The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

S1 and S2 heard with diaphragm of stethoscope

A blowing sound heard over the mitral area with the bell of the stethoscope

Apical pulse palpated at 5th intercostal space, midclavicular line

Absent sound over carotid arteries with bell of the stethoscope

Answer and Explanation

The Correct Answer is B

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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Correct Answer is ["A","B","E"]

Explanation

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

A. Inquire about personal and family cardiac history B. Ask about fatigue and chest pain C. Inspect for intercostal retractions and nasal flaring D. Palpate the chest for any thrills and heaves E. Auscultate the heart with the diaphragm and bell of stethoscope

Correct Answer is ["A","B"]

Explanation

A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.
B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.
C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.
D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.
E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.

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The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?

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