Chapter 20-21 - EAQs - Heart
While assessing a patient, the nurse finds elevated jugular venous pressure, ventricular gallop, and a pulse deficit. The diagnostic results of the patient indicate that the diameter of heart is 5 cm. Which complication does the nurse suspect in the patient? Aneurysm Heart failure Cardiomyopathy Left ventricular hypertrophy
Heart failure An elevated jugular venous pressure, pulse deficit, and a heart diameter of greater than 4 cm indicate the patient has heart failure. A pathologic S 3 (ventricular gallop) occurs due to decreased compliance of the ventricles in the patient with heart failure. Unilateral distention of the external jugular veins is the characteristic sign of aneurysm. The patient with an aneurysm will not have a pulse deficit and an enlarged heart. Cardiomyopathy is a chronic disease. The nurse would not find a pulse deficit in the patient with cardiomyopathy. The patient with left ventricular hypertrophy would not have a heart diameter greater than 4 cm.
Which component of the jugular venous pulse corresponds to the opening of the tricuspid valve? A wave V wave Y descent X descent
Y descent There are five components of jugular venous pressure—A wave, C wave, X descent, V wave, and Y descent. Y descent indicates passive ventricular filling and opening of the tricuspid valve. A wave reflects atrial contraction due to the backward flow of blood to the vena cava. V wave occurs with passive atrial filling due to increase in pressure and volume in the right atria. X descent indicates atrial relaxation.
A student nurse attends a lecture on the position of the heart. Which statement by the student nurse indicates effective learning? "The position of the heart changes during early pregnancy." "The position of the heart is centered in dextrocardia." "The position of the heart depends on the age of the patient." "The position of the heart depends on the body build, chest configuration, and diaphragm level."
"The position of the heart depends on the age of the patient." The position of the heart in an adult is different from that of an infant. The position of the heart in the chest is more horizontal in the infant than in the adult. The apex is higher, and is located at the fourth left intercostal space. It reaches the adult position when the child reaches the age of 7. In aging adults, the position rarely changes. However, the position of the heart is not dependent on the body build. If there is any anatomical change in the chest, configuration, or diaphragm, the position of the heart may change. The cardiovascular system adapts to ensure adequate blood supply to the uterus and the placenta during the pregnancy. This alteration is meant to deliver oxygen and nutrients to the fetus, and allows the mother to function normally during this altered state. Otherwise, the position of the heart is not altered during this stage. Dextrocardia is a rare anomaly in which the heart is located on the right side of the chest instead of the left side as normal.
The nurse is auscultating a patient's heart sounds. Which area is best for hearing the sound of the mitral valve? A. Fifth left intercostal space at the midclavicular line B. Second left intercostal space at the sternal border C. Fourth left intercostal space at the left sternal border D. Second right intercostal space at the sternal border
A There are four auscultatory areas where the heart sounds can be heard. The valve areas are not present across the actual anatomic locations of the valves. Ausculatory areas are the sites on the chest wall where sounds produced by the valves are best heard. The sound radiates with the direction of the blood flow. The fifth interspace around the left midclavicular line is the mitral valve area. Its sound can be heard over the entire precordium, although it is loudest at the apex. At the left lower sternal border, the sound of the tricuspid valve can be heard. The second left intercostal space is the area where the sound of the pulmonic valve is heard. The second right intercostal space is the aortic valve area.
Which findings should the nurse observe in a patient with left ventricular hypertrophy? A. Visible apical heave B. Change in heart location C. Impalpable apical impulse D. Diameter of the heart 3.5 cm E. Higher jugular venous pressure
A D Left ventricular hypertrophy is the thickening of the myocardium of the left ventricle. Apical heave occurs due to pressure loading in the left ventricular hypertrophy. Left ventricular hypertrophy will not increase the diameter of the heart, so a diameter of 3.5 cm is normal. Left ventricular hypertrophy does not cause dilation of the heart. Impalpable apical impulse is the sign of pulmonary emphysema. In heart failure, jugular venous pressure increases, the location of the heart changes because of enlargement, and the diameter of the heart increases more than 4 cm.
