HEALTH ASSESSMENT-HEART QUESTIONS
& ANSWERS(RATED A+)
The nurse performs an admission assessment on an adult client admitted through the ED with a
myocardial infarction. The nurse charts "Swooshing sound heard over right carotid artery." How
should this documentation be corrected?
a) Does not need to be corrected
b) "Murmur heard over right carotid artery"
c) "Split sound auscultated over right carotid artery"
d) "Right carotid bruit auscultated" - ANSWERCorrect response: "Right carotid bruit auscultated"
Explanation:
Bruits are swooshing sounds similar to the sound of the blood pressure. They result from turbulent
blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. With
complete obstruction, no bruit is audible, because no blood gets through. Distinguishing a murmur
from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually
louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more
superficial, and heard only over the arteries. Split sounds are not heard over arteries. (less)
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, Chapter 21: Assessing Heart and Neck Vessels, p. 431.
During an interview with the nurse, a client complains of a fatigue that seems to get worse in the
evening. Which of the following causes of fatigue would explain this pattern?
a) Decreased cardiac output
b) Depression
c) Severe muscular exertion
d) Upper respiratory infection - ANSWERCorrect response: Decreased cardiac output
,Explanation:
Fatigue may result from compromised cardiac output. Fatigue related to decreased cardiac output is
worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing
throughout the day. Severe muscular exertion and an upper respiratory infection may be associated
with fatigue, but not the pattern mentioned in the scenario. (less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, 2014, Chapter 21: Assessing Heart and Neck Vessels, p. 424.
In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse
place the fingers?
a) left midclavicular line at the fifth intercostal space
b) right of the midclavicular line at the third intercostal space
c) left midclavicular line at the third intercostal space
d) right of midclavicular line at the fifth intercostal space - ANSWERCorrect response: left
midclavicular line at the fifth intercostal space
Explanation:
The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left
midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the
mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal
space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular
line at the fifth intercostal space. (less)
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, Chapter 21: Assessing Heart and Neck Vessels, p. 432.
The client has been diagnosis with severe sepsis. Which finding would indicate the client is
experiencing low cardiac output?
a) Bradycardia; hypertension
b) Tachycardia; hypotension
c) Bradycardia; hypotension
d) Tachycardia; hypertension - ANSWERCorrect response: Tachycardia; hypotension
Explanation:
, A low cardiac output would be exhibited by tachycardia and hypotension.
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health,
2014, Chapter 21: Assessing Heart and Neck Vessel, pg. 422.
Where are the heart and great vessels located in the human body?
a) The mediastinum, between the lungs below the diaphragm
b) The mediastinum, between the lungs above the diaphragm
c) The peritoneum, below the diaphragm
d) The peritoneum, above the diaphragm - ANSWERCorrect response: The mediastinum, between
the lungs above the diaphragm
Explanation:
The heart and great vessels are located in the mediastinum between the lungs and above the
diaphragm from the center to the left of the thorax. Therefore, the other options are incorrect. (less)
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins, Chapter 21: Assessing Heart and Neck Vessels, p. 416.
A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor
frequently?
a) Heart rate
b) Blood pressure
c) Respiratory rate
d) Temperature - ANSWERCorrect response: Blood pressure
Explanation:
With decreased cardiac output, the heart pumps inadequate blood to meet the body's metabolic
demands. The blood pressure is most important to assess frequently. (less)
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health,
2014, Chapter 21: Assessing Heart and Neck Vessels, pg. 422.
