TWU Assessment Exam 2 Example Questions

During a cardiovascular assessment, the nurse knows that a "thrill" is: A) a vibration that is palpable. B) palpated in the right epigastric area. C) associated with ventricular hypertrophy. D) a murmur auscultated at the third intercostal space.

ANS: A A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur. Pages: 474-475

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? A) African-Americans B) Whites C) American Indians D) Hispanics

ANS: A According to the American Heart Association, the prevalence of hypertension is higher among African-Americans than in other racial groups. Page: 466

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A) Intraluminal valves ensure unidirectional flow toward the heart. B) Contracting skeletal muscles milk blood distally toward the veins. C) The high-pressure system of the heart helps to facilitate venous return. D) Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: A Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? A) This is the result of peripheral vasodilatation and is an expected change. B) Because of increased cardiac output, the blood pressure should be higher this time. C) This is not an expected finding because it would mean a decreased cardiac output. D) This would mean a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: A Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that. Page: 465

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: A) claudication. B) sore muscles. C) muscle cramps. D) venous insufficiency.

ANS: A Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct.

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? A) Tetralogy of Fallot B) Atrial septal defect C) Patent ductus arteriosus D) Ventricular septal defect

ANS: A Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; and (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; and (3) murmur is systolic, loud, crescendo-decrescendo. Page: 493

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: A) normal for this age. B) lower than expected. C) higher than expected, probably as a result of crying. D) higher than expected, reflecting persistent tachycardia.

ANS: A The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants. Page: 481

The sac that surrounds and protects the heart is called the: A) pericardium B) myocardium C) Endocardium D) pleural space

ANS: A the pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. it has two layers that contain a few militaries of serous pericardial fluid Page: 457

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence. C) fluid volume overload. D) ventricular hypertrophy.

ANS: B A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present. Page: 471

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): A) split S1. B) atrial gallop. C) diastolic murmur. D) summation sound.

ANS: B A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position. Page: 491

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? A) Woman in her second month of pregnancy B) Person who has been on bed rest for 4 days C) Person with a 30-year, 1 pack per day smoking history D) Elderly person taking anticoagulant medication

ANS: B At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.

ANS: B Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time. Pages: 475-476

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? A) Document the finding. B) Auscultate the site for a bruit. C) Check for calf pain. D) Check capillary refill in the toes.

ANS: B If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: A) palpate the artery in the upper one third of the neck. B) listen with the bell of the stethoscope to assess for bruits. C) palpate both arteries simultaneously to compare amplitude. D) instruct patient to take slow deep breaths during auscultation.

ANS: B If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. Pages: 471-472

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? A) Excessive swelling of the lymph nodes B) The presence of palpable lymph nodes C) No nodes palpable because of the immature immune system of a child D) Fewer numbers and a smaller size of lymph nodes compared with those of an adult

ANS: B Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: A) pain related to lymphatic abnormalities. B) problems related to arterial insufficiency. C) problems related to venous insufficiency. D) pain related to musculoskeletal abnormalities.

ANS: B Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

The nurse knows that normal splitting of the second heart sound is associated with: A) expiration. B) inspiration. C) exercise state. D) low resting heart rate

ANS: B Normal or physiologic splitting of the second heart sound is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve. Pages: 477-478

While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings? A) S3 is indicative of heart disease in children. B) These can all be normal findings in a child. C) These are indicative of congenital problems. D) The venous hum most likely indicates an aneurysm

ANS: B Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood. Page: 482

The direction of blood flow through the heart is best described by which of these? A) Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle B) Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle C) Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava D) Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle

ANS: B Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta. Page 458

The component of the conduction system referred to as the pacemaker of the heart is the: A) atrioventricular (AV) node. B) sinoatrial (SA) node. C) bundle of His. D) bundle branches.

ANS: B Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is the "pacemaker." Pages: 461-462

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: A) bell at the base with the patient leaning forward. B) bell at the apex with the patient in the left lateral position. C) diaphragm in the aortic area with the patient sitting. D) diaphragm in the pulmonic area with the patient supine.

