Chapter 7 CARDIAC AND PERIPHERAL VASCULAR SYSTEMS / CHAPTER 9 CARDIO

The radiation of a mitral valve murmur is commonly heard in the: A.Carotid arteries B.Left mid-axillary line C.Base of the heart D.Left mid-clavicular line

ANS : B: A thorough cardiac examination is performed with the patient sitting, leaning forward, lying, and in the left lateral recumbent position. Some murmurs are heard better in different positions. Listen over the carotids for radiation of an aortic or pulmonic murmur, in the left mid-axillary line for radiation of a mitral murmur, and in the epigastric area for a bruit, indicating an aneurysm.

The most common cause of tricuspid regurgitation is: A.Left ventricular hypertrophy B.Left atrial enlargement C.Aortic stenosis D. Pulmonary hypertension

ANS : D: The murmur of tricuspid regurgitation is heard best at the left sternal border and may radiate to the right of the sternum. It is pansystolic, high pitched, and blowing and increases with respiration. Tricuspid regurgitation may be associated with right ventricular hypertrophy resulting in a right parasternal lift. When right ventricular failure occurs, jugular venous distention occurs with a prominent v wave, and liver enlargement may be present. There may be secondary right atrial enlargement owing to backflow into the right atrium. The most common initiator is pulmonary HTN.

In mitral stenosis, the murmur can be best heard with the patient in the: A. Squatting position B. Seated position C. Left lateral recumbent D. Supine position

ANS C: Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

Your patient has suffered an inferior wall myocardial infarction. This is most commonly due to an obstruction in the: A.Posterior branch of the right coronary artery B.Circumflex branch of the left coronary artery C.Right main coronary artery D.Left main coronary artery

ANS: A Blockage in the right coronary artery (RCA) results in damage to the posterior/inferior area of the heart. The left main coronary artery (LCA) branches off to the left anterior descending artery (LAD) and the left circumflex artery (LCX). A highly stenotic LCA or proximal LAD can cause significant heart damage and is often termed the ―widow maker.‖ Blockage in the LAD results in damage to the anterior portion of the heart. Blockage in the circumflex branch artery (CFX) results in damage to the posterior and lateral areas.

26. To hear a soft murmur or bruit, which of the following may be necessary? A) Asking the patient to hold her breath B) Asking the patient in the next bed to turn down the TV C) Checking your stethoscope for air leaks D) All of the above

Ans: D Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.

Pain associated with a dissecting thoracic aortic aneurysm is commonly described as: A.Retrosternal crushing and squeezing B.Chest stabbing and sharp C.Ripping and tearing in the chest or thoracic back D. Worse with inspiration

ANS: C Aortic aneurysms are often asymptomatic. However, in a dissecting aortic aneurysm , symptoms are often described as tearing or ripping in the chest, back, or abdomen.

20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure? A) 25% B) 50% C) 75% D) 100%

Ans: D Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease. Being "low risk" by JNC 7 criteria confers a 72%-85% reduction in CVD mortality and 40%-58% reduction in overall mortality.

Due to increased left atrial pressure, a patient with mitral stenosis often suffers from: A. Pulmonary congestion B. Hepatomegaly C. Jugular venous distension D. Ventricular tachycardia

ANS: A In mitral stenosis, the most common presenting symptoms are dyspnea on exertion and hemoptysis due to pulmonary congestion. The pulmonary congestion is caused by increased left atrial pressure related to the decrease in left atrial emptying. Crackles may be heard at the lung bases but are not present in all patients with pulmonary congestion. Orthopnea may be present because the lungs become more congested in the recumbent position. In addition, atrial fibrillation often develops in patients with mitral stenosis, which, in turn, worsens the pulmonary congestion.

Classically in mitral valve prolapse, the clinician can hear a(n) . A.Mid-systolic click followed by a grade I murmur that crescendos up to S2 B.Opening snap followed by a grade III holosystolic murmur C.Crescendo-decrescendo grade I diastolic murmur after S2 D. Rough grade III holosystolic murmur that obscures S1 and S2

ANS: A In mitral valve prolapse (MVP), a portion of the mitral valve flops open up into the left atrium, giving rise to a classic mid-systolic click followed by a soft grade I murmur that crescendos up to S2. It is high pitched and is heard best at the apex or left sternal border.

A 75-year-old patient complains of pain and paresthesias in the right foot that worsens with exercise and is relieved by rest. On physical examination you note pallor of the right foot, capillary refill of 4 seconds in the right foot, +1 dorsalis pedis pulse in the right foot, and +2 pulse in left foot. Which of the following is a likely cause of the signs and symptoms? A.Arterial insufficiency B.Femoral vein thrombus C.Venous insufficiency D.Peripheral neuropathy

ANS: A Intermittent claudication is pain in the leg or foot that becomes worse with exercise and is relieved by rest. The classic signs of peripheral arterial disease include pain, pallor, weak pulse, paresthesias, and palpable coolness. The signs of venous thrombosis are erythema, ropiness, as well as warmth and tenderness along the course of the vein. Edema of the leg and Homan's sign of the foot are also common.

