220 Chapter 19
upon assessment of a patients pulse, a nurse notices that the amplitude of the pulse varies between beats. which other finding should the nurse assess for the patient? 509
presence of an s3
during the auscultation of a patients heart sounds, the nurse hears a fixed s2 split. what does this heart sound indicate to the nurse 508
right ventricular failure
what is the function of the semilunar valve
separates ventricles from great vessels
what are two examples of atrioventricular valves
tricuspid and mitral
A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? 508 A) sinus arrhythmia B) atrial fibrillation C) premature ventricular contractions D) premature atrial contractions
A
A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take during the remainder of the physical assessment of the carotid arteries? A) perform palpation lightly B) perform only ausculation C) make patient sit upright D) avoid frequent repositioning
A
points for listening to the heart All, people, enjoy, time, magazine
aortic, pulmonic, erb's point, tricuspid, mitral
what occurs during systole
closing AV valves, opening semilunar
what occurs during diastole
closing semilunar valve, opening AV valves
what is responsible for the inspiratory splitting of s2 511
closure of aortic then pulmonic valves
areas of chest wall are visiably pulsating
heaves
A group of students is reviewing information about the different types of murmurs. which of the following would they identify as an example of midsystolic murmur 509
innocent
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 507 A) s3 B) s4 C) s2 D) s1
D
which area of the heart should be further assessed in patient with irregular pulse 489-490 A) right ventricle B) left atrium C) left ventricle D) left atrium
D
what is the function of the atrioventricular valve
separates atria from ventricles
The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.) A. examine face C.inspecting and palpating the pericordium D.examine neck E. the legs F.the hands G. ausculating the lungs
A, C, D, G
which is true of the third heart sound (s3) 509 A) it is not heard in atrial fibrillation B) it reflects normal compliance of the left ventricle C) it marks atrial contraction D) it is caused by rapid deceleration of blood against the ventricular wall
D
The nurse assesses a patients carotid pulse and finds it to be of normal amplitude. The nurse would document this as... ? 505
2+
the difference between stable and unstable angina is that stable lasts ____ minutes, and unstable lasts longer than that. Unstable has no relation to _____
20, activity
The nurse is reviewing patients cardiac output. what is the normal cardiac output ranges
5-8
a group of nurses is reviewing several ecg's the student demonstrates understanding of waveforms when they identify which component as indicating ventricular repolarization? 491 A) T wave B) ST segment C) QRS complex D) P wave
A
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) ventricles B) chordae tendineae C) percordium D) semilunar valves
A
during the auscultation of a patients heart sounds, the nurse asks the patient to turn onto the left side. why is this position used during the examination?(510) A) accentuates mitral stenosis B) accentuates the first heart sound C) accentuates aortic murmurs D) accentuates atrial repolarization
A
a patient is diagnosed with coronary heart disease and hypertension. what can the nurse instruct this patient to help reduce the modifiable risk factors for both of these disorders (select all) A) the need to increase physical activity B) importance of weight reduction C) necessity of smoking cessation D) reducing alcohol consumption E) having kidney function checked each year
A, B, C
A nurse assesses a client's jugular venous pulse to gather information about which of the following? A) left ventricular diastole filling B) hemodynamic of the right side of the heart C) left arterial pressure D) right ventricular pressure
B
A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse? A) opening snap B) midsystolic click C) ventricular gallop D) venous hum
B
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? 507 A) isometric contraction B) closure of the semilunar valves C) ventricular contraction D) closure of the atrioventricular valves
B
A patient complains of palpations and a feeling of anxiety. which of the following would be most appropriate for the nurse to keep in mind 500 A) the heart is responding to increased renal perfusion B) the heart is attempting to increase cardiac output C) this is the body's response to an increase in cardiac output D) this is the normal response by the hearts conduction system
B
When auscultating a patient's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? 489 A) mitral and aortic B) aortic and pulmonic C) tricuspid and mitral D) pulmonic and tricuspid
B
Which is true of splitting of the second heart sound? 511 A) it is best heart over the apex B) it is best heard over the pulmonic area with the bell of the stethoscope C) it normally increases with exhalation D) it does not vary with respiration
B
Which of the following statements most accurately describes preload? A) the amount of resistance that must be overcome prior to systole B) the amount of blood in the ventricles at the end of diastole C) the amount of muscle contractility possessed by the myocardium D) the blood volume in the atria that must be overcome by the ventricles
B
