EAQ ch. 19/20

A nursing instructor is teaching a nursing student about the functions of the lymphatic system. Which statements, if made by the nursing student, indicate effective learning? "The lymphatic system is a major part of the immune system in the body." "The lymphatic system helps in the absorption of lipids from the small intestine." "The lymphatic system helps in the storage of functional red blood cells." "The lymphatic system helps to destroy the old and nonfunctional red blood cells." "The lymphatic system conserves the plasma proteins that leak out of the capillaries."

"The lymphatic system conserves the plasma proteins that leak out of the capillaries." "The lymphatic system is a major part of the immune system in the body." "The lymphatic system helps in the absorption of lipids from the small intestine."

The nurse is teaching a nursing student about the functions of the spleen. Which statement by the student nurse is a misunderstanding that needs correction? "The spleen produces antibodies." "The spleen stores old red blood cells." "The spleen destroys old red blood cells." "The spleen filters microorganisms from the blood."

"The spleen stores old red blood cells."

The nurse is assessing the probability of deep vein thrombosis (DVT) in a patient. While performing the pretest, the nurse documents the clinical characteristics as swelling of the entire leg, collateral superficial non-varicose veins, localized tenderness along the distribution of the deep venous system, and an alternative diagnosis at least as likely as DVT. What is the total score of DVT probability in this patient? Record your answer using a whole number:

1 The clinical characteristics documented during the pretest are swelling of the entire leg = 1; collateral superficial non-varicose veins = 1; localized tenderness along the deep venous distribution = 1; alternate diagnosis at least as likely as DVT = -2. Therefore, the total score of DVT probability in the patient will be 1 + 1 + 1 - 2 = 1.

vWhich heart rate would be found in an infant with bradycardia? 50 beats/minute 70 beats/minute 80 beats/minute 90beats/minute

50 beats/minute

The parent of a child worries about the humming sound heard in the child's chest. After assessing the child, the nurse informs the parents that the child is healthy. Which finding does the nurse observe in the child to support this conclusion? A soft blowing sound auscultated at the left lower sternal border A soft, high-pitched sound auscultated in the third left interspace A low-pitched diastolic rumble heard at the apex that does not radiate A continuous, low-pitched, soft sound at the medial third of the clavicle

A continuous, low-pitched, soft sound at the medial third of the clavicle

The nurse finds a lift while assessing a patient presented for a cardiac checkup. Which statement describes a lift? A lift is a vibration felt over the apex of the heart. A lift is a sustained thrust of the ventricle of the heart. A lift is an exaggerated pulse felt on the carotid artery. A lift is heard during diastole over the second right intercostal space.

A lift is a sustained thrust of the ventricle of the heart. A lift is also called a heave. It occurs due to right ventricular hypertrophy and is felt as a diffused lifting impulse during the ventricular systole at the left lower sternal border. A lift may be associated with the retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle. A thrill is a vibration felt by the nurse on the palpation of the chest. The presystolic thrill is felt just before the systole over the apex of the heart. The exaggerated pulse of the carotid artery is associated with the increased stroke volume of the left ventricle and a decreased peripheral resistance, leading to the widened pulse pressure of the aortic regurgitation. A low intensity, high-pitched heart murmur is best heard over the left sternal border or over the right second intercostal space, especially if the patient leans forward and holds the breath in full expiration.

While auscultating an infant's heart sounds, the nurse notices that the infant has a fixed split S 2, P 2 louder than A 2, and a medium-pitched systolic murmur, which is clearly heard in the second left interspace. What is the most likely reason for this condition in the infant? Calcification of the aortic valve Hypertrophy of the right ventricle Abnormal opening in the atrial septum Regurgitation of blood in the mitral valve

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

After conducting a cardiac examination, the nurse concludes that the patient has normal cardiopulmonary functioning. Which findings enabled the nurse to reach this conclusion? Absence of cardiac murmur S 2 is louder at the base of the heart Presence of accentuated first heart sound (S 1) Presence of diminished second heart sound (S 2) Absence of equal and bilateral breath sounds

Absence of cardiac murmur S 2 is louder at the base of the heart

Which conditions may cause a pathologic S 3, or a ventricular gallop? Anemia Pregnancy Hyperthyroidism Cardiomyopathy Pulmonary stenosis

Anemia Pregnancy Hyperthyroidism A ventricular gallop occurs due to an increase in fluid volume. Anemia, pregnancy, and hyperthyroidism may increase cardiac output in the patient. Therefore, the nurse can hear ventricular gallop in the pregnant patient or in the patient with anemia or hyperthyroidism. An atrial gallop, or pathologic S 4, is present in the patient with cardiomyopathy or pulmonary stenosis.