Which of the following heart sounds is commonly heard after myocardial infarction? A.Friction rub B.S4 C.S3 D. Opening snap

ANS: A Opening snap is caused by the opening of a stenotic mitral or tricuspid valve and is heard early in diastole along the lower left sternal border. It is high pitched and heard best with the diaphragm of the stethoscope. Friction rubs occur frequently after a myocardial infarction (MI) or with pericarditis. The sound is a high-pitched grating, scratching sound—resulting from inflammation of the pericardial sac—that issues from the parietal and visceral surfaces of the inflamed pericardium as they rub together.

It is important for clinicians to recognize that individuals with often sustain silent myocardial infarction. A.Diabetes mellitus B.Hypertension C.Valvular disorders D. Congenital heart defects

ANS: A Pain sensitivity may be blunted in persons with diabetes. Peripheral and autonomic neuropathy is common in long-term diabetes. Individuals with diabetes often suffer infection or other disorders without sensing the pain and sustain complications without warning.

Aortic regurgitation occurs after S2 during the left ventricle after the aortic valve closes. A.Early diastole B.Late diastole C.Early systole D.Mid-systole because there is turbulent flow that refluxes into

ANS: A The aortic valve closes creating S2. After the aortic valve closes, in aortic regurgitation, some blood flows back into the left ventricle. S1 through S2 is the systolic time frame. S2 through S1 is the diastolic time frame. The sound of a leaky aortic valve would be heard after the aortic valve closes (S2) during early diastole.

Your patient has a dysrhythmia and has been on a diuretic for 2 months. Which of the following should be suspected? A.Potassium imbalance B.Sodium deficit C.Calcium imbalance D. Insufficient diuretic

ANS: A The most common electrolyte disturbance in patients on diuretics is hypokalemia. Hypokalemia is a common cause of cardiac rhythm disturbance.

From Erb's point, all the heart valves can be heard equally. Erb's point is located over the: Third intercostal space left sternal border Fifth intercostal space right sternal border Fourth intercostal space left sternal border Third intercostal space right sternal border

ANS: A The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erb's point is where all valves can be heard equally well. Erb's point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the mid- clavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

The pulmonary valve is best heard over the: A.left second intercostal space left sternal border B.left fifth intercostal space mid-clavicular line C.right fourth intercostal space right sternal border D.right second intercostal space right sternal border

ANS: A The valves are best heard over the chest at specific areas. The aortic valve is best heard over the second intercostal space right sternal border and the pulmonic valve is best heard over the second intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space mid-clavicular line.

Xanthelasma is a skin condition that should alert the clinician to in a patient. A.Familial hyperlipidemia B.Type 2 diabetes C.Congenital heart disease D. Peripheral arterial disease

ANS: A When conducting the inspection part of a physical examination, inspect the skin around the eyes for xanthelasma. Xanthelasma is a skin condition that occurs in familial hyperlipidemia that causes high cholesterol levels and early cardiovascular disease in patients. Small, yellow fatty deposits are located around the eyes.

The pain of costochondritis typically . A.Mimics cardiac crushing and squeezing pain B.Worsens with movement and full inspiration C.Radiates from epigastrium into the back D. Is a tearing and ripping pain

ANS: B Costochondritis, which is inflammatory pain of the chest wall, can often be differentiated from cardiac pain through history. A history of injury, heavy lifting, contact sports, excessive coughing, or late-stage pregnancy (which stretches the intercostal muscles) leads the examiner to consider chest wall pain. This often occurs in a younger population with no cardiac risk factors. One of the most helpful differentiating symptoms is that the pain is increased with movement, cough, or, in some cases, respiration.

Which is the most specific and sensitive test for validating a myocardial infarction? A.12-lead EKG B.Troponin C.CK-MB D. CT scan

ANS: B Diagnostic studies of myocardial infarction include: • CK-MB—The serum level of CK-MB is elevated above normal in the first few hours after MI and returns to normal within 72 hours. The levels can also be elevated following trauma or with progressive muscular dystrophy.• Troponin—An inhibitory protein found in muscle fibers, troponin is elevated within 4 hours of an MI and stays elevated for 7 to 10 days. It is more sensitive and specific than creatine kinase for cardiac muscle but may be falsely elevated in patients with kidney dysfunction.• 12-lead EKG—The practitioner should look for signs of acute ischemia, such as ST-segment elevation or depression, arrhythmias, and conduction delays. An EKG is minimally helpful in diagnosing pericarditis except in the case of cardiac tamponade or constrictive pericarditis where decreased amplitude may be seen.• Imaging—Studies such as computed tomography (CT) scan, electron beam computed tomography (EBCT) scan, positron emission tomography (PET) scan, magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT) scan can assist in diagnosing CAD, aortic aneurysms, cardiac masses, myocardial disease, and pericardial disease.

