Chapter 19: Heart and Neck Vessels

33. 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.

38. 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.

1. 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 milliliters of serous pericardial fluid.

34. 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.

39. 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. Hispanic

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

10. 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.

30. 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.

41. 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.

16. 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.

28. 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.

20. 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.

15. 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.

25. 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.

2. 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.

6. 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."

27. 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.

11. 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.

40. 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.

42. 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.

35. 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.

5. 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).

9. 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.

13. 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.

29. 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.

19. 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 echocardiographicD examinations are much more accurate in detecting heart enlargement.

26. 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.

12. 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.

22. 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.

24. 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.

7. 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. SA node, AV node, bundle of His, bundle branches D. AV node, SA node, bundle of His, bundle branches

ANS: C 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.

36. The 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.

21. 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.

4. 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.

23. 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.

8. 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.

37. 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.

32. 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.

31. 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.

17. 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.

18. 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.

14. 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.

3. 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 theventricles

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 pre systole, or atrial systole, or sometimes the "atrial kick."