The nurse is caring for an obese patient with atherosclerosis. According to the laboratory reports, the patient has high serum cholesterol levels. Which other complication does the nurse expect in the patient? Aortic aneurysm Deep venous thrombosis Aortoiliac occlusion Varicose veins

Aortic aneurysm An aortic aneurysm is a sac formed by the dilation of the arterial wall. This condition occurs commonly in patients with atherosclerosis. This condition occurs because of the overenlargement of the inner and outer layers of the aorta. Deep venous thrombosis occurs because of the formation of clots in the veins of the lower extremities. This condition is not associated with atherosclerosis. Aortoiliac occlusion results in erectile dysfunction, and it occurs because of the occlusion of the artery. Atherosclerosis is not a risk factor for this condition. Varicose veins are common in obese adults, but they do not result from atherosclerosis.

After measuring the distal calf of a patient, the nurse documents that the patient has moderate lymphedema. Which findings support this conclusion? Asymmetry of calves measuring 0.5 cm Asymmetry of calves measuring 2.0 cm Asymmetry of calves measuring 4.0 cm Asymmetry of calves measuring 6.0 cm

Asymmetry of calves measuring 4.0 cm Acute, unilateral, painful swelling and asymmetry of calves is a sign of a complication in the patient. The asymmetry of calves measuring 1 cm and above is abnormal. The asymmetry of calves measuring between 3 and 5 cm indicates moderate lymphedema. Therefore, asymmetry of the calves measuring 4 cm indicates moderate lymphedema. Asymmetry in the measurement of the calves of 0.5 cm is a normal finding. The patient with mild lymphedema may have asymmetry of the calves measuring 2.0 cm. Asymmetry of the calves of more than 5 cm occurs in patients with severe lymphedema, so asymmetry of the calves measuring 6.0 cm indicates that the patient has severe lymphedema.

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

Auscultate with the diaphragm of a stethoscope

The nurse finds that a patient has risk of atherosclerosis. What advice would the nurse provide to the patient to prevent further complications? Increase the fluid intake. Avoid smoking cigarettes. Avoid a sedentary lifestyle. Use compression garments. Reduce the intake of fatty foods.

Avoid smoking cigarettes. Avoid a sedentary lifestyle. Reduce the intake of fatty foods.

The nurse is assessing the jugular pulse of a patient. Which jugular pulse component reflects ventricular contraction? A wave C wave V wave X wave

C wave The jugular pulse, a waveform that moves backward, is caused by events upstream. The jugular pulse has five components. The C wave occurs due to ventricular contraction. It is the backflow from the bulging upward of the tricuspid valve when it closes at the beginning of the ventricular systole. The A wave reflects atrial contraction. During this phase, some blood flows backward to the vena cava during the right atrial contraction. The V wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure. Similarly, the X wave shows atrial relaxation when the right ventricle contracts during the systole and pulls the bottom of the atria downward.

The nurse is assessing an elderly patient for the presence of peripheral vascular complications. Which nursing actions are appropriate during a peripheral vascular examination? Assessing the weight of the patient Checking the epitrochlear nodes of the patient Palpating the femoral pulse of the patient Palpating the inguinal nodes of the patient Assessing the body temperature of the patient

Checking the epitrochlear nodes of the patient Palpating the femoral pulse of the patient Palpating the inguinal nodes of the patient Peripheral vascular examination involves the palpation of lymph nodes, palpation of the pulse, and evaluation of the skin changes of the extremities. The nurse palpates the epitrochlear nodes to check for enlargement, which would indicate infection. Palpation of the femoral pulse helps the nurse to identify the type of pulse in the patient. The pulse is an index for various peripheral vascular complications. Palpation of the inguinal nodes helps the nurse to assess the presence of infections that may lead to vascular complications in the patient. Assessing the patient's body weight is not a part of the peripheral vascular examination, because it does not give any clue about the presence of complications. Peripheral vascular examination includes palpating for the temperature of the hands and feet, but not body temperature. The temperature of the hands and feet may increase or decrease because of peripheral vascular complications.

The nurse is caring for a patient who reports lower-extremity cramping during exercise. The nurse records the blood pressure in the upper extremities at 20 mm Hg greater than that of the lower extremities. The nurse also notices diminished femoral pulses in the patient. Which complication should the nurse expect to find in the patient? Mitral stenosis Mitral regurgitation Coarctation of the aorta Patent ductus arteriosus

Coarctation of the aorta Coarctation of the aorta is a congenital condition which involves the severe narrowing of the descending aorta. This condition decreases the amount of blood flow to the lower extremities; therefore, it decreases the blood pressure more in the lower extremities than in the upper extremities. The patient may have leg cramping during strenuous activities. Fatigue, palpitations, orthopnea, and a low-pitched diastolic rumble at the apex are the signs and symptoms of mitral stenosis. Fatigue, palpitations, orthopnea, and a loud, blowing, pansystolic murmur at the apex are signs and symptoms of mitral regurgitation. A palpable thrill noted at the left upper sternal border, a widened pulse pressure, and machinery murmur are the signs of patent ductus arteriosus. The patient with mitral stenosis, mitral regurgitation, or patent ductus arteriosus will not have decreased blood flow to the lower extremities. p. 503

The nurse is teaching a patient with diabetes about foot care. Which instructions should the nurse include about maintaining blood flow to the feet? Curl and spread out the toes frequently. Dry feet carefully after a shower or bath. Apply a thin coat of lotion on the skin. Take a warm footbath occasionally. Keep the toenails trimmed and straight.