The best diagnostic test that allows analysis of a heart murmur is: A.CT scan B.Echocardiogram C.MRI D. ECG

ANS: B Echocardiography is the best diagnostic test for assessing a heart murmur. In addition to visualizing the diseased valve, echocardiography can assist in determining the size of the heart chambers involved in the heart murmur in real time.

Which of the following blood pressure measurements is categorized as prehypertension? A. 110/78 B. 129/85 C. 142/80 D. 145/92

ANS: B Ideal blood pressure is less than 120/80, pre-hypertension is regarded as 120 to 139 systolic / 80 to 89, and hypertension is greater than or equal to 140/90.

In aortic stenosis, the patient's point of maximal impulse is commonly located at the: A. Fifth intercostal space mid-clavicular line B. Fifth intercostal space mid-axillary line C. Second intercostal space left sternal border D. Second intercostal space right sternal border

ANS: B In aortic stenosis, the left ventricle has to work against high resistance and eventually, left ventricular hypertrophy (LVH) develops. The LVH causes an enlarged left ventricle, and the point of maximal impulse located at the fifth intercostal space moves leftward toward the mid-axillary line.

When an examiner presses on the liver and elicits hepato-jugular reflux, which of the following conditions is likely? A.Left ventricular failure B.Right ventricular failure C.Hepatomegaly D. Pulmonary edema

ANS: B In right ventricular failure, the abdomen should be examined particularly for right upper quadrant discomfort related to hepatic congestion and enlargement. The examiner can also check for hepatic jugular reflux by placing sustained pressure on the liver while observing for jugular venous distention. In right HF, ascites may also be present. Examine the extremities for edema seen in right HF.

In mitral stenosis, the murmur occurs: A. From S1 through S2 as a holosystolic murmur B. After an opening snap that is heard after S2 during diastole C. As a soft mid-systolic click D. A loud crescendo-decrescendo systolic murmur

ANS: B Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

After multiple pregnancies, the following vascular disorder is common: A.Deep venous thrombosis B.Varicose veins C.Peripheral arterial disease D.Aortic aneurysm

ANS: B Often a precursor to chronic venous insufficiency, varicose veins are usually caused by occupations that involve prolonged standing or sitting in one place, overweight, pregnancy, or a familial tendency. They may increase the patient's risk for DVT, or they may occur secondary to a DVT. Blockage to lymphatic flow can cause varicosities as seen with pelvic neoplasm. They appear as long, dilated, tortuous veins in the lower extremities.

An S3 gallop is commonly heard in: A. Children with fever B. Adults with heart failure C. Children with aortic stenosis D. Adults with hypertension

ANS: B Pathologic S3, also called a ventricular gallop, is heard in adults and is associated with decreased myocardial contractility, HF, and volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiologic S3 and is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft and can be difficult to hear.

Your 47-year-old female patient has a waist to hip ratio of 1. In terms of cardiovascular disease risk, this is considered: A.Ideal B.Greater than acceptable limits C.Less than acceptable limits D. Within acceptable limits

ANS: B The physical examination includes measurement of height and weight to calculate body mass index (BMI). The formula for calculating BMI is wt(kg)/ht(m2). A waist/hip ratio is also an indicator for risk of heart disease. A ratio greater than 0.85 for women and greater than 0.95 for men is considered to place individuals at increased risk, especially if accompanied by hyperinsulinemia or diabetes. These are part of a constellation of symptoms termed metabolic syndrome that indicates the greatest risk for the development of heart disease.

Upon inspecting the patient, you find jugular venous distension. This is a sign of: A. Left ventricular hypertrophy B. Right ventricular failure C. Hypertension D. Valve disease

ANS: B In right ventricular failure, hydrostatic pressure builds up back into the right atrium and superior as well as inferior vena cava. Venous congestion occurs throughout the body. A sign of venous congestion of the superior vena cava is jugular vein distension. Signs of right ventricular failure include jugular venous distension, ascites, hepatomegaly, splenomegaly, and ankle edema

The first heart sound (S1) occurs because of the closure of the: A)Aortic and mitral valves B)Mitral and tricuspid valves C)Pulmonic valve D)Aortic valve

ANS: BS1 is the closing of the mitral valve and with the tricuspid (T1) valve; together they are known as the atrioventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

The medical record of your patient lists a grade III systolic murmur. This indicates the patient has a heart murmur that is: A.Soft and after S2 B.Loud and crescendo in quality C.Moderately loud and after S1 D.Loud and after S2

ANS: C A grade III murmur is moderately loud and a systolic murmur immediately follows S1.

