Jarvis Ch 19
When would the nurse perform the abdominojugular test? 1 When the nurse suspects heart failure 2 When the nurse suspects premature ectopic beats 3 When the nurse suspects obstructive coronary artery disease 4 When the nurse distinguishes an innocent murmur from a pathologic murmur
If the venous pressure is elevated or if the nurse suspects heart failure, then the abdominojugular test should be performed. This test was formerly known as hepatojugular reflux. When performing the abdominojugular test, sustained venous distention is suggestive of right-sided heart failure. Premature ectopic beats are common, and these do not necessarily indicate any underlying heart disease. If there is any doubt, the nurse obtains an ECG recording for 1 minute. Sometimes, it may be supplemented by 24-hour ambulatory heart monitoring. A peripheral blood test on 23-gene expression may prove useful in diagnosing obstructive coronary artery disease (CAD) in at-risk patients; the abdominojugular test is not required. The nurse can distinguish innocent murmurs from pathologic ones by diagnostic tests such as electrocardiogram (ECG) or echocardiography.
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)
Impaired blood flow to the heart due to the presence of a clot in the artery may lead to a myocardial infarction in a patient. Aspirin (Ecotrin) helps to prevent the formation of blood clots, and therefore reduces the risk of a myocardial infarction. Ibuprofen (Advil) and diclofenac (Cambia) are nonsteroidal antiinflammatory medications, which help to reduce inflammation. Acetaminophen (Apra) helps to relieve mild to moderate pain associated with musculoskeletal complications.
Which sign would be present in a patient with atherosclerosis? 1 Low-pitched rumbling 2 Presence of bruit sound 3 Weak contraction of the ventricles 4 Unilateral distention of external jugular veins
Normally, a bruit is absent in a healthy patient. Atherosclerotic disease causes turbulence in the blood flow and results in a bruit sound. A low-pitched rumbling is a sign of mitral stenosis. Atherosclerosis would not weaken the walls of the ventricles. Weak contractions of the ventricles will occur in the patient with heart failure. Unilateral distention of the external jugular veins indicates an aneurysm.
While assessing the cardiac health of a middle-aged patient, which finding would the nurse consider abnormal? 1 Presence of apical impulse 2 Presence of a venous hum 3 Presence of jugular venous pulse 4 Presence of a third heart sound
Presence of a third heart sound In middle-aged adults, the third heart sound (S3) or ventricular gallop is usually abnormal. The S3 indicates decreased compliance of the ventricles, and it may be the earliest sign of heart failure. The normal apical impulse is the result of the heart rotating, moving forward, and striking against the chest wall during the systole. Lateral or inferior displacement of the apex beat usually indicates the enlargement of the heart. The filling level of the jugular veins help to estimate the blood pressure. The pulse rate measured at the jugular vein provides a source of information about the state of the right atrium. 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.
Which condition would cause a patient to have a diminished first heart sound of S1 due to more forceful atrial contractions? 1 Mitral stenosis 2 Atrial fibrillation 3 Severe hypertension 4 Right ventricular hypertrophy
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 due to 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 can be used to describe the pacemaker of the heart? 1 Lymph node 2 Ranvier's node 3 Sinoatrial node 4 Atrioventricular node
Sinoatrial node is another term used for the pacemaker of the heart. The automaticity of the heart enables it to contract by itself, independent of any signals or stimulation from the body. The heart contracts in response to an electrical current conveyed by a conduction system. Specialized cells in the sinoatrial node near the superior vena cava initiate an electrical impulse. The sinoatrial node triggers electrical impulses at regular intervals to cause the heart muscles to beat in an orderly sequence; hence, it is the pacemaker. The atrioventricular node is present in the auricular septum; it helps in the conduction of the cardiac impulse. Lymph nodes are oval-shaped organs of the lymphatic system which are spread throughout the body, including the armpits and the stomach, and are linked by the lymphatic vessels. Ranvier's nodes are the regular constrictions of the myelinated nerve fibers. At such locations, the myelin sheath is absent and the axon is enclosed only by Schwann cell processes.
A patient complains of sudden pain in the shoulder and the lateral region of the chest. The nurse finds that the patient has acute dyspnea and a cough. What conclusion could the nurse draw from these findings? 1 The patient has pericarditis. 2 The patient has cholecystitis. 3 The patient has a pneumothorax. 4 The patient has an esophageal spasm.
Sudden pain in the lateral region of the chest indicates that the patient has pneumothorax. It is also associated with referred shoulder pain, acute dyspnea, and cough. It is caused due to accumulation of air in the pleural space. Pericarditis is a cardiovascular disorder that is associated with a sudden, stabbing pain in the substernal region that radiates to the trapezius muscle, dry cough, and muscle and joint pain. Because the patient does not complain of pain in the substernal region and joints, the nurse would not suspect that the patient has pericarditis. Cholecystitis is a gastrointestinal disorder that is associated with pain in the right upper abdomen, nausea and vomiting, and anorexia. Esophageal spasm is associated with crushing pain in the substernal region and dysphagia.
The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings? 1 Pericarditis 2 Angina pectoris 3 Myocardial infarction 4 Pulmonary hypertension
Sudden pain in the substernal region that radiates to the trapezius muscle and is present in the upper back is a sign of pericarditis. Pericarditis refers to the inflammation of the pericardium. Fever, dry cough, and joint pains are subjective symptoms of pericarditis. The patient with angina pectoris feels pressure such as discomfort behind the sternum or in the retrosternal region. Nausea, vomiting, dyspnea, and diaphoresis are the subjective symptoms of angina pectoris. The patient with a myocardial infarction feels heaviness in the chest region. The pain associated with myocardial infarction does not radiate to the trapezius muscle. Nausea, vomiting, dizziness, palpitations, and dyspnea are the symptoms of myocardial infarction. The patient with pulmonary hypertension experiences pain in the chest region, and may have dyspnea, lower-extremity edema, and fatigue.
The nurse is caring for an infant who has frequent respiratory infections. While assessing the infant, the nurse hears a loud and harsh holosystolic murmur at the left lower sternal border. What should the nurse infer from these findings? 1 The infant has tetralogy of Fallot. 2 The infant has an atrial septal defect. 3 The infant has coarctation of the aorta. 4 The infant has a ventricular septal defect.
The infant has a ventricular septal defect. A ventricular septal defect refers to the presence of hole in the wall between the right and left ventricles of the heart. Pulmonary vascular resistance falls due to ventricular septal defect and results in frequent respiratory infections. A holosystolic murmur is common in the infant with a ventricular septal defect. Severe cyanosis and a systolic murmur are the signs of tetralogy of Fallot. Mild fatigue, dyspnea on exertion, and systolic murmur in the second left interspace are the symptoms of atrial septal defect. Lower extremity cramping, diminished femoral pulses, and systolic murmur are the signs and symptoms of the coarctation of the aorta.
A student nurse attends a lecture on the position of the heart. Which statement by the student nurse indicates effective learning? 1 "The position of the heart changes during pregnancy." 2 "The position of the heart is centered in dextrocardia." 3 "The position of the heart depends on the age of the patient." 4 "The position of the heart depends on the body build, chest configuration, and diaphragm level."
The position of the heart in an adult is different from that of an infant. The position of the heart in the chest is more horizontal in the infant than in the adult. The apex is higher, and is located at the fourth left intercostal space. It reaches the adult position when the child reaches the age of 7. In aging adults, the position rarely changes. However, the position of the heart is not dependent on the body build. If there is any anatomical change in the chest, configuration, or diaphragm, the position of the heart may change. The cardiovascular system adapts to ensure adequate blood supply to the uterus and the placenta during the pregnancy. This alteration is meant to deliver oxygen and nutrients to the fetus, and allows the mother to function normally during this altered state. Otherwise, the position of the heart is not altered during this stage. Dextrocardia is a rare anomaly in which the heart is located on the right side of the chest instead of the left side as normal
The parent of a child worries about the humming sound heard in the child's chest. After assessing the child, the nurse informs the parents that the child is healthy. Which finding does the nurse observe in the child to support this conclusion? 1 A soft blowing sound auscultated at the left lower sternal border 2 A soft, high-pitched sound auscultated in the third left interspace 3 A low-pitched diastolic rumble heard at the apex that does not radiate 4 A continuous, low-pitched, soft sound at the medial third of the clavicle
The presence of a continuous, low-pitched, soft sound at the medial third of the clavicle, especially on the right or over the upper anterior chest, indicates a venous hum. It occurs due to the turbulence of blood flow in the jugular venous system and is common in healthy children. The soft blowing sound at the left lower sternal border is the characteristic sign of tricuspid regurgitation. The presence of a soft, high-pitched sound at the third left intercostal space indicates aortic regurgitation. Mitral stenosis causes a low-pitched diastolic rumble that does not radiate.