Curl and spread out the toes frequently. Take a warm footbath occasionally. The nurse should teach proper methods of maintaining clean, healthy feet to prevent complications in diabetic patients. Curling and spreading of the toes frequently helps to maintain proper blood flow to the feet. Occasional warm baths also stimulate the blood flow to the feet and help to avoid vascular complications in the lower extremities. Drying the feet carefully after a shower or bath helps to prevent infections, but it does not help to maintain blood flow. Applying a thin coat of lotion on the skin of the feet helps to maintain moisture, but this intervention does not help to maintain blood flow. The nurse instructs the patient to keep the toenails trimmed and straight to prevent infections. This intervention does not help to stimulate blood flow to the feet.

What is indicated in a patient with pathologic S3? A stenotic heart valve Coronary artery disease Vigorous atrial contraction Decreased compliance of the ventricles

Decreased compliance of the ventricles S3 is the third heart sound. It is also known as a ventricular gallop or an S3 gallop. In adults, S3 is usually abnormal. The pathologic S3 indicates decreased compliance of the ventricles; it may be the earliest sign of heart failure. Vigorous atrial contraction occurs in the case of acute incompetence of the atrioventricular (AV) valve. It produces an S4 associated with a presystolic apical impulse. A stenotic heart valve occurs due to the narrowing of the valve of the heart. This narrowing prevents the valve from opening fully, which obstructs blood flow. The symptoms of coronary artery disease include angina, a characteristic chest pain on exertion, and decreased exercise tolerance.

During the peripheral vascular examination of a patient, the nurse palpates the radial artery and documents the amplitude of the radial pulse as full, increased, and bounding. What does the nurse expect to find in the patient's laboratory report? Decreased red blood cell count Increased serum thyroxine levels Increased white blood cell count Increased serum lipoprotein levels Increased serum albumin levels

Decreased red blood cell count Increased serum thyroxine levels The pulse will be full, increased, and bounding during hyperkinetic states such as anemia and hyperthyroidism. These conditions cause an increase in the heart rate, which results in an increased pulse rate. Hyperthyroidism causes an increase in the serum thyroxine levels. The laboratory reports of the patient with an infection will show an increase in the white blood cell count. An increase in the white blood cell count does not cause any change in the pulse rate of the patient. Occlusion of the arteries may cause an increase in serum lipoprotein levels. However, the occlusion of the arteries does not cause an increase in the pulse rate of the patient. The nurse may find increased serum albumin levels in the laboratory reports of the patient who has severe dehydration. p. 517

While assessing a patient with venous insufficiency, the nurse finds that the patient has edema in the lower extremities. The nurse also finds that the skin of the lower extremities is thick and has brownish discoloration. What could be the reason for such findings in the patient? Occlusion of a deep vein Degradation of red blood cells Bacterial invasion of the tissues Degradation of white blood cells

Degradation of red blood cells The patient may have edema in the lower extremities and the sensation of fullness in the legs because of venous insufficiency. Deposition of hemosiderin, which is a product of red blood cell degradation, may occur in the patient with venous insufficiency. This leads to the brownish discoloration and thickening of the skin. The occlusion of a deep vein causes unilateral edema in either upper or lower extremities. It is not associated with brownish discoloration of the skin. Bacterial invasion of poorly drained tissues may cause venous ulcers. The patient may have swelling and enlarged lymph nodes when there is an infection due to degradation of white blood cells.

The primary health care provider instructs the nurse to determine the ankle-brachial index (ABI) in a patient to know the severity of peripheral artery disease (PAD). Which conditions should the nurse check for in the patient's medical record before determining the ABI? Gastric ulcer Renal failure Hypothyroidism Diabetes mellitus Hepatic cirrhosis

Diabetes mellitus Renal failure

Which murmurs are caused by an obstruction of the flow of blood into the ventricles? Diastolic rumbles Early diastolic murmurs Midsystolic ejection murmurs Pansystolic regurgitant murmurs

Diastolic rumbles Diastolic rumbles occur due to filling of the ventricles at a low pressure due to the obstruction of the flow of blood into the ventricles. Semilunar valve incompetence causes early diastolic murmurs. Midsystolic ejection murmurs occur due to the forward flow of blood through the semilunar valves. The backward flow of blood from the area of higher pressure to one of lower pressure causes pansystolic regurgitant murmurs.

After assessing a patient with a cardiac disorder, the nurse determines that the patient has abnormally elevated pressure on the right side of the heart. Which observation would support this finding? Pulmonary congestion Pulmonary hypertension Distended neck veins and abdomen Systolic blood pressure higher than diastolic blood pressure

Distended neck veins and abdomen There are no valves between the vena cava and the right atrium or between the pulmonary veins and the left atrium. Therefore, when the pressure in the right side of the heart is abnormally high, the neck veins and the abdomen become distended. Similarly, abnormally high pressure in the left side of the heart reflects the symptoms of pulmonary congestion. Pulmonary hypertension refers to high blood pressure that occurs in the arteries of the lungs. It occurs when the blood vessels leading to the lungs are constricted. It is a different measurement altogether from systemic blood pressure. Systolic blood pressure that is higher than the diastolic blood pressure is a normal finding.

While assessing a patient with chronic venous insufficiency, the nurse finds dilated, bulged, and tortuous veins. The patient also reports severe leg cramps. Which technique helps infurther assessing the patient's medical condition? Profile sign Capillary refill Modified Allen test Doppler ultrasound

Doppler ultrasound In the patient with chronic venous insufficiency, the superficial veins, including the small and great saphenous veins, are affected. Bulged and tortuous veins along with leg cramping indicate the presence of varicose veins. Further assessment is necessary to assess the valve incompetency in the varicose veins. Imaging with Doppler ultrasound is an objective, noninvasive, reliable measure of valvular incompetency. The patient with congenital cyanotic heart disease may not have dilated and tortuous veins in the legs. The nurse uses the profile sign technique to evaluate clubbing in the patient with congenital cyanotic heart disease. The capillary refill technique is an indicator of peripheral perfusion and cardiac output. It indicates the time taken for return of skin color when the vessels are depressed or blanched. The modified Allen test helps to evaluate the adequacy of collateral circulation before cannulating the radial artery.

A patient who has undergone radiation therapy for breast cancer has brawny edema and unilateral swelling. The patient tells the nurse, "I feel tired all the time. My arms become so heavy, and my jewelry does not fit anymore." Which condition is the patient likely to have? Early lymphedema Chronic hypotension Superficial varicose veins Deep vein thrombosis

Early lymphedema The presence of unilateral swelling, brawny edema, heavy arms, and tiredness indicate that the patient has early lymphedema. During radiation therapy, the lymph nodes may be destroyed, resulting in the accumulation of fluid in the tissue. Because of the fluid accumulation, the patient has swelling and jewelry may not fit the patient's hand and arm anymore. Because of the accumulation of fluid in the tissues, the patient may have hypertension, not hypotension. Varicose veins occur because of increased pressure in the superficial leg veins. The risk factors for this condition include standing for a long time, leg injury, and aging. Deep vein thrombosis is associated with the formation of a clot in the blood vessels, resulting in reduced blood flow. It generally occurs in the lower extremities but not in the hands and arms. The patient with deep venous thrombosis may have leg swelling, not arm swelling.

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

Fifth left intercostal space at the midclavicular line

How would the nurse describe an innocent murmur? Grade 2, midsystolic, musical Grade 1, protodiastolic, rumbling Grade 4, pansystolic, low-pitched Grade 3, holodiastolic, high-pitched

Grade 2, midsystolic, musical A murmur is a blowing, swooshing sound that occurs with a turbulent blood flow in the heart or the great vessels. The innocent murmur is generally soft, midsystolic, short, and has a vibratory or musical quality. It is Grade 2. In patients with tricuspid regurgitation, pansystolic and low-pitched murmurs are heard. A holodiastolic, high-pitched murmur can be heard in patients with aortic stenosis. A protodiastolic and rumbling murmur is heard in patients with tricuspid stenosis.

While assessing a patient with cyanosis, the nurse hears a loud murmur that lasts throughout systole. A thrill is also palpable. Which classification best describes the murmur? Grade 1 crescendo Grade 3 holodiastolic Grade 6 decrescendo Grade 4 holosystolic

Grade 4 holosystolic The intensity of the loudness of the heart murmur is described in terms of six grades: Grade 1 is the lowest and Grade 6 is the highest. If the murmur is heard throughout the systole or diastole, then it is called holosystolic and holodiastolic, respectively. A systolic murmur may also occur with a normal heart, but a diastolic murmur always indicates heart disease. In this instance, the murmur lasts throughout the systole, is loud and is associated with a thrill. It is therefore classified as Grade 4 and holosystolic. When the loudness of the murmur gradually increases, it is called crescendo; in case of decrescendo, the murmur gradually decreases. The murmur is neither increasing nor decreasing gradually; hence, it is not a crescendo or a decrescendo murmur. Since the murmur is not heard during the diastolic phase of the heart, it is not a holodiastolic murmur.