A pulse rate of 56 beats per minute can be normal in: A. Elderly patients B. Newborns C. Athletic individuals D. Hypertensive patients

ANS: C Athletic individuals commonly have a low pulse rate because their heart is well-conditioned and physiologically more efficient. A strong heart has physiologically enlarged muscle chambers which contract slowly and efficiently deliver an adequate blood volume to the body with each contraction. In an elderly or untrained individual, bradycardia is more concerning. Although normal aging includes a decrease in SA node and AV node conduction, thus increasing the likelihood of bradycardia, sinus node pathology and heart blocks should be suspected in the elderly. Newborns have a normal pulse rate of 120 beats per minute. If the patient has hypertension, this does not decrease the heart rate

Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms? A.Femoral vein thrombosis B.Femoral artery thrombus C.Venous insufficiency D.Musculoskeletal injury

ANS: C Chronic venous insufficiency can be a long-term complication of venous thrombosis, owing to the destruction of valves in the deep veins. The calf muscle pump that returns blood from the lower legs is damaged, increasing ambulatory pressure in the calf veins. A constellation of symptoms is set up: aching or pain in the lower legs, edema, thinning and hyperpigmentation of the skin, superficial varicosities, venous stasis, and ulceration. Ankle edema is often the earliest sign.

To distinguish a physiologic split S2 heart sound, it is best to listen with the stethoscope at: A. Left fifth intercostal space midclavicular line B. Fourth intercostal space left sternal border with patient holding his or her breath C. Second intercostal space left sternal border with inspiration D. Fourth intercostal space right sternal border with expiration

ANS: C Normally, the S1 and S2 occur as single sounds. In some conditions, these sounds may be split and occur as two sounds. In healthy young adults, a physiologic split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and therefore increased stroke volume of the right ventricle, which can delay closure of the pulmonic valve, causing the second heart sound to be split. This physiologic split differs from other splits that are pathologic in origin in that it occurs with inspiration and disappears with expiration.

Your patient complains of worsening ankle edema and weight gain over the last week. On physical examination, you note jugular venous distension, ascites, hepatomegaly, and splenomegaly. These conditions are indicative of: A.Left ventricular failure B.Pulmonary embolism C. Right ventricular failure D. Myocardial infarction

ANS: C Right ventricular failure is characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with sudden shortness of breath and tachycardia. Left ventricular failure is characterized by dyspnea on exertion, cough, fatigue, orthopnea, PND, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Myocardial infarction presents with crushing retrosternal chest pain, pallor, dyspnea, and diaphoresis.

The second heart sound (S2) occurs because of the closure of the: A.Aortic valve B.Tricuspid valve C.Aortic and pulmonic valve D. AandB

ANS: C S1 is the closing of the mitral valve and with the tricuspid (T1) valve; together they are known as the atrioventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

An S4 sound is commonly heard in: A. Children with fever B. Adults with atrial fibrillation C. Adults with hypertension D. Children with pulmonic stenosis

ANS: C S4, also called an atrial gallop, occasionally occurs in a normal adult or well-trained athlete but is usually due to increased resistance to filling of the ventricle. Possible causes of a left-sided S4 include HTN, CVD, cardiomyopathy, and aortic stenosis. Possible causes of a right-sided S4 include pulmonic stenosis and pulmonary HTN. S4 is heard just before S1 with the patient supine or in the left lateral recumbent position. The sound can be as loud as S1 and S2. S4 is not heard in patients with chronic atrial fibrillation due to no distinct atrial kick.

A patient with hypertension who has hyperlipidemia should aim for LDL measurement to be: A. 130 mg/dL or less B. 40 mg/dL or less C. 100 mg/dL or less D. 60mg/dL or less

ANS: C The aim for primary prevention is to keep LDL levels below 130 mg/dL and HDL levels above 40 mg/dL. Although primary prevention lowers a person's risk of heart disease and MI, it has shown only small, if any, effect on all-cause mortality. In patients with known CVD or diabetes, the target cholesterol levels are more stringent, aiming for an LDL level below 100 mg/dL and an HDL level above 60 mg/dL.

When palpating the chest, you find the point of maximal impulse (PMI) in the left mid-axillary region. This can be indicative of: A.Normal PMI B.Congenital heart disease C.Ventricular hypertrophy D. Hypertension

ANS: C The examiner should palpate the point of maximal impulse (PMI) and the precordium for heaves or lifts, seen in ventricular hypertrophy. The apical impulse is easily observed in the pediatric client but not always visible in the adult. An accentuated or displaced apical impulse may indicate ventricular hypertrophy.

