system. Inspect the extremities for the presence of edema is correct. The nurse should inspect for the presence of edema during a cardiovascular assessment. Alterations in the efficiency of the cardiovascular system can result in the presence of edema in the lower portion of the body. A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.) - Rationale: Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct. A full and bounding pulse in the carotid arteries upon palpation is an unexpected finding and should be reported to the provider. This may indicate fluid overload or heart failure. Distention of the jugular vein on one side of the neck is correct. A distention of one or both jugular veins is not expected and may be an indicator of right-sided heart failure or an obstruction in the blood vessel. This finding should be reported to the provider. The left carotid artery pulse is weak is correct. This is an unexpected finding and should be reported to the provider. The carotid arteries should be moderate in strength bilaterally. A weak pulse can indicate a blockage or narrowing of the artery. A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? - Correct ANS: An adolescent who has an s3 heart sound Rationale: In children and young adults, it is an expected variation to hear the S3 heart sound, which is a vibration that results from rapid filling of the ventricles. A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make? - Correct ANS: "The penlight will allow me to look at the pulses in your neck." Rationale: Focused lighting, such as from a penlight, will enhance visualization of the blood vessels in the neck to check for pulsations and distention. A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? - Correct ANS: Limit sodium intake to less than 3,000 mg/day. Rationale: A heart-healthy diet aims to reduce the client's sodium intake to no more than 2 to 3 g/day. Excess sodium can lead to hypertension, which is a risk factor for cardiovascular disease. A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease? - Correct ANS: Palpable dorsalis pedal pulse Rationale: