Chapter 12

A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply. a. S4 heart sound b. Dyspnea c. Jugular vein distention d. Pericardial friction rub e. Edema of ankle and feet at the end of the day f. S3 heart sound

B, C, E, F

During a health fair, the nurse is alert for which risk factors for hypertension? Select all that apply. a. Excessive protein intake b. Having parents with hypertension c. Excessive alcohol intake d. Being Asian e. Experiencing persistent stress f. Elevated serum lipids

B, C, E, F

What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply. a. Heart rate of 102 beats/min b. S1 and S2 present with regular rhythm c. Capillary refill greater than 3 seconds d. Blood pressure of 124/86 e. Warm, elastic turgor f. Pulse of smooth contour with 2+ amplitude

B, E, F

How does a nurse assess the competence of venous valves in patients who have varicose veins? a. Notes how quickly veins fill after lifting one leg above the level of the heart b. Assesses for Homan sign in both lower extremities while the patient is supine c. Assesses capillary refill on the toes of both feet while the patient is sitting in the chair d. Measures the circumference of both calves and compares the results

a. Notes how quickly veins fill after lifting one leg above the level of the heart -Noting how quickly veins fill after lifting one leg above the level of the heart is the procedure to test for incompetent veins.

A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment? a. S4 heart sound b. Clubbing of fingers c. Splitting of the S1 heart sound d. Pericardial friction rub

a. S4 heart sound -An S4 heart sound signifies a noncompliant or stiff ventricle. Coronary artery disease is a major cause of a stiff ventricle.

A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve? a. Second intercostal space, right sternal border b. Second intercostal space, left sternal border c. Fourth intercostal space, left sternal border d. Fifth intercostal space, left midclavicular line

a. Second intercostal space, right sternal border -Second intercostal space, right sternal border is the location for listening to the aortic valve.

A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate? a. Sinoatrial (SA) node failure b. Atrial bradycardia c. A well-conditioned heart muscle d. Left ventricular hypertrophy

a. Sinoatrial (SA) node failure

A nurse expects which finding during a cardiovascular assessment of a healthy adult? a. Visible, consistent pulsations of the jugular vein b. Pink nail beds with a 90-degree angle at the base c. Capillary refill of the toes greater than 5 seconds d. Bruits heard on auscultation of the carotid arteries

a. Visible, consistent pulsations of the jugular vein -Visible, consistent pulsations of the jugular vein is an expected finding.

While assessing edema on a male patients lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patients leg. How does the nurse document this finding? a. No edema b. 1+ edema c. 2+ edema d. 3+ edema

b. 1+ edema -A barely perceptible pit is detected after palpation.

While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination? a. An extra beat just before the S2 heart sound heard during auscultation b. A raspy machine-like or blowing sound heard during auscultation c. A prominent thrust of the heart against the chest wall felt on palpation d. A visible indentation of pericardial tissue noted during inspection

b. A raspy machine-like or blowing sound heard during auscultation

The patient describes her chest pain as squeezing, crushing, and 12 on a scale of 10. This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms? a. Tachycardia, tachypnea, and hypertension b. Dyspnea, diaphoresis, and palpitations c. Hyperventilation, fatigue, anorexia, and emotional strain d. Fever, dyspnea, orthopnea, and friction rub

b. Dyspnea, diaphoresis, and palpitations -Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable angina.

Which patients statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina? a. No, I have not done anything to strain chest muscles. b. If I take a deep breath, the pain gets much worse. c. This pain feels like theres an elephant sitting on my chest. d. Whenever this pain happens, it goes right away if I lie down.

b. If I take a deep breath, the pain gets much worse. -The chest pain from pericarditis is aggravated by deep breathing, coughing, or lying supine.

To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm? a. Rhythm 100 beats/min b. Irregular rhythm c. Rhythm noted at +2 d. Bounding rhythm

b. Irregular rhythm -The rhythm should be an equal pattern or spacing between beats. Irregular rhythms without any pattern should be noted.

What does the S2 heart sound represent? a. The beginning of systole. b. The closure of the aortic and pulmonic valves. c. The closure of the tricuspid and mitral values d. A split heard sound on exhalation

b. The closure of the aortic and pulmonic valves. -The second heart sound is made by the closing of these valves, which indicates the beginning of diastole.

A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurses appropriate response? The 128 represents the pressure in your blood vessels when: a. The ventricles relax and the aortic and pulmonic valves open. b. The ventricles contract and the mitral and tricuspid valves close. c. The ventricles contract and the mitral and tricuspid valves open. d. The ventricles relax and the aortic and pulmonic valves close.

b. The ventricles contract and the mitral and tricuspid valves close.

Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border? a. Pulmonic b. Tricuspid c. Mitral d. Aortic

b. Tricuspid -Tricuspid valve sounds are best heard in the fourth intercostal space at the left of the sternal border.