Which heart sound occurs due to 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)
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 due to 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.
After assessing a patient with a cardiac disorder, the nurse determines that the patient has abnormally elevated pressure on the right side of the heart. Which observation would support this finding? 1 Pulmonary congestion 2 Pulmonary hypertension 3 Distended neck veins and abdomen 4 Systolic blood pressure higher than diastolic blood pressure
There are no valves between the vena cava and the right atrium or between the pulmonary veins and the left atrium. Therefore, when the pressure in the right side of the heart is abnormally high, the neck veins and the abdomen become distended. 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.
The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient? 1 Fifth interspace 2 Second left interspace 3 Second right interspace 4 Left lower sternal border
Tricuspid regurgitation occurs in the patient with incompetent tricuspid valve. The tricuspid valve is present near the left lower sternal border. Therefore, the nurse can feel a palpable thrill in the left lower sternal border of the patient with tricuspid regurgitation. The nurse feels a palpable thrill in the fifth interspace around the left midclavicular line of a patient with mitral stenosis. The nurse can feel a palpable thrill in the second left interspace in the patient with pulmonic stenosis. The second right interspace is the area of the aortic valve. Therefore, the palpable thrill occurs in this area in the patient with aortic stenosis.
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
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 due to the backward flow of blood to the vena cava. V wave occurs with passive atrial filling due to increase in pressure and volume in the right atria. X descent indicates atrial relaxation.
After conducting a cardiac examination, the nurse concludes that the patient has normal cardiopulmonary functioning. Which findings enabled the nurse to reach this conclusion? Select all that apply. 1 Absence of cardiac murmur 2 S2 is louder at the base of the heart 3 Presence of accentuated first heart sound (S1) 4 Presence of diminished second heart sound (S2) 5 Absence of equal and bilateral breath sounds
1, 2 While conducting a cardiac examination, the nurse should evaluate the heart sounds; this helps to determine the cardiac functioning. Cardiac murmur is caused by abnormal blood flow. Therefore, the absence of cardiac murmur indicates that the patient has intact cardiac valves. The first heart sound (S1) and second heart sound (S2) are heart sounds that are produced by the opening or closing of the heart valves; it is normal for S2 to be louder when auscultating at the base of the heart. The presence of a loud or accentuated S1 heart sound indicates a prolapsed mitral valve. A diminished S2 heart sound indicates that the patient may have aortic stenosis. The absence of bilateral breath sounds indicates that the patient may have a pulmonary disorder and is not a normal finding.
Which findings should the nurse observe in a patient with left ventricular hypertrophy? Select all that apply. 1 Visible apical heave 2 Change in heart location 3 Impalpable apical impulse 4 Diameter of the heart 3.5 cm 5 Higher jugular venous pressure
1, 4 Left ventricular hypertrophy is the thickening of the myocardium of the left ventricle. Apical heave occurs due to pressure loading in the left ventricular hypertrophy. Left ventricular hypertrophy will not increase the diameter of the heart, so a diameter of 3.5 cm is normal. Left ventricular hypertrophy does not cause dilation of the heart. Impalpable apical impulse is the sign of pulmonary emphysema. In heart failure, jugular venous pressure increases, the location of the heart changes because of enlargement, and the diameter of the heart increases more than 4 cm.
Which clinical findings does the nurse observe in the patient with mitral regurgitation? Select all that apply. 1 S1 is diminished. 2 S2 is accentuated. 3 Arterial pulse is diminished. 4 Apical impulse is heard lower. 5 Palpable thrill is heard during systole.
1,2 ,4 Mitral regurgitation is the condition in which the mitral valve does not close properly. Due to improper closure of mitral valve, the patient may have diminished S1 and accentuated S2. Apical impulse displaces down due to volume overload. Volume overload may not occur in the patient with mitral regurgitation. Diminished arterial pulse is a sign of tricuspid stenosis. A palpable thrill heard during systole is a sign of pulmonic stenosis.