Which conditions may cause a pathologic S 3, or a ventricular gallop? Anemia Pregnancy Hyperthyroidism Cardiomyopathy Pulmonary stenosis
Anemia Pregnancy Hyperthyroidism A ventricular gallop occurs due to an increase in fluid volume. Anemia, pregnancy, and hyperthyroidism may increase cardiac output in the patient. Therefore, the nurse can hear ventricular gallop in the pregnant patient or in the patient with anemia or hyperthyroidism. An atrial gallop, or pathologic S 4, is present in the patient with cardiomyopathy or pulmonary stenosis.
Which sign would be present in a patient with atherosclerosis? A. Low-pitched rumbling B. Presence of bruit sound C. Weak contraction of the ventricles D. Unilateral distention of external jugular veins
B Normally, a bruit is absent in a healthy patient. Atherosclerotic disease causes turbulence in the blood flow and results in a bruit sound. A low-pitched rumbling is a sign of mitral stenosis. Atherosclerosis would not weaken the walls of the ventricles. Weak contractions of the ventricles will occur in the patient with heart failure. Unilateral distention of the external jugular veins indicates an aneurysm.
The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing? A. Compress on the carotid artery during the assessment. B. Have the patient sit during the carotid artery assessment. C. Put the patient in a supine position to assess the precordium. D. Maintain a warm room temperature during cardiac assessment. E. Assess the neck vessels first during the cardiovascular assessment.
B C D The nurse should ask the patient to sit during the carotid artery assessment because the seated position allows proper exposure of the neck. The nurse places the patient in the supine position while auscultating the precordium to obtain accurate jugular venous pressure. The nurse needs to maintain a warm room temperature during the cardiac assessment because a cold room may make the patient uncomfortable, and shivering interferes with auscultating heart sounds. The nurse should not compress the carotid artery during the assessment, because it can cause vagal stimulation and the patient may develop bradycardia. The nurse should start observations from the periphery and move in toward the heart. Hence, the nurse should assess the pulse and blood pressure, not the neck, first.
Where is the heart located in the human body? Between the right midclavicular line and the right border of the sternum and below the clavicle to the eighth rib Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line Between the third and sixth intercostal spaces from the left midclavicular line to the left midaxillary line Between the first and fourth intercostal spaces from the left midaxillary line to the left posterior axillary line
Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line The heart is the muscular pump of the cardiovascular system. The heart extends from the second intercostal space to the fifth intercostal space and from the right border of the sternum to the left midclavicular line. It is not located between the right midclavicular line and the right border of the sternum and below the clavicle to the eighth rib. It lies anteriorly between the sternum and the anterior mediastinum. The space between the third to the sixth intercostal spaces at the left sternal border is the tricuspid region of the heart. This region is auscultated to listen to the heart sounds. The aortic region of the heart is located between the first and the fourth intercostal spaces.
Which condition would cause a patient to have a diminished first heart sound of S 1 due to more forceful atrial contractions? A. Mitral stenosis B. Atrial fibrillation C. Severe hypertension D. Right ventricular hypertrophy
C Severe hypertension leads to an increase in the force of the atrial contractions, while pushing blood into the noncompliant ventricles. This may result in delayed ventricular contraction and a diminished S 1.sound. The patient with mitral stenosis has a diminished S 1 sound due to the presence of a calcified mitral valve. The nurse may find S 1 with an irregular rhythm in the patient with atrial fibrillation, but not a diminished S 1. The first heart sound will be normal in the patient with right ventricular hypertrophy.
While auscultating the precordium of a patient, the nurse hears the first heart sound (S1). What causes the first heart sound? Closing of the mitral valve Filling of the ventricle Closing of the aortic valve Closing of the pulmonic valve
Closing of the mitral valve The first heart sound (S1) occurs with the closure of the AV valves. This signals the beginning of the systole. The mitral component of the first sound (M1) slightly precedes the tricuspid component (T1). However, the sounds of these two components are fused together as one sound. One can hear S1 over all the precordium, but usually it is the loudest at the apex. The closure of the aortic valve causes the first sound of the second heart sound (S2). The second sound of the second heart sound is produced due to the closure of the pulmonary valve. Ventricular filling causes the third heart sound (S3).