ANS: B The S4 is a ventricular filling sound. It occurs when atria contract late in diastole. It is heard immediately before S1. This is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for it. It is heard best at the apex, with the person in the left lateral position. Page: 479

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? A) "Lymph flow is propelled by the contraction of the heart." B) "The flow of lymph is slow compared with that of the blood." C) "One of the functions of the lymph is to absorb lipids from the biliary tract." D) "Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream."

ANS: B The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? A) Hard and fixed cervical nodes B) Enlarged and tender inguinal nodes C) Bilateral enlargement of the popliteal nodes D) "Pellet-like" nodes in the supraclavicular region

ANS: B The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.

ANS: B The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

Which of these statements is true regarding the arterial system? A) Arteries are large-diameter vessels. B) The arterial system is a high-pressure system. C) The walls of arteries are thinner than those of veins. D) Arteries can expand greatly to accommodate a large blood volume increase

ANS: B The pumping heart makes the arterial system a high-pressure system.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? A) The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is working properly. B) The jugular veins will remain elevated as long as pressure on the abdomen is maintained. C) An impulse will be visible at the fourth or fifth intercostal space, at or inside the midclavicular line. D) The jugular veins will not be detected during this maneuver.

ANS: B When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing; however, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained. Page: 473

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? A) Increase in resting heart rate B) Increase in systolic blood pressure C) Decrease in diastolic blood pressure D) Increase in diastolic blood pressure

ANS: B With aging, there is an increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging. Pages: 465-466

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply. A) Ethnicity B) Abnormal lipids C) Smoking D) Gender E) Hypertension F) Diabetes G) Family history

ANS: B, C, E, F Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: A) heard at the onset of atrial diastole. B) usually a normal finding in the elderly. C) heard at the end of ventricular diastole. D) heard best over the second left intercostal space with the individual sitting upright.

ANS: C An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1. Pages: 461-462

Which of these statements describes the closure of the valves in a normal cardiac cycle? A) The aortic valve closes slightly before the tricuspid valve. B) The pulmonic valve closes slightly before the aortic valve. C) The tricuspid valve closes slightly later than the mitral valve. D) Both the tricuspid and pulmonic valves close at the same time.

ANS: C Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1). Page 460

When assessing a newborn infant who is 5 minutes old, the nurse knows that which of these statements would be true? A) The left ventricle is larger and weighs more than the right ventricle. B) The circulation of a newborn is identical to that of an adult. C) There is an opening in the atrial septum where blood can flow into the left side of the heart. D) The foramen ovale closes just minutes before birth and the ductus arteriosus closes immediately after.

ANS: C First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side. Pages: 464-465

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? A) Family history, hypertension, stress, age B) Personality type, high cholesterol, diabetes, smoking C) Smoking, hypertension, obesity, diabetes, high cholesterol D) Alcohol consumption, obesity, diabetes, stress, high cholesterol

ANS: C For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level. Pages: 468-469

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: A) increased cardiac output. B) another myocardial infarction. C) inflammation of the precordium. D) ventricular hypertrophy resulting from muscle damage.

ANS: C Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed. It is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall. Page: 491

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. A) venous obstruction of B) claudication due to venous abnormalities in C) ischemia caused by partial blockage of an artery supplying D) ischemia caused by complete blockage of an artery supplying

ANS: C Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? A) Ask the patient about a past history of frostbite. B) Suspect that the patient has a venous insufficiency problem. C) Consider this a delayed capillary refill time and investigate further. D) Consider this a normal capillary refill time that requires no further assessment.

ANS: C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? A) Percussion is a useful tool for outlining the heart's borders. B) Percussion is easier in obese patients. C) Studies show that percussed cardiac borders do not correlate well with the true cardiac border. D) Only expert health care providers should attempt percussion of the heart

ANS: C Numerous comparison studies have shown that the percussed cardiac border correlates "only moderately" with the true cardiac border. Percussion is of limited usefulness with the female breast tissue or in an obese person, or a person with a muscular chest wall. Chest x-rays or echocardiogram examinations are much more accurate in detecting heart enlargement. Pages: 474-475

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: A) right ventricular hypertrophy. B) increased volume and size of the heart as a result of pregnancy. C) displacement of the heart from elevation of the diaphragm. D) increased blood flow through the internal mammary artery.