When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? a. A systolic murmur b. An S3 heart sound c. A friction rub d. An S4 heart sound

c. A friction rub - Two classic findings of pericarditis are pericardial friction rub and chest pain.

A nurse who is auscultating a patients heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? a. An opening snap b. A diastolic murmur c. A systolic murmur d. A pericardial friction rub

c. A systolic murmur -The blowing sound is a murmur. The nurse determines whether it is a systolic or a diastolic murmur based on where it is heard during the cardiac cycle. S1 indicates the beginning of systole; the sound is made by the closing of the mitral and tricuspid valves, which is followed by ventricular contraction or systole.

A nurse is assessing a patients peripheral circulation. Which finding indicates venous insufficiency of this patients legs? a. Paresthesias and weak, thin peripheral pulses b. Leg pain that can be relieved by walking c. Edema that is worse at the end of the day d. Leg pain that increases when the legs are lowered

c. Edema that is worse at the end of the day -Dependent edema is an indication of venous insufficiency.

When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect a thrill? a. Sustained thrust of the heart against the chest wall during systole b. Visible sinking of the tissues between and around the ribs c. Fine, palpable vibration felt over the precordium d. Bounding pulse noted bilaterally

c. Fine, palpable vibration felt over the precordium -A thrill is a palpable vibration over the precordium or artery.

A nurse is having difficulty auscultating a patients heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds? a. Lie in a supine position. b. Cough. c. Hold his or her breath for a few seconds. d. Sit up and lean forward.

c. Hold his or her breath for a few seconds. -Holding the breath for a few seconds eliminates the noise of breathing long enough to hear several cardiac cycles of heart sounds. The holding of the breath can be repeated if needed to hear the heart sounds again.

Which patient does the nurse identify as the one at greatest risk for hypertension? a. Woman with coronary artery disease b. Hispanic male c. Obese male with diabetes mellitus d. Postmenopausal woman

c. Obese male with diabetes mellitus -Obese men with diabetes mellitus have three risk factors: obesity, gender, and comorbidity of diabetes mellitus.

A nurse determines that a patients jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find? a. Weight loss b. Tented skin turgor c. Peripheral edema d. Capillary refill greater than 5 seconds

c. Peripheral edema -The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A pressure of 3.5 inches indicates fluid volume excess, which causes peripheral edema due to excessive fluid in blood vessels.

Which pulse may be a challenge for a nurse to palpate? a. Temporal b. Femoral c. Popliteal d. Dorsalis pedis

c. Popliteal -For the popliteal pulse, palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion. This pulse may be difficult to find.

After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings? a. Visit 1, 118/78; Visit 2, 116/76 b. Visit 1, 130/88; Visit 2, 134/88 c. Visit 1, 144/92; Visit 2, 150/90 d. Visit 1, 162/100; Visit 2, 166/104

c. Visit 1, 144/92; Visit 2, 150/90 -These readings are stage 1 because the systolic pressures are 140 to 159 and diastolic pressures are 90 mm Hg or greater.

A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient? a. 1+ edema of the feet and ankles bilaterally b. The circumference of the right leg is larger than the left leg c. Patchy petechiae and purpura of the lower extremities d. Cool feet with capillary refill of toes greater than 3 seconds

d. Cool feet with capillary refill of toes greater than 3 seconds -The pain while walking that is relieved by rest is called intermittent claudication and is an indication of arterial insufficiency. Cool feet and prolonged capillary refill also occur due to arterial insufficiency.

A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patients chest pain? a. Stable angina b. Esophageal reflux disease c. Mitral valve prolapse d. Costochondritis

d. Costochondritis -Coughing, deep breathing, laughing, and sneezing worsen the chest pain associated with costochondritis.

Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement. a. A b. B c. D d. E

d. E -E is the location of the mitral valve areathe fifth intercostal space, midclavicular line.

While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? a. Flat jugular neck veins b. Red, shiny skin on the legs c. Weak, thready peripheral pulses d. Edema of the feet and ankles

d. Edema of the feet and ankles -his patient may have heart failure. Edema of the feet occurs with right ventricular heart failure. Dyspnea occurs with left ventricular heart failure.

How is the first heart sound (S1) created? a. Pulmonic and tricuspid valves close. b. Mitral and aortic valves close. c. Aortic and pulmonic valves close. d. Mitral and tricuspid valves close.

d. Mitral and tricuspid valves close. -The first heart sound (S1) is made by the closing of the mitral (M1) and tricuspid (T1) valves.

How does a nurse accurately palpate carotid pulses? a. Two fingers of each hand are placed firmly over the right and left temples at the same time. b. One finger is placed gently in the space between the biceps and triceps muscles. c. Two fingers are placed at the thumb side of the forearm at the wrist. d. One finger is placed along the right and then the left medial sternocleidomastoid muscle.

d. One finger is placed along the right and then the left medial sternocleidomastoid muscle. -One finger placed along the right and then the left medial sternocleidomastoid muscle is the correct procedure for palpating the carotid pulses, checking each side separately.