The nurse is taking care of a patient with 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 does the nurse suspect? A. Right atrial enlargement B. Rheumatic heart disease C. Coronary artery disease D. Left ventricular dilation
D Left ventricular dilation (volume overload) displaces impulse down and to left and increases size more than one space. A diameter of greater than or equal to 4 cm is likely a dilated heart. Right atrial enlargement is a form of cardiomegaly, which can broadly be classified as either right atrial hypertrophy (RAH) or dilation. It can be diagnosed by an electrocardiogram (ECG). Sometimes these disorders create a sound like a whooshing or swishing noise. Rheumatic heart disease describes a group of short-term and long-term heart disorders that can occur because of rheumatic fever. Damage to the heart valves is a common outcome of rheumatic fever. Symptoms of coronary artery disease include angina. In angina, a characteristic chest pain on exertion and decreased exercise tolerance occurs.
While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient? A. Accentuated S 1 B. Fixed split S 2 C. Pathologic S 3 D. Pathologic S 4
D Murmurs can be heard in the left intercostal space in the patient with pulmonic stenosis. Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S 4, occurs after the diastole due to resistance of the ventricles to fill with blood. It commonly occurs in the presence of an enlarged right ventricle. Pathologic S 3 occurs due to the backward flow of blood into the left atrium in the patient with mitral regurgitation. A fixed split S 2 occurs in the patient with atrial septal defect due to the earlier closure of the aortic valves than the pulmonic valves. An accentuated S 1 occurs with mitral stenosis.
What is indicated in a patient with pathologic S3? A. A stenotic heart valve B. Coronary artery disease C. Vigorous atrial contraction D. Decreased compliance of the ventricles
D S3 is the third heart sound. It is also known as a ventricular gallop or an S3 gallop. In adults, S3 is usually abnormal. The pathologic S3 indicates decreased compliance of the ventricles; it may be the earliest sign of heart failure. Vigorous atrial contraction occurs in the case of acute incompetence of the atrioventricular (AV) valve. It produces an S4 associated with a presystolic apical impulse. A stenotic heart valve occurs due to the narrowing of the valve of the heart. This narrowing prevents the valve from opening fully, which obstructs blood flow. The symptoms of coronary artery disease include angina, a characteristic chest pain on exertion, and decreased exercise tolerance.
What are chordae tendineae? A. These are muscles that are attached to the ventricles. B. These are tendons that hold the semilunar valves in alignment. C. These are structures that separate the right and the left ventricles. D. These are collagenous fibers that anchor the leaflets of the atrioventricular valves.
D The thin leaflets of the tricuspid and bicuspid valves are anchored by the chordae tendineae to the papillary muscles embedded in the floor of the ventricle. Chordae tendineae are made up of collagenous fibers. These prevent the prolapse of the atrioventricular valves into the atria during ventricular contraction. The papillary muscles are located in the ventricles of the heart. They are attached to the cusps of the atrioventricular valves via the chordae tendineae and contract to prevent the inversion or prolapse of these valves. The septum separates the right and left ventricles. The semilunar valves use the blood's pressure to snap shut; these do not have any tendons to hold them in alignment.
Which murmurs are caused by an obstruction of the flow of blood into the ventricles? Diastolic rumbles Early diastolic murmurs Midsystolic ejection murmurs Pansystolic regurgitant murmurs
Diastolic rumbles Diastolic rumbles occur due to filling of the ventricles at a low pressure due to the obstruction of the flow of blood into the ventricles. Semilunar valve incompetence causes early diastolic murmurs. Midsystolic ejection murmurs occur due to the forward flow of blood through the semilunar valves. The backward flow of blood from the area of higher pressure to one of lower pressure causes pansystolic regurgitant murmurs.
