(Osborn) Chapter 37: Learning Outcomes (Number and Title)

[Osborn] chapter 37
Learning Outcomes [Number and Title ]

Learning Outcome 1
Compare and contrast the significance of cardiovascular
assessment findings.
Learning Outcome 2
Evaluate the relationship of current health status and the
presence of cardiac risk factors.
Learning Outcome 3
Describe the relationship of clinical manifestations to data
obtained from the review of a patients social history.
Learning Outcome 4
Describe the essential components of a cardiovascular physical
assessment.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
1. The client presents to the emergency department (ED) complaining of chest pain,
fatigue, and dyspnea. The priority assessment for the ED nurse includes assessing the
clients:
1.
2.
3.
4.
Airway and oxygen status.

Medications.
Chest pain.
Activities.
Correct Answer: Airway and oxygen status.

Rationale: The priority assessment should be to first assess the airway and oxygen status
of the client, with the goal to maintain an open airway and adequate oxygen levels. The
next focus would be on assessing the clients pain to determine the clients description of
the pain, its location, and its intensity. Assessing the clients activities will provide clues
as to what brought on the pain. The clients medications will provide insight into the
clients past medical history as well as potential adverse effects from the medications.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
2. A client is admitted to the telemetry unit. Which of the following nursing assessments
would have the highest priority for further investigation?
1.
2.
3.
4.
The client complains of intermittent chest pain during mild exercise.

The clients father has a history of smoking.
The client has a history of urinary retention.
The client complains of fatigue and dyspnea after walking up several flights of
stairs.
Correct Answer: The client complains of intermittent chest pain during mild exercise.
Rationale: The clients history of intermittent chest pain during mild exercise signals the
highest need for the further investigation into the clients cardiovascular status. The past
history of urinary retention may be of concern if the client will be receiving medications
that could cause urinary retention or if surgery is planned, but should not be a high
priority initially. The complaint of fatigue and dyspnea with climbing stairs may need
further investigation, but also may not be significant, depending upon how many flights
of stairs the client climbs and whether chest pain or discomfort develops. The fathers
history of smoking is relevant based upon second-hand smoke exposure.
LO: 1
3. A client presents to the medicalsurgical unit confused and with a blood pressure of
90/50. The nurse does a quick physical assessment upon the clients arrival to the unit to
determine if the cause of confusion is cardiac in nature. Which of the following
assessment findings might indicate low cardiac output?
1.
2.
3.
4.
Prolonged capillary refill and diminished peripheral pulses

Bounding peripheral pulses and pulse oximeter reading 90%
Pallor and peripheral edema
Skin tenting (poor turgor) and heart rate 102
Correct Answer: Prolonged capillary refill and diminished peripheral pulses

Rationale: The client with low cardiac output will have signs of poor circulation, such as
prolonged capillary refill and diminished peripheral pulses. Bounding peripheral pulses
indicates good output, though perhaps a rapid heart rate. Oxygen saturation of 90% is on
the low side, but accompanied by bounding pulses will not indicate poor output. Pallor
can be an indication of poor output; however, there are several causes of peripheral
edema other than just poor cardiac output, so this answer choice is not definitive. Poor
skin turgor and heart rate of 102 could indicate dehydration.
Cognitive Level: Analysis
LO: 1
4. The nurse is taking care of a male client who comes to the health clinic for a wellness
check. During the routine physical exam by the nurse, the assessment findings are as
follows: The blood pressure is 148/88, heart rate is 92, waist circumference is 120 cm,
weight is 80 kilograms, lungs clear. The lab results are: HDL 32mg/dL; glucose of 120
mg/dL. Which of the following is the priority teaching point for this client?
1. Advise the client to begin an exercise and weight-loss program because the client
is at higher risk for development of cardiovascular disease.
2. Advise the client to continue with current practices because the client is
experiencing no health problems.
3. Advise the client that there is a high risk for cardiovascular disease, but there is
nothing that can be done until signs and symptoms of cardiovascular disease
develop.
4. Advise the client to not smoke because tobacco is associated with cardiovascular
disease.
Correct Answer: Advise the client to begin an exercise and weight-loss program because
the client is at higher risk for development of cardiovascular disease.
Rationale: The client is at risk for developing cardiovascular disease because this client
has metabolic syndrome based upon the elevated blood pressure, the abdominal fat, the
low HDL, and the elevated glucose. Advising the client to continue with current practices
is not sound advice, as a weight reduction and exercise plan could decrease the clients
risk factors. Once the client experiences signs of cardiovascular disease, it becomes too
late to prevent cardiovascular disease. Advising the client to not smoke is a valid
intervention and should be included in the overall plan to reduce the clients risk for
cardiovascular disease, but will not by itself reduce the factors that place this client in the
category of metabolic syndrome.
Nursing Process: Implementation
LO: 2
5. A 66-year-old client arrives in the emergency department complaining of crushing