While assessing a patient, the nurse finds elevated jugular venous pressure, ventricular gallop, and a pulse deficit. The diagnostic results of the patient indicate that the diameter of heart is 5 cm. Which complication does the nurse suspect in the patient? Aneurysm Heart failure Cardiomyopathy Left ventricular hypertrophy

HF

For which complications should the nurse monitor in a patient with deep vein thrombosis? Hypotension Heart failure Diabetes mellitus Hyperthyroidism Myocardial infarction

Heart failure Myocardial infarction

A patient who is in the third trimester of pregnancy has increased venous pressure and reduced blood flow because of obstruction of the iliac veins and inferior vena cava. Which complications may the patient develop related to these findings? Hemorrhoids Pulmonary embolism Varicosities in the vulva Varicosities in the legs Increased uterine contractions

Hemorrhoids Varicosities in the vulva Varicosities in the legs The growing fetus blocks the iliac veins and inferior vena cava during pregnancy. This reduces the drainage of fluid from the iliac veins and inferior vena cava, resulting in increased venous pressure and reduced blood flow. Because of the accumulation of blood and fluid in the veins, pressure builds up in the veins and may cause hemorrhoids, varicosities in the vulva, and varicosities in the legs. Obstruction of the pulmonary veins results in pulmonary embolism. Therefore, obstruction of the iliac veins and inferior vena cava will not cause a pulmonary embolism. Obstruction of the iliac veins and inferior vena cava will not increase the contractility of the uterine muscles. Therefore, the patient will not have increased uterine contractions.

After reviewing the laboratory reports of a patient, the nurse concludes that the patient is at risk of atherosclerosis. Which findings support this conclusion? Increase in the serum glucose levels Increase in the serum albumin levels Increase in the serum cholesterol levels Increase in the serum platelet count Increase in the serum triglyceride levels

Increase in the serum glucose levels Increase in the serum cholesterol levels Increase in the serum triglyceride levels

The nurse is caring for a patient with atherosclerosis. Which intervention should the nurse follow to obtain this patient's ankle-brachial index? Place the patient in the sitting position. Instruct the patient to be in a standing position. Maintain the room temperature at 22 o C (72 o F). Provide fluids to the patient before the examination.

Maintain the room temperature at 22 o C (72 o F). The room temperature may cause vasodilation and vasoconstriction resulting in the variation of the blood pressure. Therefore, in order to determine the patient's blood pressure accurately, the nurse should maintain the room temperature at 22 o C (72 o F). The patient should be in a supine position to measure ankle and arm blood pressures; the patient should not be sitting or standing. Providing fluids to the patient increases the fluid content and may increase the blood pressure. Therefore, providing fluids before the examination may alter the blood pressure.

Which conditions are associated with venous pooling? Obesity Smoking Diabetes Arteriosclerosis Multiple pregnancies

Obesity Multiple pregnancies

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

Opening snap Fatigue and orthopnea are the subjective symptoms of mitral stenosis. The patient may have an enlarged left atrium due to mitral stenosis. The nurse can hear a low-pitched diastolic rumble when the patient with mitral stenosis is in the left lateral position. The opening of the atrioventricular (AV) valves does not normally produce any sound. The patient with mitral stenosis requires high atrial pressure to open the AV valve; therefore, this may result in an extra sound called the opening snap. The ejection click occurs just after S 2 in the patient with aortic stenosis or pulmonary stenosis. The summation sound refers to the superimposed sounds of S3 and S4. This may occur in the patient who has tachycardia. The patient with mitral stenosis may not have tachycardia. Ventricular gallop is a sign of heart failure or cardiac stress.

Which extra sounds may occur in early diastole? Ejection click Opening snap Summation sound Pacemaker-induced sound Mitral prosthetic valve sound

Opening snap Mitral prosthetic valve sound The early diastolic stage involves the closing of the semilunar valves and opening of the atrioventricular (AV) valves. The opening of the AV valves is normally silent, but in cases of stenosis, more intra-atrial pressure is required to open the AV valve. Therefore, the opening of the atrioventricular valve makes a noise referred to as an opening snap. The opening of a ball-in-cage mitral prosthesis in early diastole gives an opening click termed as mitral prosthetic valve sound. An ejection click is the sound of the opening of the semilunar valves in the presence of stenosis. Therefore, this sound occurs in early systole. A summation sound refers to the superimposed S3 and S4 sounds, and this occurs in mid- diastole. A pacemaker-induced sound occurs in late diastole.

