Ch. 20 EAQ Questions

The patient complains of pain on the right side of the abdomen and right shoulder that is most severe after eating a fatty meal. The nurse suspects which condition?

Cholecystitis

While assessing a patient with cyanosis, the nurse hears a loud murmur that lasts throughout systole. A thrill is also palpable. Which is the most appropriate term to use to document this finding?

Grade 4 holosystolic

The patient with pathologic S 3 heart sound has which condition?

decreased compliance of the ventricles

Which statement is correct regarding the position of the heart?

depends on the age of the patient

Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart?

endocardium

How would the nurse document a loud heart murmur with a palpable thrill?

4/6

The nurse is auscultating a patient's heart sounds. Which area is best for hearing the sound of the mitral valve?

5th left intercostal space at the midclavicular line

Which interventions would the nurse perform during a cardiac assessment?

have patient sit during carotid artery assessment maintain warm room put patient in supine position to assess precordium

Suspicion of which condition prompts the nurse to perform the abdominojugular test?

heart failure

Which jugular pulse component reflects ventricular contraction?

C Wave - C wave occurs because of first ventricular contraction. it is the backflow from the bulging upward of the tricuspid valve when it closes at the beginning of ventricular systole

Which conditions may cause a pathologic S3 or a ventricular gallop?

hyperthyroidism Anemia Pregnancy

Where would the nurse observe the palpable thrill in the patient with an incompetent tricuspid valve?

left lower sternal border

Which description of semilunar valves is correct?

lie between the ventricles and the great vessels

Which description of the semilunar valves is correct?

lie between the ventricles and the great vessels

Which finding in the precordium indicates pulmonic hypertension?

lifting impulse in the left sternal border - lifting impulse occurs with right ventricular hypertrophy as in pulmonic disease and pulmonic hypertension, may be caused by the presence of an enlarged right ventricle which results in the posterior rotation of the left ventricle

Which finding in the precordium indicates pulmonic hypertension?

lifting impulse on the left sternal border

Which statement describes the pericardium?

tough fibrous sac surrounding the heart

Which statement best describes the pericardium?

tough, fibrous sac surrounding the heart

The nurse determines that a patient has an increased risk for having a myocardial infarction. Which medication would be beneficial for the patient?

aspirin

Which method would the nurse use to detect pericardial friction rub?

auscultate with the diaphragm of the stethoscope

The human heart is found in which location?

between the 2nd and 5th intercostal spaces from the right edge of the sternum to the left midclavicular line

Which physiologic mechanism causes the first heart sound?

closing of the atrioventricular valves (tricuspid and mitral)

Which description of the chordae tendinae is correct?

collagenous fibers that anchor the leaflets of the atrioventricular valves

Which condition can cause a wide split in the second heart sound?

right bundle branch block

The patient with pneumonia complains of fever, cough, and myalgia. Which other complaint would the nurse expect from the patient?

sharp stabbing pain located in chest with cough on one side

Which term is used to describe the pacemaker of the heart?

sinoatrial node

Which statement describes a lift with respect to the cardiovascular system?

sustained thrust of the ventricle of the heart

Which feature is characteristic of the 3rd heart sound, S3?

Occurs at the left lower sternal border - does not change with respiration

Which extra heart sounds may occur in early systole?

Opening Snap Mitral prosthetic valve sound

Which section of the Electrocardiogram indicates atrial depolarization?

P Wave P: atrial depolarization QRS complex: simultaneous activation of the R and L ventricles ST: ventricular repolarization

The patient reports having a sudden stabbing pain below the stern, in the upper back, and in the neck. During the assessment the nurse also finds the patient has a fever, joint pains, and a dry cough. Which condition is most consistent with these findings?

Pericarditis

Which condition would the nurse suspect in the patient with acute dyspnea and cough who complains of pain in the shoulder and the lateral region of the chest?

Pneumothorax

Which blood vessel drains blood from the head and upper extremities?

Superior Vena Cava

The presence of which finding in the cardiac assessment of a middle-aged patient would the nurse consider to be abnormal?

Third heart sound

What component of the jugular venous pulse corresponds to the opening of the tricuspid valve?

Y Descent - indicates passive ventricular filling and opening of the tricuspid valve

Which cardiac assessment findings are documented as normal?

Absence of cardiac murmur S2 is louder at base of the heart S1 is louder at apex

Which murmur is caused by an obstruction of the flow of blood into the ventricles?

Diastolic Rumble

Which murmur is caused by an obstruction of the flow of blood into the ventricles?

Diastolic Rumble -occurs as a result of filling the ventricles at a low pressure because of the obstruction of the flow into the ventricles

Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart and the valves?

Endocardium

The nurse is caring for a patient who has pain in the substernal region. The patient states, "I feel like some object is blocking my throat". The nurse suspects further assessment will indicate which condition?

Esophageal Spasm

After reviewing the medical history of a female patient, the nurse suspects that the patient is at risk for developing cardiovascular complications. Which findings led the nurse to this conclusion?

LDL level of 150mg/dL Body mass index of 30 kg/m2 total cholesterol of 240mg/ dL

The patient is noted to have a visible apical impulse in the sixth left intercostal space lateral to the midclavicular line. On palpation, the nurse finds that the impulse is approximately 4 cm in diameter and is more forceful than usual. Which disorder would the nurse suspect?

Left ventricular dilation

Which would the nurse assess first in the patient during a regional cardiovascular assessment?

Pulse and BP

Which assessment finding would the nurse document as a sinus arrhythmia?

Pulse that varies with respiration

Which condition can cause a wide split in the second heart sound?

Right bundle branch block

Which clinical finding would the nurse observe in the patient with mitral regurgitation?

S1 diminished S2 Diminished Apical pulse observed lower

Which heart sound occurs because of the closure of the semilunar valves?

S2 second heart sound

What description of pain by the patient indicates the pain is of pulmonary origin?

Sharp stabbing pain that worsens with breathing and a cough with hemoptysis

Which positions are appropriate for a cardiac assessment?

Sitting Supine left lateral Recumbent

During an assessment, the nurse finds that the liver and the jugular vein have become enlarged. A soft pansystolic heart murmur is best heard at the lower right and left sternal borders. Which disorder would the nurse suspect?

Tricuspid regurgitation

Which type of intensity is characteristic of the first heart sound in the patient who has complete heart block?

Varied

What findings would the nurse observe in a patient with left ventricular hypertrophy?

Visible apical heave Diameter of the heart 3.5cm

Which statement describes a thrill?

palpable vibration in the chest

The nurse instructs a student nurse to palpate the patient's carotid artery. Which action made by the student nurse needs correction?

palpating both carotid arteries at once

Which assessment finding may be present in a patient with atherosclerosis?

presence of a bruit sound