ANS: C Palpation of the apical impulse is higher and more lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis. Page: 483

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: A) "When was your last electrocardiogram?" B) "It's probably because it's been so hot at night." C) "Do you have any history of problems with your heart?" D) "Have you had a recent sinus infection or upper respiratory infection?"

ANS: C Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air. Pages: 467-468

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: C Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

When listening to heart sounds, the nurse knows that S1: A) is louder than S2 at the base of the heart. B) indicates the beginning of diastole. C) coincides with the carotid artery pulse. D) is caused by closure of the semilunar valves.

ANS: C S1 coincides with the carotid artery pulse. S1 is the start of systole and is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. The nurse should feel the carotid artery pulse gently while auscultating at the apex; the sound heard as each pulse is felt is S1. Pages: 476-477

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? A) S3 when sitting up B) Persistent tachycardia above 150 C) Murmur at second left intercostal space when supine D) Palpable apical impulse in fifth left intercostal space lateral to midclavicular line

ANS: C Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction. Page: 479

he nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.

ANS: C The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle. Page: 473

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. A) ulnar B) radial C) brachial D) deep palmar

ANS: C The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique? A) While listening with the bell of the stethoscope, have the patient take a deep breath and hold it. B) While auscultating one side with the bell of the stethoscope, palpate the carotid artery on the other side to check pulsations. C) Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly. D) Firmly place the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly.

ANS: C The nurse should lightly apply the bell of the stethoscope over the carotid artery at three levels; while listening, the nurse should have the patient take a breath, exhale, and hold it briefly. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids. Examine only one carotid artery at a time to avoid compromising arterial blood flow to the brain. Avoid pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope. Pages: 471-472

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? A) Talk with the patient about his intake of caffeine. B) Perform an electrocardiogram after the examination. C) No further response is needed because this is normal. D) Refer the patient to a cardiologist for further testing.

ANS: C The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration. Pages: 476-477

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: A) mitral and tricuspid. B) tricuspid and aortic. C) aortic and pulmonic. D) mitral and pulmonic.

ANS: C The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart. Pages 460-461

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? A) Have the patient turn to the left side while the nurse listens with the bell. B) Ask the patient to hold his breath while the nurse listens again. C) No further assessment is needed because the nurse knows it is an S3. D) Watch the patient's respirations while listening for effect on the sound

ANS: D A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing. Pages: 477-478

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: A) "Venous insufficiency is a common problem after this type of surgery." B) "Oh, we have lots of veins—you won't even notice that it has been removed." C) "You will probably experience decreased circulation after the veins are removed." D) "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

ANS: D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: A) decreased fluid volume. B) increased cardiac output. C) narrowing of jugular veins. D) elevated pressure related to heart failure.

ANS: D Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure. Page: 473

During an assessment, the nurse notes that the patient's apical impulse is displaced laterally, and it is palpable over a wide area. This indicates: A) systemic hypertension. B) pulmonic hypertension. C) pressure overload, as in aortic stenosis. D) volume overload, as in mitral regurgitation.

ANS: D Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present. This is volume overload, as in mitral regurgitation, aortic regurgitation, or left-to-right shunts. Page: 492

During a cardiac assessment on a 38 year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? A) Fluid overload B) Atrial septal defect C) Myocardial infarction D) Heart failure

ANS: D Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after age 35. The S3 may be the earliest sign of heart failure. Pages: 471-472

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with: A) heart failure. B) aortic stenosis. C) pulmonary edema. D) mitral regurgitation.

ANS: D Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla. Page: 495

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: A) a normal heart. B) a systolic murmur. C) enlargement of the left ventricle. D) enlargement of the right ventricle.

