Sherpath Ch.20 Heart and Neck Vessels

How would the nurse document a loud heart murmur with a palpable thrill? 1/6 2/6 3/6 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. p. 475

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

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. p. 478

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

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.

The nurse auscultates a fixed split S 2, P 2 louder than A 2, and a medium-pitched systolic murmur, which is clearly heard in the second left interspace of the infant. The nurse is concerned about which condition? Calcification of the aortic valve Hypertrophy of the right ventricle Abnormal opening in the atrial septum Regurgitation of blood in the mitral valve

Abnormal opening in the atrial septum The presence of an abnormal opening in the atrial septum or atrial septal defect will increase blood flow through the pulmonic valve. This may lead to an earlier closure of the aortic valve than the pulmonic valve, resulting in a fixed split S2. The heart sound that occurs after the pulmonic valve closure, or P 2, is louder than A 2 because of the increased blood flow through the pulmonic valve. The infant with an atrial septal defect may have a medium-pitched systolic cardiac murmur. An infant who has a calcified aortic valve will have S 2 with paradoxical split, and a loud, harsh midsystolic murmur. In an infant with right ventricular hypertrophy, S 1 will be normal; A 2 will be louder than P 2, and the murmur that is heard during systole will be loud and crescendo/decrescendo. The nurse may find diminished S 1, accentuated S 2, and pansystolic murmur best heard at the apex in the infant with mitral regurgitation. p. 497

Which cardiac assessment findings are documented as normal? Select all that apply. Absence of cardiac murmur S 2 is louder at the base of the heart Accentuated first heart sound (S 1) Diminished second heart sound (S 2) Absence of equal and bilateral breath sounds Confident

Absence of cardiac murmur S 2 is louder at the base of the heart While conducting a cardiac examination, the nurse would evaluate the heart sounds; this helps 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 (S 1) and second heart sound (S 2) are heart sounds that are produced by the opening or closing of the heart valves; it is normal for S 2 to be louder when auscultating at the base of the heart. The presence of a loud or accentuated S 1 heart sound indicates a prolapsed mitral valve. A diminished S 2 heart sound indicates that the patient may have aortic stenosis. The absence of equal and bilateral breath sounds indicates that the patient may have a pulmonary disorder and is not a normal finding. p. 479

Which conditions may cause a pathologic S 3, or a ventricular gallop? Select all that apply. Anemia Pregnancy Hyperthyroidism Cardiomyopathy Pulmonary stenosis

Anemia Pregnancy 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 S 4, is present in the patient with cardiomyopathy or pulmonary stenosis. p. 475

Which findings are considered normal in a patient who is pregnant? Select all that apply. Apical impulse sits higher Increase in loudness of S 1 A slight left axis deviation Harsh holosystolic murmur Low-pitched diastolic rumble

Apical impulse sits higher Increase in loudness of S 1 A slight left axis deviation The pregnant patient will have an apical impulse that sits higher because of the presence of an elevated diaphragm. During pregnancy, the loudness of S 1 increases because of increased blood volume and cardiac workload. The pregnant patient's electrocardiogram shows a slight left axis deviation because of changes in the heart rate and cardiac output. A harsh holosystolic murmur occurs in the patient with a ventricular septal defect. A low-pitched diastolic rumble is the characteristic sign of mitral stenosis. p.z

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

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. p. 465

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

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.

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

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. p. 452

Which jugular pulse component reflects ventricular contraction? A wave C wave V wave X wave

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. p. 459

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? Pancreatitis Cholecystitis Esophageal spasms Gastroesophageal reflux disease

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.Test- p. 485

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

Closing of the mitral valve The first heart sound (S 1) occurs with the closure of the AV valves. This signals the beginning of systole. The mitral component of the first sound (M 1) slightly precedes the tricuspid component (T 1). However, the sounds of these two components are fused together as one sound. One can hear S 1 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 (S 2). 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 (S 3). p. 455

