HA - Unit 2 - Chapter 21: Assessing Heart and Neck Vessels Questions And Correct Answers.
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Course
Heart and Neck Vessels
Institution
Heart And Neck Vessels
The nurse is reviewing dietary changes for a client with hypertension in order to manage the condition. What should the nurse include in the teaching? Select all that apply.
Consume 2,300 mg sodium per day.
Use alcohol in moderation.
Have a dietary intake of more than 3,500 mg of potassium...
HA - Unit 2 - Chapter 21: Assessing
Heart and Neck Vessels Questions And
Correct Answers.
The nurse is reviewing dietary changes for a client with hypertension in order to manage the condition.
What should the nurse include in the teaching? Select all that apply.
Consume 2,300 mg sodium per day.
Use alcohol in moderation.
Have a dietary intake of more than 3,500 mg of potassium per day.
Include more fruits and vegetables in meals.
Use low-fat dairy products with reduced saturated and total fat. - Answer Use alcohol in moderation.
Have a dietary intake of more than 3,500 mg of potassium per day.
Include more fruits and vegetables in meals.
Use low-fat dairy products with reduced saturated and total fat.
The nurse should include using alcohol in moderation, having a dietary intake of more than 3,500 mg of
potassium per day, including more fruits and vegetables during meals, and using low-fat dairy products
with reduced saturated and total fat in the teaching. A client with hypertension should limit sodium
consumption to no more than 1,500 mg of sodium per day.
,A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a
manifestation of dyspnea?
Shortness of breath
Painful breathing
Rapid breathing
Inability to breathe - Answer Shortness of breath
Clients with heart failure may be short of breath from fluid accumulation in the pulmonary bed. Onset
may be sudden with acute or chronic pulmonary edema. It is important to assess how much activity
brings on dyspnea, such as rest, walking on a flat surface, or climbing. The other options listed are
distracters to the question.
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully
extended. The nurse contacts the client's physician because the client's signs are indicative of
pulmonary emphysema.
diastolic murmurs.
patent ductus arteriosus.
increased central venous pressure. - Answer increased central venous pressure.
The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right
ventricular diastolic filling pressure. Right-sided heart failure raises pressure and volume, thus raising
jugular venous pressure.
,The nurse is caring for a client in a medical-surgical unit and reviews the above assessment notes. Which
is the priority question that the nurse should ask the client? - Answer "How long have your feet been
swollen?"
When blood flow out of the heart is reduced, blood returning to the heart through the veins backs up,
causing fluid to accumulate in the dependent areas of the body. Usually standing exacerbates leg edema.
It is important to understand how long the client has been experiencing edema as well as the level of
severity. The notes do not mention any sort of chest pain, the client is afebrile, and the client's weight
change is insignificant, making these findings normal.
The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this
sound indicative of?
Bruits
Murmurs
Normal findings
Gallops - Answer Bruits
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. A gallop is a generic term for an additional heart
sounds heard besides the normal S1 and S2 sound.
What nursing diagnosis would be most appropriate for a client admitted with heart failure?
Ineffective tissue perfusion
Acute pain
, Risk for denial
Impaired gas exchange - Answer Ineffective tissue perfusion
Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity
intolerance. Impaired gas exchange would be more appropriate for respiratory disorders
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
The mediastinum, between the lungs below the diaphragm
The peritoneum, above the diaphragm
The peritoneum, below the diaphragm - Answer The mediastinum, between the lungs above the
diaphragm
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.
The nurse is conducting a health history with a female client who reports upper back and jaw pain. In
order to assess the client's risk for a cardiac event, which question should the nurse ask first?
"Do you have any pain or discomfort in your chest?"
"Is the pain worse on exertion?"
"Do you have cramping pain?'
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