ANS: D Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex. Pages: 473-474

The electrical stimulus of the cardiac cycle follows which sequence? A) AV node SA node bundle of His B) Bundle of His AV node SA node C) AV node SA node bundle of His bundle branches D) SA node AV node bundle of His bundle branches

ANS: D Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles. Pages: 461-462

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line

ANS: D The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line. Pages: 473-474

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe

ANS: D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? A) Assess the patient's abdomen, and notice any tenderness. B) Carefully assess the cervical lymph nodes, and check for any enlargement. C) Ask additional history questions regarding any recent ear infections or sore throats. D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

ANS: D The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

Which of these veins are responsible for most of the venous return in the arm? A) Deep B) Ulnar C) Subclavian D) Superficial

ANS: D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? A) The infant's sleeping position B) Sibling history of eating disorders C) Amount of background noise when eating D) Presence of dyspnea or diaphoresis when sucking

ANS: D To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again. Pages: 469-470

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick? A) The atria contract during systole and attempt to push against closed valves. B) The contraction of the atria at the beginning of diastole can be felt as a palpitation. C) This is the pressure exerted against the atria as the ventricles contract during systole. D) The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: D Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick." Pages 458-459

Briefly relate the route of a blood cell from the liver to tissue in the body.

Liver to right atrium via inferior vena cava, through tricuspid valve to right ventricle, through pulmonic valve to the pulmonary artery, picks up oxygen in the lungs, returns to left atrium, to left ventricle via mitral valve, through aortic valve to aorta, and out to the body.

List the major risk factors for heart disease and stroke in the text.

The major risk factors for heart disease and stroke are hypertension, smoking, high cholesterol levels, obesity, and diabetes. Physical inactivity, family history of heart disease, and age are other risk factors.

Endocardium

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

A function of the venous system is: a) to hold more blood when blood volume increases b) to conserve fluid and plasma proteins that leak out of the capillaries c) to form a major part of the immune system that defends the body against disease d) to absorb lipids from the intestinal tract.

a

A known risk factor for venous ulcer development is: a) obesity b) male gender c) history of hypertension d) daily aspirin therapy

a

Atrophic skin changes that occur with peripheral arterial insufficiency include: a) thin, shiny skin with loss of hair b) brown discoloration c) thick, leathery skin d) slow-healing blisters on the skin

a

During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should: a) proceed with the examination. It is often impossible to palpate this pulse. b) refer the patient to a vascular surgeon for further evaluation. c) schedule the patient for a venogram. d) schedule the patient for an ateriogram.

a

Select the statement that best differentiates a split S2 from S3. a) S3 is lower pitched and is heard at the apex. b) S2 is heard at the left lower sternal border. c) The timing of S2 varies with respirations. d) S3 is heard at the base; timing varies with respirations.

a

The examiner wishes to listen for a pericardial friction rub. Select the best method of listening. a) with the diaphragm, patient sitting up and leaning forward, breath held in expiration b) using the bell with the patient leaning forward c) at the base during normal respiration d) with the diaphragm, patient turned to the left side

a

When auscultating the heart, your first step is to: a) identify S1 and S2. b) listen for S3 and S4. c) listen for murmurs. d) identify all four sounds on the first round.

a

Fill in the following blanks: S1 is best heard at the ____ of the heart, whereas S2 is loudest at the ____ of the heart. S1 coincides with the pulse in the ______________ and coincides with the ___ wave if the patient is on an ECG monitor.

apex; base; carotid artery; R.

A pulse with an amplitude of 3+ would be considered: a) irregular, with 3 premature beats b) increased, full c) normal d) weak

b

Arteriosclerosis is the: a) deposition of fatty plaques on the intima of the arteries. b) loss of elasticity of the walls of blood vessels. c) loss of lymphatic tissue that occurs in the aging process. d) progressive enlargement of the intramuscular valf veins.

b

Atrial systole occurs: a) during ventricular systole. b) during ventricular diastole c) concurrently with ventricular systole d) independently of ventricular function.

b

Raynaud's phenomenon occurs: a) when the patient's extremities are exposed to heat and compression. b) in hands and feet as a result of exposure to cold, vibration, and stress. c) after removal of lymph nodes or damage to lymph nodes and channels. d) as a result of leg cramps due to excessive walking of climbing stairs.

b

Select the best description of the tricuspid valve. a) left semilunar valve b) right atrioventricular valve. c) left atrioventricular valve. d) right semilunar valve.

b

The examiner is palpating the apical impulse. The normal size of this impulse: a) is less than 1cm b) is about 2 cm c) is 3 cm d) varies depending on the size of the person

b

The examiner wishes to assess for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the leg, the color should return in: a) 5 seconds or less b) 10 seconds or less c) 15 seconds. d) 30 seconds.