The adolescent patient reports lower-extremity cramping during exercise. The upper-extremity blood pressure is 130/74 mm Hg and the lower-extremity blood pressure is 108/62 mm Hg. The nurse also notices diminished femoral pulses in the patient. The nurse anticipates which diagnosis? Mitral stenosis Mitral regurgitation Coarctation of the aorta Patent ductus arteriosus

Coarctation of the aorta Coarctation of the aorta is a congenital condition that involves the severe narrowing of the descending aorta. This condition decreases the amount of blood flow to the lower extremities; therefore it decreases the blood pressure more in the lower extremities than in the upper extremities. The patient may have leg cramping during strenuous activities. Fatigue, palpitations, orthopnea, and a low-pitched diastolic rumble at the apex are the signs and symptoms of mitral stenosis. Fatigue, palpitations, orthopnea, and a loud, blowing pansystolic murmur at the apex are signs and symptoms of mitral regurgitation. A palpable thrill noted at the left upper sternal border, a widened pulse pressure, and a machinery murmur are the signs of patent ductus arteriosus. The patient with mitral stenosis, mitral regurgitation, or patent ductus arteriosus will not have decreased blood flow to the lower extremities. p. 495

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

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 S 3 heart sound has which condition? A stenotic heart valve Coronary artery disease Vigorous atrial contraction Decreased compliance of the ventricles

Decreased compliance of the ventricles S 3 is the third heart sound. It is also known as a ventricular gallop, or an S 3 gallop. In adults, S 3 is usually abnormal. The pathologic S 3 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 S 4 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. p. 491

Which statement is correct regarding the position of the heart? Changes during early pregnancy Centered in dextrocardia Depends on the age of the patient Depends on the body build, chest configuration, and diaphragm level

Depends on the age of the patient 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. p. 460

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

Diabetes mellitus Vitamin D deficiency 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. p. 465

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

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. p. 498

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

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. p. 452

The nurse auscultates a continuous soft, low-pitched sound at the medial third of the clavicle of a child. Which action by the nurse is appropriate? Document the venous hum and continue with the assessment. Assess for signs of carotid insufficiency caused by carotid bruit. Check upper and lower extremity blood pressures for signs of a coarctation of the aorta. Contact the provider to request an order for an echocardiogram to assess for atrial septal defect.

Document the venous hum and continue with the assessment. The presence of a continuous soft, low-pitched sound at the medial third of the clavicle, especially on the right or over the upper anterior chest, indicates a venous hum, which occurs because of the turbulence of blood flow in the jugular venous system and is common in healthy children. The appropriate action would be to document the venous hum and continue the assessment. A murmur above the clavicle indicates a carotid bruit. Coarctation of the aorta is associated with a systolic murmur heard at the left-sternal border that radiates to the back. A medium-pitch systolic ejection murmur is heard at the 2nd left intercostal space in atrial septal defect. p. 480

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

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. p. 452

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? Cholecystitis Pancreatitis Esophageal spasms Gastroesophageal reflux

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. p. 486

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

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. p. 471

Which type of murmur is considered to be innocent? Grade 2, midsystolic, musical Grade 1, protodiastolic, rumbling Grade 4, pansystolic, low-pitched Grade 3, holodiastolic, high-pitched

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. p. 475

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? Grade 1 crescendo Grade 3 holodiastolic Grade 6 decrescendo 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 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. p. 475

Which interventions would the nurse perform during a cardiac assessment? Select all that apply. Compress on the carotid artery. Have the patient sit during the carotid artery assessment. Put the patient in a supine position to assess the precordium. Maintain a warm room temperature. Assess the neck vessels first.

