Health Assessment Heart + Vessels
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying it as which of the following? A) Myocardium B) Epicardium C) Endocardium D) Pericardium
a
During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade? A) I B) II C) III D) IV
b
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
b
When describing the major arteries of the arms and legs, which of the following would the instructor identify as the major supplier of blood to the arms? A) Radial artery B) Brachial artery C) Femoral artery D) Ulnar artery
b
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency? A) Split B) Diminished C) Accentuated D) Varying
b
Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? A) This indicates the heart is working efficiently. B) Increased urination at rest may indicate heart failure. C) The client has decreased performance levels of activities of daily living. D) The client most likely sleeps without a pillow at night.
b
A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply. A) Avoid eating dark chocolate. B) Eat foods low in sodium. C) Walk for at least 30 minutes/day. D) Limit alcohol intake to 3 drinks per day. E) Use relaxation techniques to manage stress.
b c e
A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client? A) It filters harmful substances from the body. B) It produces protective antibodies. C) It manufactures T lymphocytes. D) It drains capillary blood from the circulation.
a
A client presents with chest pain described as a pressure and squeezing sensation that is steady and severe. The nurse would suspect which system as the most likely source? A) Cardiac B) Gastrointestinal C) Musculoskeletal D) Pulmonary
a
A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs? A) Innocent B) Mitral regurgitation C) Mitral stenosis D) Ventricular septal defect
a
A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following would the nurse do next? A) Document this finding as normal. B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.
a
A nurse obtains the following information: right arm brachial pressure, 160; left arm brachial pressure, 150; right ankle pressure, 80; left ankle pressure, 94. The nurse determines that the right ankle-brachial index would be which of the following? A) 0.50 B) 0.53 C) 0.59 D) 0.63
a
An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect? A) Arterial insufficiency B) Musculoskeletal weakness C) Venous insufficiency D) Neurologic impairment
a
Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next? A) Compare measurements of both extremities. B) Perform the Allen's test C) Check for bilateral varicosities. D) Palpate the femoral pulses.
a
During a health visit, a client says, "I know that arteries and veins are blood vessels, but what's the difference?" Which of the following would the nurse include in the response? A) Arteries have thicker walls than veins. B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.
a
On examination, the nurse would expect what finding if a client is in right-sided failure? A) Increased jugular venous pressure B) Decreased right-sided volume C) Decreased central venous pressure D) Decreased stroke volume
a
The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? A) Palpate each artery individually to compare B) Palpate the arteries before auscultating them C) Use the diaphragm of the stethoscope D) Ask the client to breathe in and out deeply
a
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following? A) Venous insufficiency B) Stasis ulceration C) Arterial occlusion D) Dependent edema
a
When assessing a client for possible varicose veins, which of the following would the nurse do? A) Have the client stand for the exam B) Tell the client to raise his or her leg C) Dorsiflex the client's foot D) Obtain the ankle-brachial index
a
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? A) S1 B) S2 C) S3 D) S4
a
While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document which of the following? A) Pericardial friction rub B) Midsystolic click C) Summation gallop D) Aortic ejection click
a
A nurse is having difficulty determining a client's heart sounds, specifically S1 and S2. Which of the following would be appropriate for the nurse to do? A) Use the bell of the stethoscope to help distinguish the sounds B) Palpate the carotid pulse while auscultating the heart C) Determine the pulse deficit D) Palpate the apical impulse
b
A nurse is having difficulty palpating the femoral pulse on an adult client. Which of the following would be most appropriate for the nurse to do? A) Ask another nurse to assess the pulse. B) Listen for femoral bruits. C) Perform the Allen's test. D) Assess the popliteal pulse.
b
A nurse is preparing a presentation for a local community group about coronary artery disease and culture. Which information would the nurse include? A) Caucasians take higher lifestyle risks than African Americans. B) Hypertension is more prevalent in African Americans. C) Hypertension is seen more in white women than in African-American women. D) Hispanic Americans have a higher rate of coronary artery disease than white Americans.
b
A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position? A) Supine with head of bed elevated 30 degrees B) Leaning forward while in a sitting position C) Flat, left lateral D) Sitting upright in a straight back chair
b
After teaching a group of students about blood flow through the heart, the instructor determines that the teaching was successful when the students state that after being received by the atria, the blood goes to which of the following? A) Chordae tendineae B) Ventricles C) Semilunar valves D) Precordium
b
After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? A) Fifth intercostal space near the left midclavicular line B) Third to fifth intercostal space at the left sternal border C) Second intercostal space at the right sternal border D) Second or third intercostal space at the left sternal border
b
An instructor is observing a student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb B) Student compresses the client's nailbed until it blanches C) Student applies firm pressure to the hand, noting any indentation D) Student asks client to turn hands slowly over and back
b
While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. A) Irregular border B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain
b c e
A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis? A) Antihypertensive B) Antidepressant C) Oral contraceptive D) Antilipid agent
c
A client complains of palpitations and a feeling of anxiety. Which of the following would be most appropriate for the nurse to keep in mind? A) This is a normal response by the heart's conduction system. B) This is the body's response to an increase in cardiac output. C) The heart is attempting to increase cardiac output. D) The heart is responding to increased renal perfusion.
