Author Question: The nurse is performing a cardiac assessment on an older adult client admitted with hypertension. ... (Read 81 times)

Zulu123 · **on:** Jun 25, 2018

The nurse is performing a cardiac assessment on an older adult client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse.

Which conclusion by the nurse is appropriate based on this data?
1. Left ventricular hypertrophy.
2. Aortic stenosis.
3. Right ventricular volume overload.
4. Enlarged left atrium.

Question 2

The nurse is reviewing the client's medical record and notes a consistently elevated blood pressure over the last eight years. The client has been noncompliant with lifestyle changes and medication use designed to reduce the client's blood pressure.

Today, the nurse is able to palpate a heave on the client's chest. Where is the heave located?

1. A.
2. B.
3. C.
4. D.

Liamb2179 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1
If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation. Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space. The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload. Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium.

Answer to Question 2

Correct Answer: 1
Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension.