ATI Medical Surgical Assessment D

Ans: Systole - A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? Ans: Left midclavicular line of the chest at the fifth intercostal space - During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? Ans: 46 mm Hg - The nurse is calculating a cardiac patient's pulse pressure. If the patient's blood pressure is 122/76 mm Hg, what is the patient's pulse pressure? Ans: This is an accurate indicator of myocardial injury. - The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? Ans: Increased LDL and decreased HDL increase my risk of coronary artery disease. - The nurse is conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? Ans: Possible hypovolemia - The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate? Ans: A 20-year-old patient - While auscultating a patient's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in what patient? Ans: Myocardial ischemia - The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? Ans: A heart rate of 54 bpm - The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? Ans: Widening of the aorta - The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult? Ans: The pain occurs immediately following physical exertion. - A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? Ans: Hypervolemia - The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patient's CVP is increasing. Of what may this indicate? Ans: To assess the patient's response to fluid and drug administration - The critical care nurse is caring for a patient with a pulmonary artery pressure monitoring system. The nurse is aware that pulmonary artery pressure monitoring is used to assess left ventricular function. What is an additional function of pulmonary artery pressure monitoring systems? Ans: SA node to AV node to bundle of His to Purkinje fibers - The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates