Health Assessment-Chapter 20-Heart,Neck, & Vessels

Which heart rate would be found in a 4-month-old infant with bradycardia? 1 50 2 70 3 80 4 90

1 50 The heart rate of a newborn ranges from 100 to 180 beats per minute. After birth, the heart rate stabilizes to an average of 120 to 140 beats per minute. Infants may have wide fluctuations in the heart rate with activity. The infant may have 170 beats per minute or more while crying, and 70 to 90 beats per minute while sleeping. Therefore a heart rate of less than 60 beats per minute indicates bradycardia in the infant. The heart rate of 70 beats per minute and 80 beats per minute may indicate bradycardia in the newborn, but not in the infant. A heart rate of 90 beats per minute is a normal finding in infants.

Which conditions may cause a pathologic S3, or a ventricular gallop? Select all that apply. 1 Anemia 2 Pregnancy 3 Hyperthyroidism 4 Cardiomyopathy 5 Pulmonary stenosis

1 Anemia 2 Pregnancy 3 Hyperthyroidism A ventricular gallop occurs as a result of 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 S4, is present in the patient with cardiomyopathy or pulmonary stenosis.

The nurse determines that a patient has an increased risk for having a myocardial infarction. Which medication would be beneficial for the patient? 1 Aspirin (Ecotrin) 2 Ibuprofen (Advil) 3 Diclofenac (Cambia) 4 Acetaminophen (Apra)

1 Aspirin (Ecotrin) Impaired blood flow to the heart resulting from the presence of a clot in the artery may lead to a myocardial infarction in a patient. Aspirin (Ecotrin) helps prevent the formation of blood clots; therefore it reduces the risk of a myocardial infarction. Ibuprofen (Advil) and diclofenac (Cambia) are nonsteroidal anti-inflammatory medications, which help reduce inflammation. Acetaminophen (Apra) helps relieve mild to moderate pain associated with musculoskeletal complications.

Which physiologic mechanism causes the first heart sound? 1 Closing of the mitral valve 2 Filling of the ventricle 3 Closing of the aortic valve 4 Closing of the pulmonic valve

1 Closing of the mitral valve The first heart sound (S1) occurs with the closure of the AV valves. This signals the beginning of 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 because of the closure of the pulmonary valve. Ventricular filling causes the third heart sound (S3).

Patients with which comorbidities are at the highest risk for developing cardiac disease? Select all that apply. 1 Diabetes mellitus 2 Vitamin D deficiency 3 Vitamin A deficiency 4 Obesity 5 Carpal tunnel syndrome

1 Diabetes mellitus 2 Vitamin D deficiency 4 Obesity Diabetes mellitus causes damage to the large blood vessels, which nourish the heart. Therefore it increases the risk of cardiac disease. Vitamin D deficiency decreases the levels of calcium and results in weakness of the heart muscle. Obesity leads to an increase in the cardiac output and cardiac workload. Vitamin A does not interfere with cardiac function; therefore its deficiency may not lead to cardiac disease. Carpal tunnel syndrome is a musculoskeletal disorder; it does not affect cardiac function.

Which murmur is caused by an obstruction of the flow of blood into the ventricles? 1 Diastolic rumble 2 Early diastolic 3 Midsystolic ejection 4 Pansystolic regurgitant

1 Diastolic rumble Diastolic rumbles occur as a result of filling of the ventricles at a low pressure because of the obstruction of the flow of blood into the ventricles. Semilunar valve incompetence causes early diastolic murmurs. Midsystolic ejection murmurs occur as a result of 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.

The nurse is auscultating a patient's heart sounds. Which area is best for hearing the sound of the mitral valve? 1 Fifth left intercostal space at the midclavicular line 2 Second left intercostal space at the sternal border 3 Fourth left intercostal space at the left sternal border 4 Second right intercostal space at the sternal border

1 Fifth left intercostal space at the midclavicular line 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. Auscultatory 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 type of murmur is considered to be innocent? 1 Grade 2, midsystolic, musical 2 Grade 1, protodiastolic, rumbling 3 Grade 4, pansystolic, low-pitched 4 Grade 3, holodiastolic, high-pitched

1 Grade 2, midsystolic, musical A murmur is a blowing, swooshing sound that occurs with a turbulent blood flow in the heart or the great vessels. The innocent murmur is generally soft, midsystolic, short, and has a vibratory or musical quality. It is Grade 2. In patients with tricuspid regurgitation, pansystolic and low-pitched murmurs are heard. A holodiastolic, high-pitched murmur can be heard in patients with aortic stenosis. A protodiastolic and rumbling murmur is heard in patients with tricuspid stenosis.

Which finding in the precordium indicates pulmonic hypertension? 1 Lifting impulse in the left sternal border 2 Thrill in the second right intercostal space 3 Increase in the force of the apical impulse 4 The lateral displacement of apical impulse

1 Lifting impulse in the left sternal border A lifting impulse occurs with right ventricular hypertrophy, as in pulmonic disease and pulmonic hypertension. This may be caused by the presence of an enlarged right ventricle, which results in the posterior rotation of the left ventricle. A thrill in the right intercostal space is characteristic of aortic stenosis and systemic hypertension. A sustained increase in the force of the apical impulse occurs with left ventricular hypertrophy. A lateral displacement of apical impulse occurs with left ventricular hypertrophy.

Which statement describes a thrill? 1 Palpable vibration in the chest 2 Apical impulse 3 Associated with a venous hum 4 Sustained thrust of the ventricle of the heart

1 Palpable vibration in the chest A thrill is a vibration felt by the nurse on palpation of the chest. It is likened to the throat of a purring cat. The thrill signifies turbulent blood flow and directs the nurse to locate the origin of loud murmurs. 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 and is not associated with a thrill. A thrill is an abnormal pulsation on the precordium and is not found over the apical impulse. The normal apical impulse is the result of the heart rotating, moving forward, and striking against the chest wall during the systole. A lift refers to a sustained thrust of the ventricles.

Which pathologic conditions can cause heart murmurs? Select all that apply. 1 Septal defect 2 Regurgitant valve 3 Increased blood flow 4 Right bundle branch block 5 Decreased myocardial contraction

1 Septal defect 2 Regurgitant valve 3 Increased blood flow Turbulent blood flow and collision currents can cause heart murmurs. A murmur is a gentle blowing, swooshing sound that can be heard in the chest wall. Structural defects in the valves such as regurgitant valves can cause heart murmurs. Similarly, septal defects such as unusual openings in the heart chambers may produce heart murmurs. Flow murmurs may occur when the velocity of the blood increases because of exercise or thyrotoxicosis. Decreased myocardial contraction may result in ischemic heart disease. The right bundle branch block causes a wide split in the second heart sound.

Which patient positions are necessary during a cardiac assessment? Select all that apply. 1 Sitting 2 Supine 3 Prone 4 Right lateral semi-Fowler's 5 Left lateral recumbent

1 Sitting 2 Supine 5 Left lateral recumbent The patient is positioned differently for assessing the different aspects of cardiac health. During assessment of the carotid artery, the patient should be placed in the sitting position. 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's or the prone positions. Cardiac assessment is not performed in these positions.

Which statement by the nursing student is an accurate response concerning the vascular system? 1 "The walls of the arteries are thinner, and the walls of the veins are thicker." 2 "The arteries are high-pressure systems, and the veins are low-pressure systems." 3 "The arteries contain intraluminal valves, and the veins are devoid of intraluminal valves." 4 "The arteries build up metabolic wastes, and the veins cause symptoms of oxygen deficit."

2 "The arteries are high-pressure systems, and the veins are low-pressure systems." Arteries carry oxygenated blood pumped by the heart to all the tissues. The blood pressure inside the arteries is greater than that in the veins. Therefore arteries are the high-pressure systems. Veins do not have any mechanism to pump the blood; therefore veins are low-pressure systems. The walls of the veins are thinner, and the walls of the arteries are thicker. The veins contain intraluminal valves to maintain unidirectional blood flow. The arteries are devoid of these intraluminal valves. The diseases associated with veins build up metabolic wastes in the body. The diseases associated with arteries produce signs and symptoms of oxygen deficit.

The accumulation of lymph in the breasts and upper arms is a result of an obstruction of which lymph nodes? 1 Cervical 2 Axillary 3 Inguinal 4 Epitrochlear

2 Axillary The lymph from the breasts and the upper arms drains into the axillary nodes. Obstruction of the axillary nodes results in the accumulation of lymph in the breasts and the upper arms. Obstruction of the cervical nodes results in the accumulation of lymph in the head and the neck, because they drain the lymph from the head. Obstruction of the inguinal nodes results in the accumulation of lymph in the genitalia and the abdomen. This is because they drain the lymph from the external genitalia and the anterior abdominal wall. Obstruction of the epitrochlear nodes results in the accumulation of lymph in the hands and lower arms, because these nodes drain the lymph from the hands and the lower arms.

The human heart is found in which location? 1 Between the right midclavicular line and the right border of the sternum and below the clavicle to the eighth rib 2 Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line 3 Between the third and sixth intercostal spaces from the left midclavicular line to the left midaxillary line 4 Between the first and fourth intercostal spaces from the left midaxillary line to the left posterior axillary line

2 Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line 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 jugular pulse component reflects ventricular contraction? 1 A wave 2 C wave 3 V wave 4 X wave

2 C wave The jugular pulse, a waveform that moves backward, is caused by events upstream. The jugular pulse has five components. The C wave occurs because of 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.

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? 1 Pancreatitis 2 Cholecystitis 3 Esophageal spasms 4 Gastroesophageal reflux disease

2 Cholecystitis Cholecystitis is the inflammation of the gallbladder, which results in an accumulation of bile. Bile helps in the digestion of fats in the small intestine, so a patient with cholecystitis may not be able to digest the fats; this may produce pain in the right upper abdominal region, which radiates to the right shoulder. A patient with pancreatitis may experience nausea, vomiting, diarrhea, and epigastric pain, but this pain is not in relation to eating a fatty meal. A patient who has esophageal spasms may have substernal pain, but not abdominal pain. A patient with gastroesophageal reflux disease may have pain in the retrosternal region, but this would not radiate to the shoulders.

Which extra heart sounds may occur in early diastole? Select all that apply. 1 Ejection click 2 Opening snap 3 Summation sound 4 Pacemaker-induced sound 5 Mitral prosthetic valve sound

2 Opening snap 5 Mitral prosthetic valve sound The early diastolic stage involves the closing of the semilunar valves and opening of the atrioventricular (AV) valves. The opening of the AV valves is normally silent, but in cases of stenosis, more intra-atrial pressure is required to open the AV valve. Therefore the opening of the atrioventricular valve makes a noise referred to as an opening snap. The opening of a ball-in-cage mitral prosthesis in early diastole gives an opening click termed as mitral prosthetic valve sound. An ejection click is the sound of the opening of the semilunar valves in the presence of stenosis. Therefore this sound occurs in early systole. A summation sound refers to the superimposed S3 and S4 sounds, and this occurs in mid-diastole. A pacemaker-induced sound occurs in late diastole.

Which section of the electrocardiogram (ECG) indicates atrial depolarization? 1 T wave 2 P wave 3 QRS complex 4 ST segment

2 P wave An ECG records the heart's electrical activity and helps the nurse understand the functioning of the heart. The ECG waves are arbitrarily recorded as PQRST. The P wave indicates the depolarization of the atria. During atrial depolarization and contraction, electrodes placed on the surface of the body record a small burst of electrical activity lasting for a fraction of a second. This is the P wave. It is a recording of the spread of depolarization through the atrial myocardium from beginning to end. The T wave is the positive deflection that occurs after each QRS complex. It represents ventricular repolarization. The QRS complex represents the simultaneous activation of the right and the left ventricles. The ST segment represents ventricular repolarization, where repolarization follows upon contraction and depolarization.

Which heart sound occurs because of the closure of the semilunar valves? 1 First heart sound (S1) 2 Second heart sound (S2) 3 Third heart sound (S3) 4 Fourth heart sound (S4)

2 Second heart sound (S2) The second heart sound (S2) occurs with the closure of the semilunar valves, and it indicates the end of systole. The first heart sound (S1) occurs with the closure of the atrioventricular valves and indicates the beginning of systole. The third heart sound (S3) occurs because of the filling of the ventricles with blood. The fourth heart sound (S4) is heard at the end of diastole and occurs when the atria contract and push the blood into the noncompliant ventricle.

Which statement describes a lift with respect to the cardiovascular system? 1 Vibration felt over the apex of the heart 2 Sustained thrust of the ventricle of the heart 3 Exaggerated pulse felt on the carotid artery 4 Murmur over the second right intercostal space during diastole

2 Sustained thrust of the ventricle of the heart A lift, or heave, occurs because of right ventricular hypertrophy and is felt as a diffused lifting impulse during the ventricular systole at the left lower sternal border. A lift may be associated with the retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle. A thrill is a vibration felt by the nurse on the palpation of the chest. The presystolic thrill is felt just before the systole over the apex of the heart. The exaggerated pulse of the carotid artery is associated with the increased stroke volume of the left ventricle and a decreased peripheral resistance, leading to the widened pulse pressure of the aortic regurgitation. A low-intensity, high-pitched heart murmur is best heard over the left sternal border or over the right second intercostal space, especially if the patient leans forward and holds the breath in full expiration.

Which method would the nurse use to detect a pericardial friction rub? 1 Use a bedside Doppler ultrasound. 2 Listen to the heart with the bell of a stethoscope. 3 Auscultate with the diaphragm of a stethoscope. 4 Evaluate heart sounds with the ear near the patient's chest.

3 Auscultate with the diaphragm of a stethoscope. Inflammation of the pericardium leads to a friction rub. The sound is high-pitched and scratchy, like sandpaper being rubbed. It is best heard using the diaphragm of a stethoscope, with the person sitting up and leaning forward, holding the breath in expiration. It is not heard properly with the ear without using a stethoscope. Filling murmurs at low pressures are best heard with the bell of a stethoscope that touches the skin lightly. Bedside doppler ultrasound is used to monitor blood flow through a blood vessel.

Which assessment finding indicates abnormally elevated pressures in the right side of the heart? 1 Pulmonary congestion 2 Pulmonary hypertension 3 Distended neck veins and abdomen 4 Systolic blood pressure higher than diastolic blood pressure

3 Distended neck veins and abdomen When the pressure in the right side of the heart is abnormally high, the neck veins and the abdomen become distended because there are no valves between the vena cava and the right atrium or between the pulmonary veins and the left atrium. 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.

Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart and the valves? 1 Myocardium 2 Epicardium 3 Endocardium 4 Pericardium

3 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.

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? 1 Cholecystitis 2 Pancreatitis 3 Esophageal spasms 4 Gastroesophageal reflux

3 Esophageal spasms An esophageal spasm involves the over-squeezing of the muscles of the esophagus, which may prevent food from reaching the stomach, leaving it stuck in the esophagus. This may lead to the feeling in the patient that some object is obstructing the throat or esophagus and cause pain in the substernal region. Cholecystitis is the inflammation of the gallbladder, leading to the blockage of the cystic duct and causing pain in the epigastric region. Inflammation of the pancreas and upper abdominal pain are early signs of pancreatitis. The pain associated with gastroesophageal reflux disease occurs in the retrosternal region, but not the substernal region.

Which description of semilunar valves is correct? 1 Intra-arterial valves 2 Closed during the ventricular systole 3 Lie between the ventricles and the great vessels 4 Also called the tricuspid and the mitral valves

3 Lie between the ventricles and the great vessels The semilunar valves are set between the ventricles and the arteries. Each valve has three cusps that look like half-moons. The tricuspid and mitral valves are atrioventricular valves; they are different from the semilunar valves. Semilunar valves are not Intra-arterial valves; they are present between ventricles and arteries. No intra-atrial valves are present in any organism. During ventricular systole, the semilunar valves open. This helps the ventricles drain the blood in the great vessels.

Which condition would the nurse document after assessing the carotid artery and finding a double pulse? 1 Pulsus bigeminus 2 Pulsus alternans 3 Pulsus bisferiens 4 Pulsus paradoxus

3 Pulsus bisferiens The presence of a double pulse over the carotid artery indicates that the patient has pulsus bisferiens. The patient with pulsus bisferiens has two strong systolic peaks with a dip in between because of the backflow of the blood. It is most commonly associated with aortic valve stenosis. Pulsus bigeminus is characterized by the presence of an early heartbeat that is followed by a premature beat. If the patient has a regular rhythm along with an alternate strong and weak heartbeat, then it indicates that the patient has pulsus alternans. If the patient's pulse is weak during inspiration and strong during expiration, then it indicates that the patient has pulsus paradoxus.

Which condition can cause a wide split in the second heart sound? 1 Aortic stenosis 2 Right ventricular failure 3 Right bundle branch block 4 Left bundle branch block

3 Right bundle branch block A right bundle branch block causes a wide split in the second heart sound. When the right ventricle has a delayed electrical activation, the split is very wide on inspiration and can still be heard on expiration. Right ventricular failure causes a fixed split. In patients who have a left bundle branch block or aortic stenosis, a paradoxical split of the second heart sound is heard.

Which condition causes the patient to have a diminished first heart sound of S1 because of more forceful atrial contractions? 1 Mitral stenosis 2 Atrial fibrillation 3 Severe hypertension 4 Right ventricular hypertrophy

3 Severe hypertension 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 S1 sound. The patient with mitral stenosis has a diminished S1 sound because of the presence of a calcified mitral valve. The nurse may find S1 with an irregular rhythm in the patient with atrial fibrillation, but not a diminished S1. The first heart sound will be normal in the patient with right ventricular hypertrophy.

Which term is used to describe the pacemaker of the heart? 1 Bundle of His 2 Purkinje fibers 3 Sinoatrial node 4 Atrioventricular node

3 Sinoatrial node Sinoatrial node is another term used for the pacemaker of the heart. Specialized cells in the sinoatrial node near the superior vena cava initiate electrical impulses at regular intervals to cause the heart muscles to beat in an orderly sequence; hence, the sinoatrial node is the pacemaker. The atrioventricular node is present in the atrial septum; it helps in the conduction of the cardiac impulse. If the SA node fails, the AV node takes over as the pacemaker. The Bundle of His and Purkinje fibers also have automaticity and can serve as the pacemaker if the SA and AV nodes fail.

The patient with pneumonia complains of fever, cough, and myalgia. Which other complaint would the nurse expect from the patient? 1 Pressure-like pain felt in the chest during morning hours 2 Sudden severe pain in the chest with a change in location 3 Stabbing pain located in the chest with a cough on one side 4 Burning sensation within the chest after having large meals

3 Stabbing pain located in the chest with a cough on one side The patient feels stabbing pain with a cough on one side of the chest because of inflammation of the pleura related to a bacterial infection 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.

Which statement describes the pericardium? 1 Muscular wall of the heart 2 Area of the chest overlying the heart 3 Tough, fibrous sac surrounding the heart 4 Thin layer of endothelial tissue lining the inner surface of the heart

3 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.

Which component of the jugular venous pulse corresponds to the opening of the tricuspid valve? 1 A wave 2 V wave 3 Y descent 4 X descent

3 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 because of the backward flow of blood to the vena cava. V wave occurs with passive atrial filling because of increase in pressure and volume in the right atria. X descent indicates atrial relaxation.

Which description of chordae tendineae is correct? 1 Muscles that are attached to the ventricles 2 Tendons that hold the semilunar valves in alignment 3 Structures that separate the right and the left ventricles 4 Collagenous fibers that anchor the leaflets of the atrioventricular valves

4 Collagenous fibers that anchor the leaflets of the atrioventricular valves 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.

The patient with pathologic S3 heart sound has which condition? 1 A stenotic heart valve 2 Coronary artery disease 3 Vigorous atrial contraction 4 Decreased compliance of the ventricles

4 Decreased compliance of the ventricles 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 valve. It produces an S4 associated with a presystolic apical impulse. A stenotic heart valve occurs because of 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.

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? 1 Grade 1 crescendo 2 Grade 3 holodiastolic 3 Grade 6 decrescendo 4 Grade 4 holosystolic

4 Grade 4 holosystolic The intensity of the loudness of the heart murmur is described in terms of six grades: Grade 1 is the lowest and Grade 6 is the highest. If the murmur is heard throughout the systole or diastole, then it is called holosystolic and holodiastolic, respectively. A systolic murmur may also occur with a normal heart, but a diastolic murmur always indicates heart disease. In this instance, the murmur lasts throughout the systole, is loud and is associated with a thrill. It is therefore classified as Grade 4 and holosystolic. When the loudness of the murmur gradually increases, it is called crescendo; in decrescendo, the murmur gradually decreases. The murmur is neither increasing nor decreasing gradually; hence, it is not a crescendo or a decrescendo murmur. Because the murmur is not heard during the diastolic phase of the heart, it is not a holodiastolic murmur.