Have the patient sit during the carotid artery assessment. Put the patient in a supine position The nurse would ask the patient to sit during the carotid artery assessment because the seated position allows proper exposure of the neck. The nurse places the patient in the supine position while auscultating the precordium to obtain accurate jugular venous pressure. The nurse needs to maintain a warm room temperature during the cardiac assessment because a cold room may make the patient uncomfortable, and shivering interferes with auscultating heart sounds. The nurse would not compress the carotid artery during the assessment, because it can cause vagal stimulation, and the patient may develop bradycardia. The nurse would start observations from the periphery and move in toward the heart. Hence, the nurse would assess the pulse and blood pressure, not the neck, first. p. 467

The nurse instructs a student nurse to palpate the patient's carotid artery. Which action made by the student nurse needs correction? Having the patient sit during the examination Palpating both carotid arteries at once Refraining from excess vagal stimulation Not compressing the carotid sinuses

Having the patient sit during the examination The nurse would 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 would instruct the patient to sit during carotid artery palpation because this position allows proper exposure of the neck. The nurse would refrain from excessive vagal stimulation and compression of the carotid sinuses because it slows the heart rate. p. 467

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 the heart is 5 cm. Which complication would the nurse suspect in the patient? Aneurysm Heart failure Cardiomyopathy Left ventricular hypertrophy

Heart Failure An elevated jugular venous pressure, pulse deficit, and a heart diameter of greater than 4 cm indicate the patient has heart failure. A pathologic S 3 (ventricular gallop) occurs because of 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. p. 470

Suspicion of which condition prompts the nurse to perform the abdominojugular test? Heart failure Premature ectopic beats Obstructive coronary artery disease Pathologic murmur

Heart failure 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, but these do not necessarily indicate any underlying heart disease. If there is any doubt, the nurse obtains an electrocardiogram (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 in at-risk patients; the abdominojugular test is not required. The nurse can distinguish innocent murmurs from pathologic ones by diagnostic tests such as ECG or echocardiography. p. 477

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. LDL level of 150 mg/dL Body mass index of 30 kg/m 2 Total cholesterol of 240 mg/dL Blood pressure of 120/80 mm Hg Fasting blood glucose level of 90 mg/dL

LDL level of 150 mg/dL Body mass index of 30 kg/m 2 Total cholesterol of 240 mg/dL 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/m 2 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.

Where would the nurse observe the palpable thrill in the patient with an incompetent tricuspid valve? Second left interspace Second right interspace Left lower sternal border Fifth interspace at around the left midclavicular line

Left lower sternal border Tricuspid regurgitation occurs in the patient with incompetent tricuspid valve, which 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. p. 471

The patient is noted to have a visible apical impulse in the sixth left intercostal space lateral to the midclavicular line. On palpation, the nurse finds that the impulse is approximately 4 cm in diameter and is more forceful than usual. Which disorder would the nurse suspect? Right atrial enlargement Rheumatic heart disease Coronary artery disease Left ventricular dilation

Left ventricular dilation Left ventricular dilation (volume overload) displaces impulse down and to left and increases size more than one space. A diameter of greater than or equal to 4 cm is likely a dilated heart. Right atrial enlargement is a form of cardiomegaly, which can broadly be classified as either right atrial hypertrophy or dilation. It can be diagnosed by an electrocardiogram. Sometimes these disorders create a sound like a whooshing or swishing noise. Rheumatic heart disease describes a group of short-term and long-term heart disorders that can occur because of rheumatic fever. Damage to the heart valves is a common outcome of rheumatic fever. Symptoms of coronary artery disease include angina. In angina, a characteristic chest pain on exertion and decreased exercise tolerance occurs. p. 470

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

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. p. 452

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

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. p. 493

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

Occurs at the left lower sternal border S 3 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. p. 491

A patient with an enlarged left atrium reports fatigue and orthopnea. The nurse auscultates a low-pitched diastolic rumble when the patient is in the left lateral position. The nurse observes a palpable thrill at the apex. Which extra sound would the nurse expect to hear upon auscultating the heart? Opening snap Ejection click Summation sound Ventricular gallop Confident