The pain of pancreatitis is described as: A.Abdominal sharp and piercing pain in the left upper quadrant B.Dull and cramping pain in the right upper quadrant C.Severe, epigastric pain radiating straight into the back D.Sharp pain radiating to the shoulder

ANS: C The pain of pancreatitis is severe, steady, and ―boring‖—radiating from the epigastric region through to the back. It is often accompanied by nausea and vomiting, tachycardia, hypotension, and diaphoresis. These symptoms are also seen in MI; however, the exquisite abdominal tenderness present in pancreatitis assists in differentiating it from cardiac pain.

Which of the following is the most important question to ask during cardiovascular health history? A.Number of offspring B.Last physical examination C.Sudden death of a family member D. Use of caffeine

ANS: C The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke.

The tricuspid valve is best heard over the: A.Third intercostal space left sternal border B.Fifth intercostal space right sternal border C.Fourth intercostal space left sternal border D.Third intercostal space right sternal border

ANS: C The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erb's point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the mid-clavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

The murmur of a ventricular septal defect (VSD) occurs when the ventricle contracts and blood flows from the left ventricle into the right ventricle. This creates a heart murmur. A.Holodiastolic B.Early diastolic C.Holosystolic D.Late systolic

ANS: C Ventricular septal defect (VSD) is a congenital heart defect in which oxygenated blood is shunted from a higher-pressured left ventricle to a lower-pressured right ventricle through an abnormal opening in the ventricular septum. This left-to-right shunt causes an increased blood flow across the pulmonic valve. The signs and symptoms depend on the size of the defect and the age of the patient. A VSD murmur occurs after the mitral valve closes (S1). Characteristic of a VSD is a loud, harsh, pansystolic murmur at the lower left sternal border, usually accompanied by a thrill.

The target body mass index for women is: A.27 kg/m2 B.25 kg/m2 C.22 kg/m2 D. 16 kg/m2

ANS: C Weight loss through diet and exercise has been found to be the most important factor in the prevention of the progression of metabolic syndrome. Insulin sensitivity increases with weight loss and is thought to be due to the loss of visceral fat. The target BMI is less than 22 kg/m2 for women and less than 27 kg/m2 for men. BMI of 16 kg/m2 is considered too low.

On an electrocardiogram (ECG), an anterior wall myocardial infarction is demonstrated on leads: A.II, III, AVR B.II, III, AVF C. V1, V2, V3, V4 D. I, AVL, V5, V6

ANS: C With angina and MI, acute ischemic changes may be seen on the 12-lead EKG. Each lead reflects an area of the heart, and an EKG can determine the location of the ischemia. The lateral wall of the heart is reflected in leads I, aVL, V5, and V6. The inferior wall is reflected in leads II, III, and a VF. The anterior wall is reflected in leads V1, V2, V3, and V4. The posterior wall is reflected in leads V1, V2, and V3. With ischemia, an EKG changes need to occur in two contiguous leads. Reciprocal EKG changes can be seen in the area of the heart opposite the injured area.

The pain associated with pericarditis is . A.Crushing and squeezing B.Constant C.Worse with inspiration D. Only present with fever

ANS: C Unlike the symptoms associated with ACS, the pain associated with pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise.

Cardiac chest pain is most often described as: A.Stabbing, piercing pain B.Pain with inhalation C.Crushing, squeezing pain D. Burning, gnawing pain

ANS: CTypical characteristics that indicate acute coronary syndrome (ACS) include crushing, squeezing substernal chest pain with radiation to the neck or left arm, a score of greater than 7 on the pain scale, an association with exertion or stress with relief on rest, a duration of minutes, and associated symptoms of nausea, diaphoresis, weakness, or shortness of breath.

On an electrocardiogram, you see a deepened Q wave that is greater than one-third the height of the QRS complex. This is indicative of: A.Acute myocardial infarction B.Acute myocardial ischemia C.Left ventricular hypertrophy D. Past myocardial infarction

ANS: D A pathologic Q wave, indicative of a past myocardial infarction, measures greater than 0.04 seconds and is greater than one-third the height of the QRS complex.

Upon examination of a child, an innocent systolic murmur is heard at the second intercostal space left sternal border. This is usually due to: A. Atrial septal defect B. Patent foramen ovale C. Low flow velocity D. High flow turbulence

ANS: D An innocent murmur is a type of systolic murmur that results from turbulent blood flow and is not associated with heart disease. Innocent murmurs occur commonly in children and young adults and reflect the contractile force of the heart, resulting in greater velocity of flow during early systole. They are heard best in the second and third left interspaces along the left sternal border or at the apex.

