Ch. 15: Heart

32. All of the following are characteristics of the Frailty syndrome in older adults except: a. weight gain. b. inability to climb one flight of stairs. c. inability to walk one block. d. most common in adults over age 70. e. linked to comorbid conditions.

A Frailty syndrome is characterized by signs and symptoms of being frail: weakness, slowing, decreased energy, lower activity, and, when severe, unintended weight loss. It is linked to comorbid conditions and carries an elevated risk of catastrophic declines in health and function, including disability, hospitalization falls, fracture, and death It is most common in adults older than 70 years old and is increasingly common after age 80 years of age.

25. A grade I or II murmur, without radiation and of medium pitch, is a common variation found in: a. school-age children. b. older women. c. middle-aged men. d. sedentary individuals. e. older adults.

A Many murmurs, particularly in children, adolescents, and especially young athletes, have no apparent cause. These are generally grade I or II murmurs that are usually midsystolic and without radiation, are medium pitched, and are blowing, brief, and often accompanied by splitting of S2.

21. The carotid pulse should coincide with which heart sound? a. S1 b. S2 c. S3 d. S4 e. S3-4

A S1 marks the beginning of systole. S1 coincides with the rise (upswing) of the carotid pulse. Instruct patients to breathe normally and then hold their breath on expiration. Listen for S1 while you palpate the carotid pulse. S2 marks the start of diastole. S3-4 is an abnormal summation gallop sound.

5. Electrical activity recorded by the electrocardiogram (ECG) tracing that denotes the spread of the stimulus through the atria is the: a. P wave. b. PR interval. c. QRS complex. d. ST segment. e. T wave.

A The P wave represents the spread of a stimulus through the atria (atrial depolarization). The PR interval is the time from the initial stimulation of the atria to the initial stimulation of the ventricles, usually 0.12 to 0.20 second. The QRS complex is the spread of a stimulus through the ventricles (ventricular depolarization), less than 0.10 second. The ST segment and T wave are the return of stimulated ventricular muscle to a resting state (ventricular repolarization).

14. If the apical impulse is more vigorous than expected to the chest wall, it is called: a. a lift. b. a thrill. c. a bruit. d. a murmur. e. crepitus.

A The apical impulse is more vigorous than expected; it is referred to as a heave or lift. A thrill is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated sound that is caused by turbulent blood flow into, through, or out of the heart. Crepitus is air in the subcutaneous tissue from respirations.

3. Contraction of the ventricles causes: a. closure of the atrioventricular valves. b. closure of the pulmonic and aortic valves. c. opening of the mitral valve and closure of the tricuspid valve. d. opening of the mitral and tricuspid valves. e. opening of the auricular septa.

A When the ventricles contract, the semilunar, pulmonic, and aortic valves open, causing blood to rush into the pulmonary artery and the aorta. At this time, the tricuspid and mitral valves close, preventing backflow into the atria. When the atria contract, the tricuspid and mitral valves open, allowing blood flow into the ventricles. When the ventricles relax during diastole (ventricles are filling), the aortic and pulmonic valves close, preventing backflow into the ventricles.

Your patient has been diagnosed with pericarditis. Which are signs and symptoms, or a precipitating factor? (Select all that apply.) a. Sharp pain b. Pain relieved by sitting up c. Pain relieved by resting d. Friction rub heard to right of sternum e. History of kidney failure f. Result of viral infection g. Result of medications such as procainamide

ANS: A, B, E, F, G Pericarditis may be seen with a viral infection, kidney failure, or medications such as procainamide. Symptoms include pain relieved by sitting up or leaning forward. A friction rub is heard at the left of the sternum, at the third or fourth intercostal space.

Chest pain with an organic cause in a child is most likely the result of: a. cardiac disease. b. asthma. c. esophageal reflux. d. arthritis.

ANS: B Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. More likely, the case is related to trauma, exercise-induced asthma, or cocaine use.

Mr. O, age 50 years, comes for his annual health assessment, which is provided by his employer. During your initial history-taking interview, Mr. O mentions that he routinely engages in light exercise. At this time, you should: a. ask if he makes his own bed daily. b. have the patient describe his exercise. c. make a note that he walks each day. d. record "light exercise" in the history

ANS: B When Mr. O says that he engages in light exercise, have him describe his exercise. To qualify his use of the term light, ask him the type, length of time, frequency, and intensity of his activities

A condition that is likely to present with dizziness and syncope is: a. bacterial endocarditis. b. hypertension. c. sick sinus syndrome. d. pericarditis.

ANS: C Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart disease. SSS causes dysrhythmia with subsequent syncope, transient dizzy spells, light-headedness, seizures, palpitations, angina, or congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of neurologic dysfunction, and sudden onset of CHF. Chest pain is an initial symptom in acute pericarditis, along with a triphasic friction rub

A patient you are seeing in the emergency department for chest pain is believed to be having a myocardial infarction. During the health history interview of his family history, he relates that his father had died of "heart trouble." The most important follow-up question you should pose is which of the following? a. "Did your father have coronary bypass surgery?" b. "Did your father's father have heart trouble also?" c. "What were your father's usual dietary habits?" d. "What age was your father at the time of his death?"