After reviewing the medical history of a female patient, the nurse suspects that the patient is at risk for developing cardiovascular complications. Which findings led the nurse to this conclusion? Select all that apply. 1 LDL level of 150 mg/dL 2 Body mass index of 30 kg/m2 3 Total cholesterol of 240 mg/dL 4 Blood pressure of 120/80 mm Hg 5 Fasting blood glucose level of 90 mg/dL
1,2,3 High levels of low-density lipoprotein (LDL or "bad" cholesterol) slowly block arteries, which can result in myocardial infarction and stroke. LDL levels above 130 are considered high. A body mass index of greater than 25 kg/m2 indicates obesity in the patient. The obese patient is at high risk for developing heart disease. Total blood cholesterol is a measure of LDL cholesterol, HDL cholesterol, and other lipid components. It should be less than 200 mg/dL. Therefore, total cholesterol levels of 240 mg/dL indicate high risk for developing cardiovascular complications. A blood pressure of 120/80 mm Hg is a normal finding. The blood glucose level of 90 mg/dL is also a normal finding.
How would the nurse describe an innocent murmur? 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 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 extra 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 and 5 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.
The nurse is caring for a child who often has cyanotic episodes while crying. The nurse notices that the child uses the squatting posture during exertion. While assessing the child, the nurse finds that the sound A2 is louder than P2. Which complication would the nurse expect in the child? 1 Aortic stenosis 2 Tetralogy of Fallot 3 Pulmonic stenosis 4 Patent ductus arteriosus
2. Tetralogy of Fallot is a congenital heart condition in which four abnormalities occur together. These include right ventricular stenosis, right ventricular hypertrophy, ventricular septal defect, and overriding aorta. Tetralogy of Fallot causes mixing of oxygenated and deoxygenated blood in the left ventricle and reduces oxygenation of the tissues, which may result in cyanosis. The squatting position increases perfusion and helps to alleviate the effect of cyanosis. Increased pressure and blood volume in the atria may cause louder A2 than P2. Frequent cyanotic episodes may not occur in the patient with aortic stenosis, pulmonic stenosis, or patent ductus arteriosus. Fatigue, palpitation, dizziness, anginal pain, and loud, harsh, midsystolic murmur are the signs and symptoms of aortic stenosis. A thrill during systole between the second and third intercostal space, diminished S2,and a medium pitch systolic murmur may occur in the patient with pulmonic stenosis. A wide pulse pressure and a machinery murmur are the signs of patent ductus arteriosus.
The nurse instructs a student nurse to palpate the carotid artery of a patient. Which action made by the student nurse needs correction? 1 Having the patient sit during the exam 2 Palpating both carotid arteries at once 3 Refraining from excess vagal stimulation 4 Not compressing on the carotid sinuses
2. The nurse should palpate only one carotid artery at a time. Palpating both carotid arteries at the same time will compromise arterial blood supply to the brain. The nurse should instruct the patient to sit during carotid artery palpation because this position allows proper exposure of the neck. The nurse should refrain from excessive vagal stimulation and compression of the carotid sinuses because it slows the heart rate.
A patient reports pain and discomfort in the chest. After assessing the patient, the nurse determines that the pain is of pulmonary origin. Which characteristics in the patient enabled the nurse to make this conclusion? 1 Squeezing burning pain, dyspnea on exertion, and an intolerance to exercise 2 Sharp pain that does not radiate, dyspnea on exertion, along with diaphoresis 3 Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis 4 Sharp pleuritic pain that worsens with deep breathing along with tightness in the chest
3. When caring for a patient with chest pain, the first intervention of the nurse is to differentiate whether the chest pain is of cardiac, pulmonary, gastrointestinal, or musculoskeletal origin. A sharp stabbing pain in the chest worsens with deep breathing due to blockage in the pulmonary artery. Hemoptysis refers to the coughing of blood from the respiratory tract. These are the characteristics of a pulmonary embolism. A squeezing pain occurs due to the obstruction of coronary arteries and is a symptom of cardiac complications. A sharp pain that does not radiate, dyspnea on exertion, and diaphoresis may occur in the patient with mitral valve prolapse. Sharp pleuritic pain that worsens with deep breathing, chest tightness, and warmth at the site are the characteristics of costochondritis, which is a musculoskeletal complication. Due to inflammation of the costal cartilage, the patient may feel chest tightness.