The nurse is going through the electrocardiogram (ECG) report of a patient complaining of chest pain. Which section of the electrocardiograph indicates atrial depolarization? T wave P wave QRS complex ST segment

P wave An electrocardiogram records the heart's electrical activity and helps the nurse to understand the functioning of the heart. The ECG waves are arbitrarily recorded as PQRST. The P wave indicates the depolarization of the atria. During atrial depolarization and contraction, electrodes placed on the surface of the body record a small burst of electrical activity lasting for a fraction of a second. This is the P wave. It is a recording of the spread of depolarization through the atrial myocardium from the beginning to the end. The T wave is the positive deflection that occurs after each QRS complex. It represents ventricular repolarization. The QRS complex represents the simultaneous activation of the right and the left ventricles. The ST segment represents ventricular repolarization, where repolarization follows upon contraction and depolarization.

The nurse documents the pulse of the patient as weak and thready (1+). Which conditions in the patient does the nurse identify as the reason for such findings? Shock Fever Anemia Anxiety Peripheral artery disease (PAD)

PAD Shock A weak, thready pulse (1+) occurs with shock and PAD. This is because shock and PAD may result in a decreased heart rate, thereby decreasing the pulse rate. Full, bounding pulses (3+) occur during hyperkinetic states such as fever and anxiety. They also occur if the patient is anemic. This is because these conditions are associated with an increase in pulse rate.

The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings? Pericarditis Angina pectoris Myocardial infarction Pulmonary hypertension

Pericarditis Sudden pain in the substernal region that radiates to the trapezius muscle and is present in the upper back is a sign of pericarditis. Pericarditis refers to the inflammation of the pericardium. Fever, dry cough, and joint pains are subjective symptoms of pericarditis. The patient with angina pectoris feels pressure such as discomfort behind the sternum or in the retrosternal region. Nausea, vomiting, dyspnea, and diaphoresis are the subjective symptoms of angina pectoris. The patient with a myocardial infarction feels heaviness in the chest region. The pain associated with myocardial infarction does not radiate to the trapezius muscle. Nausea, vomiting, dizziness, palpitations, and dyspnea are the symptoms of myocardial infarction. The patient with pulmonary hypertension experiences pain in the chest region, and may have dyspnea, lower-extremity edema, and fatigue.

The nurse is caring for an elderly patient who says, "I've been having severe leg pain." If the patient's ankle-brachial index (ABI) is 0.65, what conditions should the nurse check for in the medical records? Arthritis Renal failure Diabetes mellitus Hyperthyroidism Peripheral neuropathy

Peripheral neuropathy Arthritis The ABI value of 0.65 indicates the presence of moderate peripheral artery disease (PAD). This ABI value on the first assessment indicates that the patient has a delayed diagnosis of PAD. Arthritis and peripheral neuropathy often have symptoms similar to those of PAD; they mask the symptoms of PAD and result in delayed diagnosis. Renal failure and diabetes mellitus may cause calcification of the arteries and lead to false ABI results. However, renal failure and diabetes mellitus are not associated with leg pain. Hyperthyroidism is associated with an increased rate of metabolism; it does not have symptoms similar to those of PAD.

While assessing the cardiac health of a middle-aged patient, which finding would the nurse consider abnormal? Presence of apical impulse Presence of a venous hum Presence of jugular venous pulse Presence of a third heart sound

Presence of a third heart sound In middle-aged adults, the third heart sound (S3) or ventricular gallop is usually abnormal. The S3 indicates decreased compliance of the ventricles, and it may be the earliest sign of heart failure. The normal apical impulse is the result of the heart rotating, moving forward, and striking against the chest wall during the systole. Lateral or inferior displacement of the apex beat usually indicates the enlargement of the heart. The filling level of the jugular veins help to estimate the blood pressure. The pulse rate measured at the jugular vein provides a source of information about the state of the right atrium. The venous hum, a continuous murmur usually of maximum intensity in the supraclavicular area, is a common auscultatory finding in children; it is of no known pathologic significance.

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

Presence of bruit sound Normally, a bruit is absent in a healthy patient. Atherosclerotic disease causes turbulence in the blood flow and results in a bruit sound. A low-pitched rumbling is a sign of mitral stenosis. Atherosclerosis would not weaken the walls of the ventricles. Weak contractions of the ventricles will occur in the patient with heart failure. Unilateral distention of the external jugular veins indicates an aneurysm.

The nurse observes bilateral pitting edema and abnormal distention of the jugular veins in a patient. Which condition is the patient likely to have? Hyperthyroidism Diabetes mellitus Cervical malignancy Pulmonary hypertension

Pulmonary HTN

The nurse is assessing a patient with aortic valve stenosis. The nurse checks the pulse over the carotid artery and finds that the patient has a double pulse. Which condition does the nurse document in the patient's case report? Pulsus bigeminus Pulsus alternans Pulsus bisferiens Pulsus paradoxus

Pulsus bisferiens

Which clinical findings does the nurse observe in the patient with mitral regurgitation? S 1 is diminished. S 2 is accentuated. Arterial pulse is diminished. Apical impulse is heard lower. Palpable thrill is heard during systole.