ANS: D A family history of sudden death, particularly in young and middle-aged relatives, significantly increases one's chance of a similar occurrence.

Which of the following information belongs in the past medical history section related to heart and blood vessel assessment? a. Adolescent inguinal hernia b. Childhood mumps c. History of bee stings d. Previous unexplained fever

ANS: D Previous unexplained fever should be included in the past medical history of a heart and blood vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart valve damage.

4. The major heart sounds are normally created by: a. valves opening. b. valves closing. c. the rapid movement of blood. d. rubbing together of the cardiac walls. e. pulmonic veins.

B At the beginning of systole, ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed, which produces the first heart sound S1 "lubb." When the pressure in the ventricles falls, below that of the aorta and pulmonary artery, and when the ventricles are almost empty, the aortic and pulmonic valves close, producing the second heart sound S2 "dubb." Valve opening is usually a silent event.

11. Closure of the ductus arteriosus usually occurs: a. just before the initiation of labor. b. 24 to 48 hours after birth. c. after 7 days of life. d. between the second and third months of life. e. during the toddler stage.

B Closure of the ductus arteriosus usually occurs within 24 to 48 hours after birth.

19. Normal heart sounds are best heard: a. directly over the semilunar and bicuspid heart valves. b. over areas where blood flows after it passes through a valve. c. near the carotid vessels. d. over the central sternum. e. over the ribs.

B Normal heart sounds are best heard in areas where blood flows after it passes through a valve in the direction of blood flow.

22. You are listening to a patient's heart sounds in the aortic and pulmonic areas. The sound becomes asynchronous during inspiration. The prevalent heart sound to this area is most likely which of the following? a. S1 b. S2 c. S3 d. S4 e. S3-4

B S2 marks the closure of the semilunar valves, which indicates the end of systole, and is best heard in the aortic and pulmonic areas. It is higher pitched and shorter than S1. S2 typically splits during inspiration.

26. A split second heart sound is: a. abnormal. b. greatest at the peak of inspiration. c. heard best after forceful expiration. d. supposed to disappear with deep inspiration. e. always accompanied by a thrill.

B Splitting of S2 is an expected event because pressures are higher and depolarization occurs earlier on the left side of the heart. Ejection times on the right are longer, and the pulmonic valve closes a bit later than the aortic valve. Splitting of S2 is greatest at the peak of inspiration. During expiration, the split may disappear. It is never accompanied by a thrill.

23. During auscultation of heart tones, you are uncertain whether the sound you hear is an S2 split. You should ask the patient to inhale deeply while listening at the _____ area. a. aortic b. pulmonic c. tricuspid d. mitral e. apex

B Splitting results from the failure of the mitral and tricuspid valves or the pulmonic and aortic valves to close simultaneously. Splitting of S1 is usually not heard because the closing of the tricuspid valve is too faint. Rarely, it may be audible in the tricuspid area on deep inspiration. Splitting of S2 is greatest at the peak of inspiration and best heard at the pulmonic site.

9. The spread of the impulse through the ventricles (ventricular depolarization) is depicted on the ECG as the: a. P wave. b. QRS complex. c. PR interval. d. T wave. e. U wave.

B The QRS complex is the spread of a stimulus through the ventricles and is measured as less than 0.10 second. The P wave is the spread of a stimulus through the atria. The PR interval is the time from the initial stimulation of the atria to the initiation of stimulation of the ventricles. The T wave is the return of the stimulated ventricular muscle to a resting state. The U wave is a small deflection sometimes seen just after the T wave.

20. To hear diastolic heart sounds, you should ask patients to: a. lie on their backs. b. lie on their left sides. c. lie on their right sides. d. sit up and lean forward. e. lie prone.

B The left lateral recumbent position is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope. Sitting up and leaning forward is the best position to hear relatively high-pitched murmurs with the diaphragm of the stethoscope. The right lateral recumbent position is the best position for evaluating a right rotated heart of dextrocardia.

1. Heart position can vary depending on body habitus. In a short, stocky individual, you would expect the heart to be located: a. more to the right and hanging more vertically. b. more to the left and lying more horizontally. c. riding higher in the chest and pushed anteriorly. d. hanging lower in the chest and riding more vertically. e. more to the right and lying more horizontally.

B The position of the heart varies depending on body build, configuration of the chest, and level of the diaphragm. A tall, slender person's heart tends to hang vertically and is positioned centrally. A stocky, short person's heart tends to lie more to the left and more horizontally.

10. In a fetus, the right ventricle pumps blood through the: a. left atrium. b. ductus arteriosus. c. lungs. d. foramen ovale. e. septum primum.

B The right ventricle of a fetal heart pumps blood through the patent ductus arteriosus rather than into the lungs.

15. A palpable rushing vibration over the base of the heart at the second intercostal space is called a: a. heave. b. lift. c. thrill. d. thrust. e. murmur.

C A thrill is a fine, palpable, rushing vibration, or a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A thrust is a movement forward suddenly and forcibly. A murmur is an auscultated sound caused by turbulent blood flow.