Opening snap Fatigue and orthopnea are the subjective symptoms of mitral stenosis. The patient may have an enlarged left atrium caused by mitral stenosis. The nurse can hear a low-pitched diastolic rumble when the patient with mitral stenosis is in the left lateral position. The opening of the atrioventricular (AV) valves does not normally produce any sound. The patient with mitral stenosis requires high atrial pressure to open the AV valve; therefore this may result in an extra sound called the opening snap. The ejection click occurs just after S 2 in the patient with aortic stenosis or pulmonary stenosis. The summation sound refers to the superimposed sounds of S 3 and S 4. This may occur in the patient who has tachycardia. The patient with mitral stenosis may not have tachycardia. Ventricular gallop is a sign of heart failure or cardiac stress. p. 491

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

Opening snap 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 S 3 and S 4 sounds, and this occurs in mid-diastole. A pacemaker-induced sound occurs in late diastole. p. 491

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

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 statement describes a thrill? Palpable vibration in the chest Apical impulse Associated with a venous hum Sustained thrust of the ventricle of the heart Confident

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 heart sound would the nurse auscultate in the patient with pulmonic stenosis? Accentuated S 1 Fixed split S 2 Pathologic S 3 Pathologic S 4

Pathologic S 4 Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S 4, 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 S 3 occurs as a result of the backward flow of blood into the left atrium in the patient with mitral regurgitation. A fixed split S 2 occurs in the patient with atrial septal defect because of the earlier closure of the aortic valves than the pulmonic valves. An accentuated S 1 occurs with mitral stenosis. p. 492

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. Which condition is most consistent with these findings? Pericarditis Angina pectoris Myocardial infarction Pulmonary hypertension

Pericarditis 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 pain 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. p. 485

Which condition would the nurse suspect in the patient with acute dyspnea and cough who complains of pain in the shoulder and the lateral region of the chest? Pericarditis Cholecystitis Pneumothorax Esophageal spasm

Pneumothorax Sudden pain in the lateral region of the chest with referred shoulder pain, acute dyspnea, and cough indicates that the patient has a pneumothorax. It is caused by an 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. p. 485

Which assessment finding may be present in a patient with atherosclerosis? Low-pitched rumbling Presence of bruit sound Weak contraction of the ventricles Unilateral distention of external jugular veins

Presence of bruit sound 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. p. 468

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

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. p. 467

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

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. p. 479

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

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. p. 489

Which clinical findings would the nurse observe in the patient with mitral regurgitation? Select all that apply. S 1 is diminished. S 2 is accentuated. Arterial pulse is diminished. Apical impulse is observed lower. Palpable thrill is observed during diastole.

S 1 is diminished. S 2 is accentuated. Apical impulse is observed lower. Mitral regurgitation is the condition in which the mitral valve does not close properly. As a result of improper closure of mitral valve, the patient may have diminished S 1 and accentuated S 2. The apical impulse is observed lower than normal. A palpable thrill is observed during systole, not diastole. Diminished arterial pulse is a sign of tricuspid stenosis. p.497

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

Second heart sound (S 2) The second heart sound (S 2) occurs with the closure of the semilunar valves, and it indicates the end of systole. The first heart sound (S 1) occurs with the closure of the atrioventricular valves and indicates the beginning of systole. The third heart sound (S 3) occurs because of the filling of the ventricles with blood. The fourth heart sound (S 4) is heard at the end of diastole and occurs when the atria contract and push the blood into the noncompliant ventricle. p. 452

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

Septal defect Regurgitant valve 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. p. 452

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

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 S 1 sound. The patient with mitral stenosis has a diminished S 1 sound because of the presence of a calcified mitral valve. The nurse may find S 1 with an irregular rhythm in the patient with atrial fibrillation, but not a diminished S 1. The first heart sound will be normal in the patient with right ventricular hypertrophy.

Which description of pain by the patient indicates the pain is of pulmonary origin? Squeezing, burning pain with dyspnea on exertion and an intolerance to exercise Sharp pain that does not radiate, with dyspnea on exertion and diaphoresis Sharp, stabbing pain that worsens with deep breathing and a cough with hemoptysis Sharp pleuritic pain that worsens with deep breathing, along with tightness in the chest

Sharp, stabbing pain that worsens with deep breathing and a cough with hemoptysis A sharp, stabbing pain in the chest worsens with deep breathing because of 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 because of 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. Because of inflammation of the costal cartilage, the patient may feel chest tightness. p. 485

Which term is used to describe the pacemaker of the heart? Bundle of His Purkinje fibers Sinoatrial node Atrioventricular 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. p. 452

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

Sitting Supine 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.