While assessing a patient who has fever, cough, and myalgia, the nurse confirms that the patient has pneumonia. Which other symptom would the nurse expect to find in 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. Pneumonia is an inflammatory condition which may occur due to bacterial infection. The patient feels stabbing pain with a cough on one side of the chest due to inflammation 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.
What are chordae tendineae? 1 These are muscles that are attached to the ventricles. 2 These are tendons that hold the semilunar valves in alignment. 3 These are structures that separate the right and the left ventricles. 4 These are collagenous fibers that anchor the leaflets of the atrioventricular valves.
4. These are 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.
While examining a patient, the nurse detects a loud heart murmur with a palpable thrill. How does the nurse record this finding? 1 1/6 2 2/6 3 3/6 4 4/6
4/6 The nurse documents the loud murmur with a palpable thrill as a grade 4/6 murmur, according to the Levine scale. A grade 2/6 indicates a faint murmur, but it is clearly audible when placing the stethoscope on the patient's chest. The nurse records the readily audible murmur without a palpable thrill as a grade 3/6 murmur. The grade 1/6 indicates that the murmur is audible only in a quiet room.
While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient? 1 Accentuated S1 2 Fixed split S2 3 Pathologic S3 4 Pathologic S4
4Pathologic S4 Murmurs can be heard in the left intercostal space in the patient with pulmonic stenosis. 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 the diastole due to resistance of the ventricles to fill with blood. It commonly occurs in the presence of an enlarged right ventricle. Pathologic S3 occurs due to 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 due to the earlier closure of the aortic valves than the pulmonic valves. An accentuated S1 occurs with mitral stenosis.
What is the characteristic of the first heart sound in the patient who has a complete heart block? 1 Loud intensity 2 Faint intensity 3 Split intensity 4 Varied intensity
4Varied intensity 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. Due to 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.
After auscultating the precordium of a patient, the nurse suspects that the patient has pulmonic hypertension. Which finding would the nurse observe in the patient? 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
A lifting impulse occurs with right ventricular hypertrophy, as in pulmonic disease and pulmonic hypertension. This may be due to 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 thrill in the left intercostal spaces is palpable in the patient with pulmonic hypertension. A lateral displacement of apical impulse occurs with left ventricular hypertrophy.
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
A ventricular gallop occurs due to 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 is going through the electrocardiogram (ECG) report of a patient complaining of chest pain. Which section of the electrocardiograph indicates atrial depolarization? 1 T wave 2 P wave 3 QRS complex 4 ST segment
An electrocardiogram records the heart's electrical activity and helps the nurse to 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 the beginning to the 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.
While assessing a patient, the nurse finds elevated jugular venous pressure, ventricular gallop, and a pulse deficit. The diagnostic results of the patient indicate that the diameter of heart is 5 cm. Which complication does the nurse suspect in the patient? 1 Aneurysm 2 Heart failure 3 Cardiomyopathy 4 Left ventricular hypertrophy
An elevated jugular venous pressure, pulse deficit, and a heart diameter of greater than 4 cm indicate the patient has heart failure. A pathologic S3 (ventricular gallop) occurs due to decreased compliance of the ventricles in the patient with heart failure. Unilateral distention of the external jugular veins is the characteristic sign of aneurysm. The patient with an aneurysm will not have a pulse deficit and an enlarged heart. Cardiomyopathy is a chronic disease. The nurse would not find a pulse deficit in the patient with cardiomyopathy. The patient with left ventricular hypertrophy would not have a heart diameter greater than 4 cm.
The nurse is caring for a patient who reports pain in the right side of the abdomen and right shoulder. The patient reports that the pain is most severe after eating a fatty meal. What should the nurse infer from these findings? 1 The patient has pancreatitis. 2 The patient has cholecystitis. 3 The patient has esophageal spasms. 4 The patient has gastroesophageal reflux disease.
Cholecystitis is the inflammation of the gallbladder, which results in the 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 and 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.
While assessing a patient with cyanosis, the nurse hears a loud murmur that lasts throughout systole. A thrill is also palpable. Which classification best describes the murmur? 1 Grade 1 crescendo 2 Grade 3 holodiastolic 3 Grade 6 decrescendo 4 Grade 4 holosystolic
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 case of decrescendo, the murmur gradually decreases. The murmur is neither increasing nor decreasing gradually; hence, it is not a crescendo or a decrescendo murmur. Since the murmur is not heard during the diastolic phase of the heart, it is not a holodiastolic murmur.