After assessing a patient with a cardiac disorder, the nurse determines that the patient has abnormally elevated pressure on the right side of the heart. Which observation would support this finding? Pulmonary congestion Pulmonary hypertension Distended neck veins and abdomen Systolic blood pressure higher than diastolic blood pressure
Distended neck veins and abdomen There are no valves between the vena cava and the right atrium or between the pulmonary veins and the left atrium. Therefore, when the pressure in the right side of the heart is abnormally high, the neck veins and the abdomen become distended. Similarly, abnormally high pressure in the left side of the heart reflects the symptoms of pulmonary congestion. Pulmonary hypertension refers to high blood pressure that occurs in the arteries of the lungs. It occurs when the blood vessels leading to the lungs are constricted. It is a different measurement altogether from systemic blood pressure. Systolic blood pressure that is higher than the diastolic blood pressure is a normal finding.
What is the thin layer of endothelial tissue that lines the inner surface of the heart and the valves called? Myocardium Epicardium Endocardium Pericardium
Endocardium The endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and the valves. The myocardium is the muscular wall of the heart; it does the pumping. The visceral pericardium, which is continuous with the serous layer, is sometimes known as the epicardium. The pericardium is a tough, fibrous, double-walled sac that surrounds and protects the heart and has two layers. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient? Fifth interspace at around the left midclavicular line Second left interspace Second right interspace Left lower sternal border
Left lower sternal border Tricuspid regurgitation occurs in the patient with incompetent tricuspid valve. The tricuspid valve is present near the left lower sternal border. Therefore, the nurse can feel a palpable thrill in the left lower sternal border of the patient with tricuspid regurgitation. The nurse feels a palpable thrill in the fifth interspace around the left midclavicular line of a patient with mitral stenosis. The nurse can feel a palpable thrill in the second left interspace in the patient with pulmonic stenosis. The second right interspace is the area of the aortic valve. Therefore, the palpable thrill occurs in this area in the patient with aortic stenosis.
he nurse instructs a student nurse to palpate the carotid artery of a patient. Which action made by the student nurse needs correction? Having the patient sit during the exam Palpating both carotid arteries at once Refraining from excess vagal stimulation Not compressing on the carotid sinuses
Palpating both carotid arteries at once The nurse should palpate only one carotid artery at a time. Palpating both carotid arteries at the same time will compromise arterial blood supply to the brain. The nurse should instruct the patient to sit during carotid artery palpation because this position allows proper exposure of the neck. The nurse should refrain from excessive vagal stimulation and compression of the carotid sinuses because it slows the heart rate.
While assessing the cardiac health of a middle-aged patient, which finding would the nurse consider abnormal? Presence of apical impulse Presence of a venous hum Presence of jugular venous pulse Presence of a third heart sound
Presence of a third heart sound In middle-aged adults, the third heart sound (S3) or ventricular gallop is usually abnormal. The S3 indicates decreased compliance of the ventricles, and it may be the earliest sign of heart failure. The normal apical impulse is the result of the heart rotating, moving forward, and striking against the chest wall during the systole. Lateral or inferior displacement of the apex beat usually indicates the enlargement of the heart. The filling level of the jugular veins help to estimate the blood pressure. The pulse rate measured at the jugular vein provides a source of information about the state of the right atrium. The venous hum, a continuous murmur usually of maximum intensity in the supraclavicular area, is a common auscultatory finding in children; it is of no known pathologic significance.
Which heart sound occurs due to the closure of the semilunar valves? First heart sound (S 1) Second heart sound (S 2) Third heart sound (S 3) Fourth heart sound (S 4)
Second heart sound (S 2) The second heart sound (S2) occurs with the closure of the semilunar valves, and it indicates the end of systole. The first heart sound (S 1) occurs with the closure of the atrioventricular valves, and indicates the beginning of systole. The third heart sound (S 3) occurs due to the filling of the ventricles with blood. The fourth heart sound (S 4) is heard at the end of diastole and occurs when the atria contract and push the blood into the noncompliant ventricle.