16. An apical point of maximal impulse (PMI) palpated beyond the left fifth intercostal space may indicate: a. decreased cardiac output. b. dextrocardia. c. left ventricular hypertrophy. d. hyperventilation. e. obesity.

C An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large breasts, and muscularity can obscure the visibility of the apical impulse. In dextrocardia, the PMI would be displaced to the right.

6. A third heart sound is created by: a. atrial contraction. b. ventricular contraction. c. diastolic filling. d. regurgitation between the right and left ventricles. e. blood in the pericardium.

C Diastole is a relatively passive interval until ventricular filling is almost complete. Diastole occurs when the ventricle is filling with blood from the atria, and the filling sometimes produces a third heart sound S3.

30. The most helpful finding in determining left-sided heart failure is: a. dyspnea. b. orthopnea. c. jugular vein distention. d. an S4 heart sound. e. tachycardia.

C Evidence-based research has shown that the most helpful clinical examination finding supportive of left-sided heart failure is jugular vein distention. The other choices are not as reliable.

8. Purkinje fibers are located in the: a. sinoatrial node. b. atrioventricular node. c. myocardium. d. aortic arch. e. pericardium.

C The Purkinje fibers are located in the ventricular myocardium.

2. Which two heart structures are most anterior in the chest? a. Both atria b. Both ventricles c. The right atrium and ventricle d. The left atrium and ventricle e. Superior and inferior venae cavae

C The most anterior surface of the heart is formed by the right ventricle. The heart is turned ventrally on its axis, putting its right side more forward. The left atrium is above the left ventricle, forming the most posterior aspect of the heart. The superior and inferior venae cavae lie posteriorly.

24. The bell of the stethoscope placed at the apex is more useful than the diaphragm for hearing: a. the splitting of S2. b. high-pitched murmurs. c. presystolic gallops. d. systolic ejection sounds. e. pericardial friction rub.

C Using the bell of the stethoscope at the apex is more useful for low-pitched presystolic gallops. The patient should lie in the supine or left lateral recumbent position.

17. A lift along the left sternal border is most likely the result of: a. aortic stenosis. b. atrial septal defect. c. pulmonary hypertension. d. right ventricular hypertrophy. e. left ventricular hypertrophy.

D A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill indicates a disruption of the expected blood flow related to a defect in the closure of one of the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or atrial septal defect.

12. Which ECG change would not be expected as an age-related pattern? a. First-degree block b. Bundle branch block c. Left ventricular hypertrophy d. Ventricular fibrillation e. Atrial fibrillation

D Common ECG changes in older adults include first-degree atrioventricular block, bundle branch blocks, ST-T wave abnormalities, premature systole (atrial and ventricular), left anterior hemiblock, left ventricular hypertrophy, and atrial fibrillation.

29. Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the palms. These findings are consistent with the development of: a. rheumatic fever. b. cor pulmonale. c. pericarditis. d. endocarditis. e. cardiac tamponade.

D Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected with at-risk patients (e.g., IV drug abusers) who present with fever and a sudden onset of congestive heart symptoms. The lesions described are Janeway lesions.

28. Which dysrhythmia is a physiologic event during childhood? a. First-degree AV block b. Mobitz type II c. Multifocal PVCs d. Sinus dysrhythmia e. Third-degree AV block

D Sinus dysrhythmia is a physiologic event during childhood. The heart rate varies in a cyclic pattern, usually faster on inspiration and slower on expiration. The heart rates of children react with wider swings to stress, exercise, fever, or tension.

31. Chest pain that is intensified or provoked by movement, particularly twisting, is long lasting, and is often associated with focal tenderness is most likely: a. cardiac. b. pleural. c. esophageal. d. musculoskeletal. e. psychoneurotic.

D The description given is a classic example of musculoskeletal chest pain.

7. The "pacing" structure of the heart's electrical activity is the: a. atrioventricular (AV) node. b. bundle of His. c. Purkinje fibers. d. coronary sinus. e. sinoatrial (SA) node.

E An electrical impulse stimulates each myocardial contraction, and this impulse originates in and is paced by the SA node.

18. To estimate heart size by percussion, you should begin tapping at the: a. apex. b. left sternal border. c. midclavicular line. d. midsternal line. e. anterior axillary line.

E Estimating the size of the heart can be done by percussion. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border.

27. The earliest sign of heart failure in an infant is frequently: a. an apical impulse in the fourth intercostal space. b. moisture in the lungs. c. enlarged thyroid. d. clubbing of the fingers. e. liver enlargement.

E If heart failure is suspected, note that the infant's liver may enlarge before there is any suggestion of moisture in the lungs, and the left lobe of the liver may be more distinctly enlarged than the right. An apical impulse in the fourth intercostal space is a normal finding.

13. In an adult, the apical impulse should be most visible when the patient is in which position? a. Supine b. Leaning backward c. Lithotomy d. Right lateral recumbent e. Upright

E In most adults, the apical impulse should be visible at about the midclavicular line in the fifth left intercostal space, but is easily obscured by obesity, large breasts, or muscularity. The apical impulse may become visible only when the patient sits upright and the heart is brought closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests an intensity that may be the result of a problem.