b

The examiner wishes to listen in the pulmonic valve area. To do this, the stethoscope would be placed at the: a) second right interspace b) second left interspace c) left lower sternal border d) fifth interspace, left midclavicular line

b

When assessing the carotid artery, the examiner should palpate: a) bilaterally at the same time, while standing behind the patient. b) medial to the sternomastoid muscle, one side at a time. c) for a bruit while asking the patient to hold his or her breath briefly. d) for unilateral distention while turning the patient's head to one side.

b

You will hear a split S2 most clearly in what area? a) apical b) pulmonic c) tricuspid d) aortic

b

A murmur heard after S1 and before S2 is classified as: a) diastolic (possibly benign). b) diastolic (always pathologic). c) systolic (possibly benign). d) systolic (always pathologic).

c

Brawny edema is: a) acute in onset. b) soft. c) nonpitting. d) associated with diminished pulses.

c

Inspection of a person's right hand reveals a red, swollen area. To further assess for infection, you would palpate the: a) cervical node b) axillary node c) epitrochlear node d) inguinal node

c

Intermittent claudication is: a) muscular pain relieved by exercise b) neurologic pain relieved by exercise. c) muscular pain brought on by exercise d) neurologic pain brought on by exercise

c

Ms. T. has come for a prenatal visit. She complains of dependent edema, varicosities in the legs, and hemorrhoids. The best response is: a) "If these symptoms persist, we will perform an amniocentesis." b) "If these symptoms persist, we will discuss having you hospitalized." c) "The symptoms are caused by the pressure of the growing uterus on the veins. They are usual conditions of pregnancy." d) "At this time, the symptoms are a minor inconvenience. You should learn to accept them."

c

The function of the pulmonic valve is to: a) divide the left atrium and left ventricle. b) guard the opening between the right atrium and right ventricle. c) protect the orifice between the right ventricle and the pulmonary artery. d) guard the entrance to the aorta from the left ventricle.

c

The organs that aid the lymphatic system are: a) liver, lymph nodes, and stomach b) pancreas, small intestine, and thymus c) spleen, tonsils, and thymus d) pancreas, spleen, and tonsils

c

The precordium is: a) a synonym for the mediastinum. b) the area on the chest where the apical impulse is felt. c) the area on the anterior chest overlying the heart and great vessels. d) a synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart.

c

The stethoscope bell should be pressed lightly against the skin so that: a) chest hair doesn't stimulate crackles. b) high-pitched sounds can be heard better. c) it does not act as a diaphragm d) it does not interfere with amplification of heart sounds

c

A 54-year-old woman with five children has varicose veins of the lower extremities. Her most characteristic sign is: a) reduced arterial circulation b) blanching, deathlike appearance of the extremities on elevation c) loss of hair on feet and toes d) dilated, tortuous superficial bluish vessels.

d

The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal. a) patient elevated to 30 degrees, internal jugular vein pulsation at 1cm above sternal angle b) patient elevated to 30 degrees, internal jugular vein pulsation at 2cm above sternal angle c) patient elevated to 40 degrees, internal jugular vein pulsation at 1cm above sternal angle d) patient elevated to 45 degrees, internal jugular vein pulsation at 4cm above sternal angle

d

The second heart sound is the result of: a) opening of the mitral and tricuspid valves b) closing of the mitral and tricuspid valves c) opening of the aortic and pulmonic valves d) closing of the aortic and pulmonic valves.

d

To screen for deep vein thrombosis, you would: a) measure the circumference of the angle. b) check the temperature with the palm of the hand. c) compress the dorsalis pedis pulse, looking for blood return. d) measure the widest point with a tape measure.

d

While reviewing a medical record, a notation of 4+ edema of the right leg is noted. The best description of this type of edema is: a) mild pitting, no perceptible swelling of the leg. b) moderate pitting, indentation subsides rapidly. c) deep pitting, leg looks swollen. d) very deep pitting, indentation lasts a long time.

d

Pericardial fluid

ensures smooth, friction-free movement of the heart muscle

Ventricle

muscular pumping chamber

Myocardium

muscular wall of the heart

Atrium

reservoir for holding blood

Pericardium

tough, fibrous, double-walled sac that surrounds and protects the heart