A patient reports pain and discomfort in the chest. After assessing the patient, the nurse determines that the pain is of pulmonary origin. Which characteristics in the patient enabled the nurse to make this conclusion? Squeezing burning pain, dyspnea on exertion, and an intolerance to exercise Sharp pain that does not radiate, dyspnea on exertion, along with diaphoresis Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis Sharp pleuritic pain that worsens with deep breathing along with tightness in the chest
Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis When caring for a patient with chest pain, the first intervention of the nurse is to differentiate whether the chest pain is of cardiac, pulmonary, gastrointestinal, or musculoskeletal origin. A sharp stabbing pain in the chest worsens with deep breathing due to blockage in the pulmonary artery. Hemoptysis refers to the coughing of blood from the respiratory tract. These are the characteristics of a pulmonary embolism. A squeezing pain occurs due to the obstruction of coronary arteries and is a symptom of cardiac complications. A sharp pain that does not radiate, dyspnea on exertion, and diaphoresis may occur in the patient with mitral valve prolapse. Sharp pleuritic pain that worsens with deep breathing, chest tightness, and warmth at the site are the characteristics of costochondritis, which is a musculoskeletal complication. Due to inflammation of the costal cartilage, the patient may feel chest tightness.
Which term can be used to describe the pacemaker of the heart? Lymph node Ranvier's node Sinoatrial node Atrioventricular node
Sinoatrial node Sinoatrial node is another term used for the pacemaker of the heart. The automaticity of the heart enables it to contract by itself, independent of any signals or stimulation from the body. The heart contracts in response to an electrical current conveyed by a conduction system. Specialized cells in the sinoatrial node near the superior vena cava initiate an electrical impulse. The sinoatrial node triggers electrical impulses at regular intervals to cause the heart muscles to beat in an orderly sequence; hence, it is the pacemaker. The atrioventricular node is present in the auricular septum; it helps in the conduction of the cardiac impulse. Lymph nodes are oval-shaped organs of the lymphatic system which are spread throughout the body, including the armpits and the stomach, and are linked by the lymphatic vessels. Ranvier's nodes are the regular constrictions of the myelinated nerve fibers. At such locations, the myelin sheath is absent and the axon is enclosed only by Schwann cell processes.
The nurse is planning the cardiac assessment of a patient. Which patient positions are necessary during this assessment? Sitting Supine Prone Right lateral semi-Fowler Left lateral recumbent
Sitting Supine Left lateral recumbent The patient is positioned differently for assessing the different aspects of the cardiac health. During the assessment of the carotid artery, the patient should be placed in the sitting position. In order to assess the jugular veins and the precordium, the patient should rest in the supine position with the head and chest elevated between 30 and 45 degrees. The left lateral recumbent position is used to measure the blood pressure in a pregnant patient. This finding is significant in determining the functionality of the heart during pregnancy. The patient need not be placed in the right lateral semi-Fowler and the prone positions. Cardiac assessment is not performed in these positions.
While assessing a patient who has fever, cough, and myalgia, the nurse confirms that the patient has pneumonia. Which other symptom would the nurse expect to find in the patient? Pressure-like pain felt in the chest during morning hours Sudden severe pain in the chest with a change in location Stabbing pain located in the chest with a cough on one side Burning sensation within the chest after having large meals
Stabbing pain located in the chest with a cough on one side Pneumonia is an inflammatory condition which may occur due to bacterial infection. The patient feels stabbing pain with a cough on one side of the chest due to inflammation of the pleura. Pressure-like discomfort in the chest during the morning hours may occur in the patient with variant angina. Sudden severe pain with a change in location occurs in the patient with aortic dissection. The patient with gastroesophageal reflux disease may have a burning sensation in the chest after eating large meals.
The nurse is assessing the jugular pulse of a patient. Which jugular pulse component reflects ventricular contraction? A wave C wave V wave X wave
The jugular pulse, a waveform that moves backward, is caused by events upstream. The jugular pulse has five components. The C wave occurs due to ventricular contraction. It is the backflow from the bulging upward of the tricuspid valve when it closes at the beginning of the ventricular systole. The A wave reflects atrial contraction. During this phase, some blood flows backward to the vena cava during the right atrial contraction. The V wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure. Similarly, the X wave shows atrial relaxation when the right ventricle contracts during the systole and pulls the bottom of the atria downward.