chest pain following a large meal 4 hours before the onset. The pain has been recurring
over the last several hours. The nurse assesses the client for presence of cardiac risk
factors and finds none. The client asks the nurse if this means that there is no chance the
client is having a cardiac event. How should the nurse respond?
1. Even though you have no cardiac risk factors, it is still possible to have cardiac
problems. We will want to completely evaluate you before we discharge you to
home.
2. Since you have no cardiac risk factors, you probably have a respiratory illness,
such as a cold, that is causing your chest pain. We will draw some blood, but will
let you go home soon.
3. You have no cardiac risk factors, so the only reason you would be having chest
pain now is related to how much you have eaten recently.
4. Since you have no cardiac risk factors, your chest pain is likely related to
gallbladder disease, so there is no need to draw lab work.
Correct Answer: Even though you have no cardiac risk factors, it is still possible to have
cardiac problems. We will want to completely evaluate you before we discharge you to
home.
Rationale: A client may still have cardiac problems even though there are no apparent risk
factors. Even though there is no family history, age increases the potential for cardiac
problems. Giving the client a false sense of security by stating it could be due to a
respiratory illness, overeating, or gallbladder disease could be misleading. It is important,
however, for the nurse to ask probing questions about the chest pain, such as when it
started, what it feels like, and so on, to evaluate the various causes of chest pain.
Client Need: Health Promotion and Maintenance
LO: 2
6. A client comes into the health clinic asking for advice on lowering the individuals risk
of heart disease. The nurses best response is to:
1. Conduct a health history and physical exam to determine the clients area of risks
and then educate the client based upon these findings.
2. Discuss the clients perceived area of health risks.
3. Determine the clients risks based upon a prior chart for the client.
4. Conduct a physical exam of the client and discuss the findings.
Correct Answer: Conduct a health history and physical exam to determine the clients
area of risks and then educate the client based upon these findings.
Rationale: A thorough health history and physical exam should disclose a clients risk
factors. Modifiable risk factors can be evaluated and discussed with the client. Discussing
the clients perceived area of health risks will not be inclusive and may only capture those
risks the client is aware of. Using the clients old chart may disclose some risk factors,
but would not include any recent concerns. Conducting a physical exam would discover
some risk factors, but is not inclusive of the health history.
LO: 2
7. An elderly client arrives in the clinic complaining of dyspnea, weight gain, chest pain,
and increasing edema of the lower extremities. The clients blood pressure is elevated.
The nurse discovers the client has a history of heart failure. The nurse questions the client
regarding which of the following that may best help with determining why the client is
currently having health problems?
1.
2.
3.
4.
Have you attended any recent family or social gatherings?