S 1 is diminished. S 2 is accentuated. Apical impulse is heard lower. Mitral regurgitation is the condition in which the mitral valve does not close properly. Due to improper closure of mitral valve, the patient may have diminished S 1 and accentuated S 2. Apical impulse displaces down due to volume overload. Volume overload may not occur in the patient with mitral regurgitation. Diminished arterial pulse is a sign of tricuspid stenosis. A palpable thrill heard during systole is a sign of pulmonic stenosis.

While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient? Accentuated S 1 Fixed split S 2 Pathologic S 3 Pathologic S 4

S 4

A patient presents with complaints of chest pain. The nurse identifies a heart murmur in the patient. Which pathologic conditions can cause heart murmurs? Septal defect Regurgitant valve Increased blood flow Right bundle branch block Decreased myocardial contraction

Septal defect Regurgitant valve Increased blood flow

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

Severe hypertension Severe hypertension leads to an increase in the force of the atrial contractions, while pushing blood into the noncompliant ventricles. This may result in delayed ventricular contraction and a diminished S 1.sound. The patient with mitral stenosis has a diminished S 1 sound due to the presence of a calcified mitral valve. The nurse may find S 1 with an irregular rhythm in the patient with atrial fibrillation, but not a diminished S 1. The first heart sound will be normal in the patient with right ventricular hypertrophy.

The nurse is assessing a patient with cyanosis who has numbness and bluish discoloration of the skin. Which other signs and symptoms in the patient would support the diagnosis of Raynaud's phenomenon? Swelling in the arms Paleness of the palms Burning pain in the arms Increased blood pressure Increased body temperature

Swelling in the arms Burning pain in the arms Raynaud's phenomenon is a peripheral vascular disease in the arms that is associated with impaired blood supply and changes in skin color. Impaired blood supply causes reduced venous return and accumulation of fluid, leading to swelling in the arms. The patient may also feel numbness and burning because of reduced blood supply. Pallor is due to arteriospasm and reduced blood supply. These changes can be seen during the first stage of the disorder but not after the second stage. Because the patient is in the second stage, as evidenced by numbness and cynosis, the nurse would not find paleness of the palms. Raynaud's phenomenon is associated with vasodilation that leads to a decrease in blood pressure, not an increase in blood pressure. Patients with Raynaud's phenomenon may have reduced body temperature due to cold, but not an increase in body temperature.

The nurse is preparing a patient for a modified Allen test. What action should the nurse take while performing the test? Instruct the patient to depress and blanch the nail beds Have the patient rotate the fingers of the hand Ask the patient to open the hand and hyperextend Tell the patient to blanch the hand by making a fist several times

Tell the patient to blanch the hand by making a fist several times The nurse instructs the patient to make a fist several times, because this action helps to occlude the radial and ulnar arteries firmly and causes the hand to blanch. The nurse instructs the patient to depress and blanch the nail beds while performing the profile sign test. The nurse does not instruct the patient to rotate the fingers of the hand, because it will not allow uniform release of pressure. The nurse instructs the patient to open the hand without hyperextending, because hyperextension may cause more pressure on the radial artery.

While assessing the lymph nodes of an infant, the nurse finds that the cervical nodes are enlarged, warm, and tender on palpation. What does the nurse infer from this finding? The infant has a hand infection. The infant has an anterior chest infection. The infant has a diaper rash infection. The infant has a respiratory infection.

The infant has a respiratory infection. If the palpable lymph nodes in the infant appear small, mobile, firm, and nontender, these nodal characteristics indicate that the infant had an infection in the past. If the cervical nodes appear enlarged, warm, and tender on palpation, it may indicate that the infant has a respiratory infection, because the cervical nodes drain the lymph from the head and neck. Enlargement of the axillary nodes indicates a hand infection. An anterior chest infection does not cause the enlargement of lymph nodes in the cervical region. Enlargement of the inguinal nodes in the infant indicates an infection from diaper rash.

The nurse is caring for an infant who has frequent respiratory infections. While assessing the infant, the nurse hears a loud and harsh holosystolic murmur at the left lower sternal border. What should the nurse infer from these findings? The infant has tetralogy of Fallot. The infant has an atrial septal defect. The infant has coarctation of the aorta. The infant has a ventricular septal defect.