The murmur of aortic stenosis is best heard in the: A.Left second intercostal space left sternal border B.Left fifth intercostal space mid-clavicular line C.Right fourth intercostal space right sternal border D.Right second intercostal space right sternal border

ANS: D Aortic stenosis is heard best in the second right intercostal space with the client leaning forward. The murmur is harsh, loud, and often associated with a thrill. It may radiate to the neck, left sternal border, and, in some cases, to the apex.

A 23-year-old patient presents the emergency department with high fever, chills, extreme fatigue, and arthralgias. Your physical examination reveals grade II heart murmur heard loudest over the fourth intercostal space left sternal border. The arms of the patient reveal past intravenous drug abuse. The clinician should recognize these are signs and symptoms of: A.Pulmonary embolism B.Right ventricular failure C.Functional heart murmur D.Bacterial endocarditis

ANS: D Bacterial endocarditis is a microbial infection of the endocardium. The most common causative organisms are Staphylococcus aureus, group A streptococcus, pneumococcus, and gonococcus. Risk factors include valvular disease, intravenous drug use, dental disease, and invasive diagnostic procedures. Initially, the signs and symptoms are similar to those of other systemic illnesses, including fever, chills, arthralgias, malaise, and fatigue. Petechiae, anemia, weight loss, new or worsening heart murmur, and emboli alert the examiner to a more serious disease process.

Cardiovascular disease risk increase in women after age: A. 30 B. 40 C. 45 D. 55

ANS: D In men, cardiovascular risk increases after age 45; however, in women, the risk of cardiovascular disease increased after age 55. Estrogen is cardioprotective and so women are at highest risk for cardiovascular disease after menopause. The average age of natural menopause for women is age 55.

The pain of can frequently be mistaken for cardiac chest pain. A.Gastroesophageal reflux disease (GERD) B.Peptic ulcer disease (PUD) C.Cholecystitis D.All of the above

ANS: D It is often difficult to differentiate the symptoms of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD) from cardiac symptoms. A thorough history and diagnostic tests are necessary. Patients with a history of GERD or PUD should still be worked up for a cardiac etiology, particularly if the characteristics of the symptoms or the history have changed to raise the index of suspicion for cardiac disease. The pain of cholecystitis, also sometimes mistaken for cardiac pain, typically presents with right upper quadrant pain with radiation to the thoracic region of the back.

Your patient has had hypertension for 10 years, a myocardial infarction 5 years ago, and now complains of dyspnea on exertion, cough, and 3-pillow orthopnea. Which of the following conditions is likely? A.Right ventricular failure B.Pulmonary embolism C.Cor pulmonale D.Left ventricular failure

ANS: D Left ventricular failure is most commonly characterized by dyspnea on exertion, cough, fatigue, orthopnea, PND, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Right ventricular failure is commonly characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with shortness of breath and tachycardia. Cor pulmonale is a heart disorder that occurs because of lung disease. The lungs are dysfunctioning which causes hypoxia and reflex pulmonary artery vasoconstriction. The right ventricle has to eject blood into the pulmonary artery, however, there is high afterload to deal because of pulmonary vasoconstriction. The high workload against the right ventricle eventually causes the right ventricle to fail. This right ventricular failure because of lung disease is called cor pulmonale.

Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: Stuvia.com - The Marketplace to Buy and Sell your Study Material A.Anemia B.Anxiety C.Hyperthyroidism D. All of the above

ANS: D Palpitations sensed by the patient are commonly indicative of atrial fibrillation, tachycardia, or premature ventricular contractions. Anemia, anxiety, and hyperthyroidism are all possible etiologies of these cardiac rhythm disturbances.

The key sign(s) of aortic stenosis are: A.Syncope B.Dyspnea C.Angina D.All of the above

ANS: D Syncope, angina, and dyspnea (remembered with the acronym SAD) on exertion are the classic symptoms of aortic stenosis. If syncope occurs with exertion, the aortic stenosis is typically severe. Angina may be present because of decreased perfusion of the left ventricle due to LVH rather than CAD, but both exist in many cases.

Which of the following ankle-brachial index measurements require a referral to a vascular consultant? ABI 1.2 ABI1 ABI 0.9 ABI 0.5

ANS: D The ankle-brachial index (ABI) is currently the easiest, least expensive noninvasive method for diagnosing PAD and is particularly helpful in the office and home settings. The ABI is obtained by the following steps:1. Obtain brachial systolic pressure in both arms. Select the higher of these two values. 2. Use Doppler stethoscope to obtain systolic pressure in the dorsalis pedis or posterior tibialis vessel.3. Divide ankle pressure by the higher brachial pressure.The index should be 1 or higher. If it is less than 0.5, impairment to blood flow is significant. An abnormal ABI indicates the need for a vascular consult.