c
A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next? A) Ask the client about any recent ear and throat infections. B) Carefully assess the cervical lymph nodes for enlargement. C) Examine the lower arm and hand for infection sites. D) Assess both legs for Homans' sign.
c
A nurse auscultates a client's hear rate and rhythm and finds the rhythm to be irregular. Which of the following would the nurse do next? A) Inspect for a lift B) Palpate for a thrill C) Auscultate for pulse rate deficit D) Listen for a ventricular gallop
c
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The nurse would suspect which of the following? A) Hypothyroidism B) Fever C) Mitral stenosis D) Heart murmur
c
A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next? A) Refer the client for medical follow-up. B) Document the finding. C) Palpate the brachial pulse. D) Auscultate the apical pulse.
c
A nurse prepares to perform the manual compression test on a client with which of the following? A) Venous ulcer B) Arterial occlusion C) Varicose veins D) Lymphedema
c
A nursing student is reviewing the electrical conduction of the heart. The student is correct in identifying the sinoatrial node of the heart as which of the following? A) Bundle of His B) Purkinje fibers C) Pacemaker D) Conduction system
c
After teaching a group of students about the great vessels, the instructor determines that the students need additional teaching when they identify which of the following as a great vessel? A) Aorta B) Pulmonary vein C) Carotid artery D) Inferior vena cava
c
Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 1+ B) 2+ C) 3+ D) 4+
c
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next? A) Document "absence of dorsalis pedis pulse." B) Auscultate the anatomic area with a stethoscope. C) Use Doppler ultrasonography to locate the pulse. D) Ask another nurse to assess the pulse.
c
When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following? A) Crescendo B) Decrescendo C) Crescendo-decrescendo D) Plateau
c
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting which of the following? A) Decreased cardiac output B) Increased central venous pressure C) A narrowed vessel D) Right ventricular failure
c
When describing fluid exchange and the capillaries, the instructor explains which mechanism as the most likely cause if oxygen, water, and nutrients are having difficulty entering the interstitial fluid? A) Osmotic pressure B) Gravitational flow C) Hydrostatic force D) Diastolic pressure
c
When reviewing the adult circulation, the nurse understands that which mechanism primarily aids in returning blood to the heart?? A) Pressure gradients B) Gravitational flow C) Muscular contractions D) Heart muscle contraction
c
Which question would be most important to ask obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) "Do your parents have trouble with circulation?" B) "When was your last prostate exam for cancer?" C) "Have you experienced a change in your usual sexual activity?" D) "Have you had an electrocardiogram recently?"
c
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? A) P wave B) QRS complex C) ST segment D) T wave
d
A group of students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes? A) Legs B) External genitalia C) Upper abdomen D) Buttocks
d
A nurse assesses a client's jugular venous pulse to gather information about which of the following? A) Left arterial pressure. B) Left ventricular diastolic filling. C) Right ventricular pressure. D) Hemodynamics of the right side of the heart.
d
A nurse is demonstrating the technique for auscultating heart sounds. Which of the following would be most important for the nurse to emphasize? A) Start at the apex. B) Listen over each of the heart chambers. C) Use both the bell and diaphragm. D) Cover the entire precordium.
d
A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client if free of arterial occlusion? A) 0.5 B) 0.7 C) 0.9 D) 1.1
d
A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Inguinal area D) Upper arm
d
The nurse determines that a client's edema of the lower extremities is most likely due to lymphedema based on which of the following? A) Pitting edema B) Ulceration of the skin C) Areas of pigmentation D) Bilaterally present
d
The nurse elicits a positive Homans' sign in a client's right leg. Which of the following might the nurse suspect? A) Arterial occlusion B) Venous insufficiency C) Varicose veins D) Thrombophlebitis
d
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? A) Isometric contraction B) Closure of the semilunar valves C) Beginning of diastole D) Closure of the atrioventricular valves
d
The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse? A) Temporal B) Brachial C) Popliteal D) Femoral
d
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? A) Second intercostal space, left sternal border B) Third intercostal space, left axillary line C) Fourth intercostal space, left sternal border D) Fifth intercostal space, left midclavicular line
d
The nurse is preparing to palpate the posterior tibial pulse. At which location would the nurse expect to palpate? A) Just behind the knee B) At the top of the foot C) In the groin area D) Behind the ankle
d
The nurse measures the circumference of a client's arms because of lymphedema in the right arm. The nurse obtains a difference of 6 cm between the right and left arms. The nurse would document this finding as which state of lymphedema? A) 0 B) I C) II D) III
d
When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency? A) Participation in daily exercise B) A family history of arterial insufficiency C) Intake of 2 beers per week D) Cigarette smoking
d
Which technique would be most appropriate to use when examining the jugular venous pulse? A) Perform the exam with the client in a supine position. B) Have the client look straight ahead with chin slightly lifted. C) Have the client sit up at a 90-degree angle. D) Inspect the suprasternal notch or around the clavicles.
d