which technique would be most appropriate to use when examining the jugular venous pulse 507 A) Perform the exam with the patient in supine position B) inspect the suprasternal notch or around the clavicles C) have the patient look straight ahead with chin slightly lifted D) have the patient sit up at a 90 degree angle
B
During the auscultation of a patient's heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse? A) Left bundle branch block B) right bundle branch block C) pulmonic stenosis D) right ventricular failure
D
The nurse is preparing to conduct a physical examination of a patient's cardiovascular system. What should the nurse instruct the patient in preparation for this examination? (Select all that apply.) A) the patient will stand during the exam B) wear the gown with opening in front C) explain that gloves will be worn during the exam D) a sheet will be draped over the patient for comfort E) the nurse will be conducting the exam from the left side
B, C, D, E
A nurse performs an initial health history on a patient admitted for new onset of chest pain. Which data is considered subjective ? A) apical heart rate 70 beats per minute B) no edema of extremities noted C) no current medications or treatments D) apical impulse palpated at 5 intercostal space
C
During auscultation of the heart, a nurse hears an extra sound immediately after s2 at the second left intercostal space. what should the nurse do to further assess this finding A) ask the client to lean forward to bring the left ventricle closer to the chest wall B) observe the jugular vein for distension at 30, 60 and 90 degrees of head elevation C) watch the patients respirations while listening for effect on heart sounds
C
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating which heart action? 507 A) beginning of diastole B) isometric contraction C) closure of the atrioventricular valves D) closure of the semilunar valves
C
When ausculating the left carotid artery, the nurse notes a swishing sound. The nurse interprets this finding as suggesting? 504 A) Increased central venous pressure B) decreased cardiac output C) a narrowed vessel D) right ventricular failure
C
Where is the point of maximal impulse (PMI) normally located? A) in the left 5th intercostal space 10-12 cm lateral to the sternum B) in the left 5th intercostal space in the anterior axillary line C) in the left 5th intercostal space 7 to 9 cm lateral to the sternum
C
Which of the following events occurs at the start of diastole? A) the first heart sound (s1) is produced B) closure of the tricuspid valve C) closure of the aortic valve D) opening of the pulmonic valve
C
what is the most important physical sign of acute pericarditis? 509 A) intense pain B) elevated white cell count C) pericardial friction rub D) murmur heard over the left sternal border
C
The nurse hears a murmur in a patient with known mitral valve prolapse. The murmur most likely occurs in: 507=508 A) early diastole B) mid-systole C) middiastole D) late systole
D
a patient is admitted to the health care facility with reports of chest pain, elevated bp, sob with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A grade III/VI systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data. 514 A) ineffective health maintenance B) impaired breathing pattern C) activity tolerance D) ineffective tissue perfusion
D
the nurse is preparing to assess a patients carotid arteries. how should she palpate each artery? 504 A) palpate the arteries before ausculating them B) ask the patient to breathe in and out deeply C) use the diaphragm of the stethoscope D) palpate each artery individually to compare
D
when auscultating a patients 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 510 A) crescendo B) decrescendo C) plateau D) crescendo-decrescendo
D
When performing an adult cardiac examination and listening to the S1 and S2, the nurse may ... (2 answers) 507
use the diaphragm of the stethoscope, use the bell of the stethoscope pressed firmly on the chest
A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? A) premature ventricular contractions B) atrial fibrillation C) premature atrial contractions D) sinus arrhythmias
D
A nurse cares for a patient who suffered a myocardial infarction two days ago. a high pitched, scratchy scraping sound is heard that increases with exhalation and when the patient leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? 509 A) inability of the atria to contract B) increased pressure within the ventricle C) incompetent mitral valve D) inflammation of the pericardial sac
D
A nurse is demonstrating the technique for auscultating heart sounds. which of the following is most important for the nurse to emphasize? A) start at the apex B) listen over each chamber of the heart C) use both the bell and diaphragm D) cover the entire pericordium 507-508
D
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) palpate the apical impulse B) use the bell of the stethoscope to help distinguish sounds C) determine the pulse deficit D) palpate the carotid pulse while ausculating the heart
D
A nurse suspects that a patient may have a pericardial friction rub. To ensure that the nurse hears this the nurse would place the patient in which position? 509 A) flat, left lateral B) sitting upright in a straight back chair C) supine with head of bed elevated 30 degrees D) leaning forward while in a sitting position
D
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 patient leaning forward. The nurse would document which of the following? 509 A) midsystolic click B) aortic ejection click C) summation gallop D) pericardial friction rub
D
what are two examples of semilunar valves
pulmonic and aoritc