While assessing the jugular venous pressure of a patient, the nurse finds that the pressure is elevated. Which observation is consistent with this conclusion? The level of pulsation is 2 cm above the sternal angle while at 30 degrees The level of pulsation is 3 cm above the sternal angle while at 45 degrees The level of pulsation is 3 cm above the sternal angle while at 30 degrees The level of pulsation is 2 cm above the sternal angle while at 45 degrees
The level of pulsation is 3 cm above the sternal angle while at 45 degrees The normal jugular pressure should be less than or equal to 2 cm above the sternal angle when the patient is elevated at 30 degrees, and the value should be 3 cm or less when elevated at 45 degrees. Therefore, the jugular venous pressure of 3 cm above the sternal angle when elevated at 45 degrees indicates that the pressure is increased. The jugular venous pressure of 2 cm and 3 cm above the sternal angle when elevated at 30 degrees is a normal finding. The jugular venous pressure of 2 cm above the sternal angle when elevated at 45 degrees indicates that the pressure is normal.
A patient complains of sudden pain in the shoulder and the lateral region of the chest. The nurse finds that the patient has acute dyspnea and a cough. What conclusion could the nurse draw from these findings? The patient has pericarditis. The patient has cholecystitis. The patient has a pneumothorax. The patient has an esophageal spasm.
The patient has a pneumothorax. Sudden pain in the lateral region of the chest indicates that the patient has pneumothorax. It is also associated with referred shoulder pain, acute dyspnea, and cough. It is caused due to accumulation of air in the pleural space. Pericarditis is a cardiovascular disorder that is associated with a sudden, stabbing pain in the substernal region that radiates to the trapezius muscle, dry cough, and muscle and joint pain. Because the patient does not complain of pain in the substernal region and joints, the nurse would not suspect that the patient has pericarditis. Cholecystitis is a gastrointestinal disorder that is associated with pain in the right upper abdomen, nausea and vomiting, and anorexia. Esophageal spasm is associated with crushing pain in the substernal region and dysphagia.
What is the pericardium? The pericardium is the muscular wall of the heart. The pericardium is the area of the chest overlying the heart. The pericardium is the tough, fibrous sac surrounding the heart. The pericardium is the thin layer of endothelial tissue lining the inner surface of the heart.
The pericardium is the tough, fibrous sac surrounding the heart. The pericardium is a tough, fibrous, double-walled sac that surrounds the heart and protects it. It has two layers that contain a few milliliters of serous pericardial fluid. This ensures smooth, friction-free movement of the heart muscle. The myocardium is the muscular wall of the heart; it does the pumping. Precordium refers to the area on the anterior chest that overlies the heart and the great vessels. The endocardium is a thin layer of endothelial tissue that lines the inner surface of the heart chambers and the valves.
While assessing a patient, the nurse finds that the liver and the jugular vein have become enlarged. The nurse could best hear the soft and pansystolic heart murmur at the lower right and left sternal borders. Which disorder does the nurse suspect? Aortic stenosis Tricuspid stenosis Aortic regurgitation Tricuspid regurgitation
Tricuspid regurgitation In tricuspid regurgitation, backflow of the blood occurs through the incompetent tricuspid valve into the right atrium. This results in engorged pulsating jugular veins and an enlarged liver. A soft, blowing, pansystolic heart murmur can be best heard at the right and the left lower sternal border. The murmur increases with inspiration. Calcification of the cusps of the aortic valve occurs in aortic stenosis. It restricts the forward flow of the blood during systole. In aortic regurgitation, a stream of blood regurgitates back through the incompetent aortic valve into the left ventricle during diastole. Left ventricle dilation and hypertrophy is caused by the increased stroke volume of the left ventricle. In tricuspid stenosis, calcification of the tricuspid valve impedes the forward flow of the blood into the right ventricle during diastole.