Have you been out of the country lately?
Are you married?
Do you have grandchildren that you babysit?
Correct Answer: Have you attended any recent family or social gatherings?
Rationale: If the client has attended a recent family or social gathering in which food was
served, it is possible that the sodium content of the food was higher than the client
anticipated. The other answer options do not apply to helping determine why the client
may suddenly be experiencing an exacerbation of the heart failure.
LO: 3
8. A client who is employed as the president of a well-known bank has been having
intermittent chest pain and has been concerned she is at risk for heart disease. The client
asked the nurse to help decrease her risk factors for cardiovascular disease. The nurse
determines that the client holds a high-stress job and is a Type A personality. What is the
best explanation for the nurse to give to the client regarding decreasing her risk factors?
1. The exposure to chronic stress causes increased workload for the heart. Managing
stress will help decrease the risk factors for cardiovascular disease.
2. Some stress is healthy for the heart. If constant chest pain develops, the client
needs to have it investigated.
3. Stress is an everyday occurrence, but should be managed by resting frequently.
4. Type A personalities tend to seek out higher-stress jobs. Advise the client to seek
different employment.
Correct Answer: The exposure to chronic stress causes increased workload for the heart.
Managing stress will help decrease the risk factors for cardiovascular disease.
Rationale: Current and previous job stress can contribute to an increased risk for
cardiovascular disease by increasing the workload on the heart. Intermittent chest pain
can be an early indication of upcoming problems. The advice to the client should be to
lower stress by utilizing stress reduction techniques. Resting often encourages decreased
exercise, while the client should be encouraged to increase her activity. Type A
personalities may tend to seek out higher-stress jobs, but instead of advising the client to
change jobs, a better choice would be to employ stress reduction techniques first.
Nursing Process: Implementation
LO: 3
9. The nurse has just received the report at the beginning of the shift. Which of the
following clients would the nurse see first based upon the report?
1. Newly admitted client complaining of substernal chest pain. Client has recently
had a father die from heart disease.
2. Client complaining of hyperventilation after a family member leaves the room
following an argument. Client has a history of anxiety-related disorders and had a
similar episode on the prior shift.
3. Client with occasional chest pain who has recently been diagnosed with
gallbladder disease. Client requires frequent pain medication.
4. Client concerned with multiple cardiac risk factors (smoking, obesity, family
history and high cholesterol) develops sudden onset of nausea and vomiting.
Correct Answer: Newly admitted client complaining of substernal chest pain. Client has
recently had a father die from heart disease.
Rationale: The top priority for this nurse is the new admit who has developed substernal
chest pain with a family history of cardiac disease. The nurse would want to assess this
client and initiate any interventions that are appropriate. The client with hyperventilation
and a history of anxiety could be having an anxiety attack, but still needs to be assessed
as soon as possible. The client with occasional chest pain and gallbladder disease may
have chest pain that is not cardiac related. The client with multiple risk factors and
sudden onset of nausea and vomiting, but no pain, would need evaluation, but after the
new admission is evaluated.
Client Need: Safe, Effective Care Environment
LO: 3
10. A nurse is assessing the heart and believes a pericardial friction rub is present, but it is
very faint. Which of the following, if utilized, might help the nurse hear this sound more
clearly?
1. Have the client lean on the overbed table.
2. Push the stethoscope tighter against the clients skin.
3. Have the client turn his or her head to the right.
4. Have the client hold his or her breath while the nurse is listening.
Correct Answer: Have the client lean on the overbed table.
Rationale: Having the client lean forward may help the nurse hear a pericardial rub more
clearly. Pushing the stethoscope harder against the clients skin will be more
uncomfortable for the client and may not reveal any clearer quality. Turning the clients
head to either side and having the client hold his or her breath will not produce better
results.
LO: 4
11. The nurse observes a client who is entering the health facility. One of the first
indications by the nurse that the client may be experiencing a problem is:
1.
2.
3.
4.
The clients facial features and body posture.

How fast the client enters the facility.
The clients clothing.
The clients speech.
Correct Answer: The clients facial features and body posture.

Rationale: One of the first observations the nurse is able to make is of the clients facial
features and the body posture. How fast the client enters the facility may be helpful, but
only if the nurse can determine that there is urgency by the clients appearance. A slow
gait does not necessarily indicate a problem. The clients clothing may be neat and clean
or disheveled and dirty, but that will not give clues of a client problem. The clients
speech may indicate problems, but will not be the first observation.
LO: 4
12. A nurse is completing a physical assessment on a clinic client who has been
complaining of fatigue and intermittent chest pain over the last several weeks. Upon
auscultation of the chest, the nurse hears an S1, S2, and an S3. Because of these findings,
the nurse will also be certain to check for:
1.
2.
3.
4.
Lung sounds for crackles.

Absence of bowel sounds.
Diminished pulses.
Sluggish pupil response.
Correct Answer: Lung sounds for crackles.

Rationale: An S3 indicates excess fluid, and the nurse would want to evaluate the client
for crackles in the lungs. S1 and S2 heart sounds are normal. The nurse might also check
for JVD, peripheral edema, ascites, and other signs of fluid overload. The absence of
bowel sounds and sluggish pupil response does not correlate with an S3 heart sound.
Diminished pulses could be a result of excess fluid, but could also be related to other
cardiac problems.
LO: 4

(Osborn) Chapter 37: Learning Outcomes (Number and Title)

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[Osborn] chapter 37

Learning Outcomes [Number and Title ]

Airway and oxygen status.

Correct Answer: Airway and oxygen status.

The client complains of intermittent chest pain during mild exercise.

Prolonged capillary refill and diminished peripheral pulses

Correct Answer: Prolonged capillary refill and diminished peripheral pulses

5. A 66-year-old client arrives in the emergency department complaining of crushing

Have you attended any recent family or social gatherings?

The clients facial features and body posture.

Correct Answer: The clients facial features and body posture.

Lung sounds for crackles.

Correct Answer: Lung sounds for crackles.

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