Which would be the likely reason an adolescent patient with an upper respiratory tract infection complains of abdominal pain? 1 Enlargement of the tonsils 2 Enlargement of the thymus 3 Inflammation of the epitrochlear nodes 4 Inflammation of the mesenteric lymph nodes

4 Inflammation of the mesenteric lymph nodes The mesenteric lymph nodes are located in the abdomen. Inflammation of the mesenteric lymph nodes will cause pain in the abdomen. Enlargement of the tonsils indicates that the patient has a respiratory infection, but it is not associated with abdominal pain. Enlargement of the thymus is a normal finding during adolescence, but it does not result in abdominal pain. The epitrochlear nodes are located in the upper arm; these nodes drain lymph from the hands and lower arm. However, inflammation of the epitrochlear nodes does not cause abdominal pain.

Which feature is characteristic of the third heart sound, S3? 1 Varies with inspiration 2 Sound pitch remains the same 3 Occurs in the second left interspace 4 Occurs at the left lower sternal border

4 Occurs at the left lower sternal border S3 is a ventricular filling sound, and it occurs as a result of the backward flow of blood into the left atrium. The third heart sound occurs in the apex or left lower sternal border, and the sound does not change with respiration. The split S2 varies with inspiration, and the pitch of the sound remains the same. The pitch of the sound lowers in the third heart sound. The second heart sound occurs in the second left intercostal space.

Which heart sound would the nurse auscultate in the patient with pulmonic stenosis? 1 Accentuated S1 2 Fixed split S2 3 Pathologic S3 4 Pathologic S4

4 Pathologic S4 Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S4, occurs after diastole because of resistance of the ventricles to filling with blood. It commonly occurs in the presence of an enlarged right ventricle. Pathologic S3 occurs as a result of the backward flow of blood into the left atrium in the patient with mitral regurgitation. A fixed split S2 occurs in the patient with atrial septal defect because of the earlier closure of the aortic valves than the pulmonic valves. An accentuated S1 occurs with mitral stenosis.

Which would the nurse assess first in the patient during a regional cardiovascular assessment? 1 Precordium 2 Extremities 3 Neck vessels 4 Pulse and blood pressure

4 Pulse and blood pressure During a regional cardiovascular assessment, the nurse starts peripherally with pulse and blood pressure then moves toward the heart. The extremities would be checked next for cyanosis, edema, or clubbing, but not first. The nurse would assess the neck vessels and precordium after checking the peripheral pulses and blood pressure.

Which assessment finding would the nurse document as a sinus arrhythmia? 1 Skipped beats 2 Faster-than-normal pulse rate 3 Highly irregular pulse rate 4 Pulse that varies with respiration

4 Pulse that varies with respiration Sinus arrhythmia describes the variation of a heart rhythm with breathing in which it increases at the peak of inspiration and decreases with expiration. Disturbances of the pacemaker and the conducting tissue of the heart can cause a missed heartbeat or irregular heartbeat. This is reflected in the pulse rate. Tachycardia indicates a faster-than-normal pulse rate.

While assessing a patient with an infection of the forearm, the nurse uses one hand to shake the patient's hand and keeps the other hand near the patient's elbow. Which is the reason for the nurse's action? 1 To check for the persistence of pallor 2 To check for arterial insufficiency 3 To check for enlarged axillary nodes 4 To check for enlarged epitrochlear nodes

4 To check for enlarged epitrochlear nodes Local infections of the hand or forearm may trigger enlargement of the epitrochlear nodes. In this case, the nurse is assessing the presence of enlarged epitrochlear lymph nodes. The modified Allen test helps determine the persistence of pallor, which occurs because of occlusion of the collateral arterial flow. The nurse palpates the brachial pulses to determine arterial insufficiency in the patient. The enlargement of axillary nodes may occur in patients with breast cancer. However, nodes in the axilla also enlarge in response to infections associated with the upper extremities. The nurse will not be able to identify enlarged axillary nodes with the help of this assessment.

Which type of intensity is characteristic of the first heart sound in the patient who has complete heart block? 1 Loud 2 Faint 3 Split 4 Varied

4 Varied The first heart sound will be of varied intensity because the atria and the ventricles beat independently in the patient with complete heart block. The first heart sound will be loud in the presence of calcified valves because increased atrial pressure is necessary to pump the blood into the noncompliant ventricles. Because of the delay in conduction between the atria to the ventricles, the first heart sound will be faint in case of first-degree heart block. Split S1 indicates that mitral and tricuspid components are heard separately. However, this does not occur in the patient who has complete heart block.