Dyspnea, cough, and pulmonary crackles are symptoms that can occur in left ventricular failure and respiratory disorders, such as pneumonia. Which of the blood tests below can be used to differentiate cardiovascular from pulmonary disease? A.B type natriuretic peptide (BNP) B.Pulse oximetry C.Arterial blood gases D.High sensitivity C reactive protein (hs-CRP)

Ans A: Brain natriuretic peptide (BNP)—For patients with cardiovascular disease and comorbid respiratory disease, BNP can help differentiate a cardiac from a respiratory etiology of dyspnea. High levels of BNP in the blood, greater than 400 mg/dL, occur if heart failure is present.

An atrial septal defect (ASD) causes a left to right shunt, which enlarges the right atrium. Because of this effect, which of the following conditions often occur with ASD? A. Asthma B. Jugular venous distension C. Atrial fibrillation D. B&C

Ans D: ASD is a congenital abnormality in which oxygenated blood is shunted from a higher-pressured left atrium to a lower-pressured right atrium through an abnormal opening in the atrial septum. Atrial arrhythmias, especially atrial fibrillation, are common in the adult population with ASD. ASDs are often accompanied by other congenital heart defects, but in an uncomplicated lesion, patients are often asymptomatic until early adulthood, when they present with dyspnea on exertion or palpitations resulting from atrial arrhythmia. Because patients may be asymptomatic for many years, right HF can be the first sign, and patients may present with jugular venous distension, edema, and ascites.

3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? A) Mitral B) Tricuspid C) Aortic D) Pulmonic .

Ans: AChapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: Mitral valve sounds are usually heard best at and around the cardiac apex

2. What is responsible for the inspiratory splitting of S2? A) Closure of aortic, then pulmonic valves B) Closure of mitral, then tricuspid valves C) Closure of aortic, then tricuspid valves D) Closure of mitral, then pulmonic valves

Ans: A Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.

14. Where is the point of maximal impulse (PMI) normally located? A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum C) In the left 5th intercostal space, in the anterior axillary line D) In the left 5th intercostal space, in the midaxillary line

Ans: A Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.

8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse? A) Palpable B) Soft, rapid, undulating quality C) Pulsation eliminated by light pressure on the vessel D) Level of pulsation changes with changes in position

Ans: A Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate? A) Second-degreeA-Vblock B) Atrial flutter C) Sinus arrhythmia D) Atrial fibrillation

Ans: A Chapter: 09Page and Header: 375, Table 9-1Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block. Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.

30. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination? A) Listen in the epigastrium. B) Listen to the patient in the left lateral decubitus position. C) Ask the patient to hold his breath for 30 seconds. D) Listen posteriorly.

Ans: A Chapter: 09 Page and Header: 348, Techniques of ExaminationFeedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.

17. Which is true of splitting of the second heart sound? A) It is best heard over the pulmonic area with the bell of the stethoscope. B) It normally increases with exhalation. C) It is best heard over the apex. D) It does not vary with respiration.

Ans: A Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system. The bell is best used because it is a low- pitched sound. S2 splitting normally increases with inhalation.

28. How should you determine whether a murmur is systolic or diastolic? A) Palpate the carotid pulse. B) Palpate the radial pulse. C) Judge the relative length of systole and diastole by auscultation. D) Correlate the murmur with a bedside heart monitor.

Ans: AChapter: 09Page and Header: 348, Techniques of ExaminationFeedback: Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error. Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.

18. Which of the following is true of jugular venous pressure (JVP) measurement? A) It is measured with the patient at a 45-degree angle. B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. C) A JVP below 9 cm is abnormal. D) It is measured above the sternal notch.

Ans: B Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: Measurement of the JVP is important to assess a patient's fluid status. Although it may be measured at 45°, it is important to adjust the level of the patient's torso so that the blood column is visible. This may be with the patient completely supine or sitting completely upright, depending on the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.

4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? A) Abdominal pain B) Orthopnea C) Hematochezia D) Tenesmus

Ans: B Chapter: 09Page and Header: 337, The Health HistoryFeedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent? A) Hypertension B) Peripheral arterial disease C) Systemic lupus erythematosus D) Chronic obstructive pulmonary disease (COPD)

Ans: B Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

5. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this? A) Normal B) Prehypertension C) Stage 1 hypertension D) Stage 2 hypertension

Ans: B Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action at this point to prevent worsening hypertension. Research shows that this population is likely to progress to more serious stages of hypertension.

12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur? A) Upright B) Upright, but leaning forward C) Supine D) Left lateral decubitus

Ans: B Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.

33. Which valve lesion typically produces a murmur of equal intensity throughout systole? A) Aortic stenosis B) Mitral insufficiency C) Pulmonic stenosis D) Aortic insufficiency

Ans: B Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: This description fits a holosystolic murmur. Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo- decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.