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

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. p. 485

Which blood vessel drains the blood from the head and upper extremities? Pulmonary vein Inferior vena cava Superior vena cava Internal jugular vein

Superior Vena Cava The superior vena cava drains blood from the head and upper extremities and carries it to the right side of the heart. The pulmonary vein carries oxygenated blood from the lungs to the heart. The internal jugular vein drains blood from the head, but not from the upper extremities. The inferior vena cava carries deoxygenated blood from the lower extremities to the right side of the heart. p. 453

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 A 2 sound is louder than P 2. Which condition would the nurse suspect? Aortic stenosis Tetralogy of Fallot Pulmonic stenosis Patent ductus arteriosus

Tetralogy of Fallot Tetralogy of Fallot is a congenital heart condition in which four abnormalities occur together, including right ventricular stenosis, right ventricular hypertrophy, ventricular septal defect, and overriding aorta. Tetralogy of Fallot causes the 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 alleviate the effect of cyanosis. Increased pressure and blood volume in the atria may cause louder A 2 than P 2. 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 S 2, 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. p. 495

The presence of which finding in the cardiac assessment of a middle-aged patient would the nurse consider to be abnormal? Apical impulse Venous hum Jugular venous pulse Third heart sound

Third heart sound In middle-aged adults, the third heart sound (S 3), or ventricular gallop, is usually abnormal. The S 3 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 systole. Lateral or inferior displacement of the apex beat usually indicates the enlargement of the heart. The filling level of the jugular veins help 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. p. 481

During an assessment, the nurse finds that the liver and the jugular vein have become enlarged. A soft pansystolic heart murmur is best heard at the lower right and left sternal borders. Which disorder would the nurse suspect? Aortic stenosis Tricuspid stenosis Aortic regurgitation Tricuspid regurgitation

Tricuspid regurgitation In tricuspid regurgitation, backflow of the blood occurs through the incompetent tricuspid valve into the right atrium. This results in engorged pulsating jugular veins and an enlarged liver. A soft, blowing pansystolic heart murmur can be best heard at the right and the left lower sternal border. The murmur increases with inspiration. Calcification of the cusps of the aortic valve occurs in aortic stenosis. It restricts the forward flow of the blood during systole. In aortic regurgitation, a stream of blood regurgitates back through the incompetent aortic valve into the left ventricle during diastole. Left ventricle dilation and hypertrophy is caused by the increased stroke volume of the left ventricle. In tricuspid stenosis, calcification of the tricuspid valve impedes the forward flow of the blood into the right ventricle during diastole. p. 497

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

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 S 1 indicates that mitral and tricuspid components are heard separately. However, this does not occur in the patient who has complete heart block. p. 488

The nurse auscultates a loud and harsh holosystolic murmur at the left lower sternal border of an infant who suffers from frequent respiratory infections. The nurse anticipates further testing will indicate which defect? Tetralogy of Fallot Atrial septal defect Coarctation of the aorta Ventricular septal defect

Ventricular septal defect A ventricular septal defect refers to the presence of a hole in the wall between the right and left ventricles of the heart. Pulmonary vascular resistance falls because of 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. p. 494

Which findings would the nurse observe in a patient with left ventricular hypertrophy? Select all that apply. Visible apical heave Change in heart location Impalpable apical impulse Diameter of the heart 3.5 cm Higher jugular venous pressure Confident

Visible apical heave Diameter of the heart 3.5 cm Left ventricular hypertrophy is the thickening of the myocardium of the left ventricle. Apical heave occurs because of 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. p.479

Which component of the jugular venous pulse corresponds to the opening of the tricuspid valve? A wave V wave Y descent 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 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. p. 459