19. Which of the following regarding jugular venous pulsations is a systolic phenomenon? A) The "y" descent B) The "x" descent C) The upstroke of the "a" wave D) The downstroke of the "v" wave

Ans: B Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the "x" descent.

23. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve? A) 80 B) 100 C) 120 D) 140

Ans: B Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: Maximum heart rate is calculated by subtracting the patient's age from 220. For Mrs. Adams, 60% of this number is about 100. She must also be instructed in how to measure her own pulse or have a device to do so. Most people are able to carry on a conversation at this level of exertion.

24. In measuring the jugular venous pressure (JVP), which of the following is important? A) Keep the patient's torso at a 45-degree angle. B) Measure the highest visible pressure, usually at end expiration. C) Add the vertical height over the sternal notch to a 5-cm constant. D) Realize that a total value of over 12 cm is abnormal.

Ans: B Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: In measuring JVP, the angle of the patient's torso must be varied until the highest oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.

10. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? A) Hypothyroidism B) Aortic stenosis, with pressure overload of the left ventricle C) Mitral stenosis, with volume overload of the left atrium D) Cardiomyopathy

Ans: B Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.

31. You are listening carefully for S2 splitting. Which of the following will help? A) Using the diaphragm with light pressure over the 2nd right intercostal space B) Using the bell with light pressure over the 2nd left intercostal space C) Using the diaphragm with firm pressure over the apex D) Using the bell with firm pressure over the lower left sternal border

Ans: BChapter: 09Page and Header: 348, Techniques of ExaminationFeedback: S2 splitting is composed of an aortic and pulmonic component. Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely, the diaphragm is best used with firm pressure.

15. Which of the following events occurs at the start of diastole? A) Closure of the tricuspid valve B) Opening of the pulmonic valve C) Closure of the aortic valve D) Production of the first heart sound (S1)

Ans: C Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).

1. You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation? A) Left atrium B) Right atrium C) Right ventricle D) Sinus node

Ans: C Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation. The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.

21. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? A) Every 6 months B) Every year C) Every 2 years D) Every 5 years

Ans: C Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.

6. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? A) Ethnicity B) Alcohol intake C) Gender D) Asthma

Ans: C Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.

22. Which of the following is a clinical identifier of metabolic syndrome? A) Waist circumference of 38 inches for a male B) Waist circumference of 34 inches for a female C) BP of 134/88 for a male D) BP of 128/84 for a female

Ans: C Chapter: 09Page and Header: 339, Health Promotion and CounselingFeedback: The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for wom

9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP? A) Left-sided heart failure B) Mitral stenosis C) Constrictive pericarditis D) Aortic aneurysm

Ans: C Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read about these conditions.

11. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position? A) Aortic B) Pulmonic C) Mitral D) Tricuspid

Ans: C Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.

34. You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely? A) Emphysema B) Asthma exacerbation C) Severe left heart failure D) Cardiac tamponade

Ans: C Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then "make it through." The other findings are associated with paradoxical pulse.

35. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis? A) Mitral stenosis B) Mitral insufficiency C) Mitral valve prolapse D) Mitral valve papillary muscle ischemia

Ans: C Chapter: 09Page and Header: 382, Table 9-8Feedback: The description above is classic for mitral valve prolapse. The extra sound is a midsystolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, low- pitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.

16. Which is true of a third heart sound (S3)? A) It marks atrial contraction. B) It reflects normal compliance of the left ventricle. C) It is caused by rapid deceleration of blood against the ventricular wall. D) It is not heard in atrial fibrillation.

Ans: C Chapter: 09Page and Header: 323, Anatomy and PhysiologyFeedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.

25. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out? A) Mitral valve prolapse B) Pulmonic stenosis C) Tricuspid insufficiency D) Aortic insufficiency

Ans: D Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: Bounding carotid pulses would be found in aortic insufficiency. This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.

27. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? A) Mitral stenosis murmur B) Opening snap of the mitral valve C) S3 and S4 gallops D) All of the above

Ans: D Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.

32. Which of the following is true of a grade 4-intensity murmur? A) It is moderately loud. B) It can be heard with the stethoscope off the chest. C) It can be heard with the stethoscope partially off the chest. D) It is associated with a "thrill."

Ans: D Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a "buzzing" feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over a dialysis fistula.

29. Which of the following correlates with a sustained, high-amplitude PMI? A) Hyperthyroidism B) Anemia C) Fever D) Hypertension

Ans: D Chapter: 09Page and Header: 348, Techniques of ExaminationFeedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.

Which of the following conditions is/are part of metabolic syndrome? A.Hypertension B.Hyperlipidemia C.Insulin resistance D. All of the above

D