The infant has a ventricular septal defect. A ventricular septal defect refers to the presence of hole in the wall between the right and left ventricles of the heart. Pulmonary vascular resistance falls due to ventricular septal defect and results in frequent respiratory infections. A holosystolic murmur is common in the infant with a ventricular septal defect. Severe cyanosis and a systolic murmur are the signs of tetralogy of Fallot. Mild fatigue, dyspnea on exertion, and systolic murmur in the second left interspace are the symptoms of atrial septal defect. Lower extremity cramping, diminished femoral pulses, and systolic murmur are the signs and symptoms of the coarctation of the aorta.

The nurse is monitoring an infant with diminished femoral pulses and normal pulses in the upper extremity. What does the nurse infer from these findings? The infant has hypotension. The infant has coarctation of the aorta. The infant has a large left-to-right shunt. The infant has diminished cardiac output.

The infant has coarctation of the aorta An infant with coarctation of the aorta will have diminished or absent femoral pulses and normal pulses in the upper extremity. Coarctation of the aorta is a congenital disorder characterized by narrowing of the aorta in an infant. Consequently, narrowing of the aorta may reduce the blood flow and increase the blood pressure, resulting in hypertension. Therefore, diminished femoral pulses do not indicate that the infant has hypotension. A large left-to-right shunt can be seen in the infant with patent ductus arteriosus, resulting in full and bounding pulses. Weak pulses can cause vasoconstriction and lead to diminished cardiac output; however, they do not cause an asymmetrical pulse in the extremities.

While assessing the jugular venous pressure of a patient, the nurse finds that the pressure is elevated. Which observation is consistent with this conclusion? The level of pulsation is 2 cm above the sternal angle while at 30 degrees The level of pulsation is 3 cm above the sternal angle while at 45 degrees The level of pulsation is 3 cm above the sternal angle while at 30 degrees The level of pulsation is 2 cm above the sternal angle while at 45 degrees

The level of pulsation is 3 cm above the sternal angle while at 45 degrees The normal jugular pressure should be less than or equal to 2 cm above the sternal angle when the patient is elevated at 30 degrees, and the value should be 3 cm or less when elevated at 45 degrees. Therefore, the jugular venous pressure of 3 cm above the sternal angle when elevated at 45 degrees indicates that the pressure is increased. The jugular venous pressure of 2 cm and 3 cm above the sternal angle when elevated at 30 degrees is a normal finding. The jugular venous pressure of 2 cm above the sternal angle when elevated at 45 degrees indicates that the pressure is normal.

The nurse is caring for a patient who reports pain in the right side of the abdomen and right shoulder. The patient reports that the pain is most severe after eating a fatty meal. What should the nurse infer from these findings? The patient has pancreatitis. The patient has cholecystitis. The patient has esophageal spasms. The patient has gastroesophageal reflux disease.

The patient has cholecystitis. Cholecystitis is the inflammation of the gallbladder, which results in the accumulation of bile. Bile helps in the digestion of fats in the small intestine, so a patient with cholecystitis may not be able to digest the fats and this may produce pain in the right upper abdominal region, which radiates to the right shoulder. A patient with pancreatitis may experience nausea, vomiting, diarrhea, and epigastric pain, but this pain is not in relation to eating a fatty meal.A patient who has esophageal spasms may have substernal pain, but not abdominal pain. A patient with gastroesophageal reflux disease may have pain in the retrosternal region,but this would not radiate to the shoulders.

After observing a patient's leg discoloration, the student nurse documents that the patient may have arterial insufficiency. The nurse checks the medical history of the patient and informs the student nurse that the assessment results are unreliable. What could be the reason for the unreliability of the assessment results? The patient has an aneurysm. The patient has atherosclerosis. The patient has arterial occlusion. The patient has venous disease.

The patient has venous disease. Color changes of the lower extremities are common findings for both arterial and venous diseases. Therefore, it is difficult to suspect arterial insufficiency on the basis of discoloration of the legs in a patient who has a concomitant venous disease. An aneurysm is a sac formed because of dilation of the arterial wall. This leads to arterial insufficiency; it is not a venous disease. Atherosclerosis results from deposition of cholesterol in the arterial walls, which interferes with the assessment of arterial insufficiency in the patient. This is not a venous disease. Arterial occlusion leads to arterial insufficiency. This does not result in venous insufficiency that would interfere with the assessment of arterial deficit.

The nurse observes that a patient's pulse is easily palpable and pounds under the fingertips. What can the nurse infer from these findings? The patient is anemic. The patient is in a hyperkinetic state. The patient may have hyperthyroidism. The patient may have decreased cardiac output. The patient may have aortic valve regurgitation.

The patient is anemic. The patient is in a hyperkinetic state. The patient may have hyperthyroidism.

The laboratory reports of a patient show that the highest right average ankle pressure is 120 mm Hg and the highest average right arm pressure is 129 mm Hg. What do these findings indicate? The patient is at mild cardiovascular risk. The patient is at severe cardiovascular risk. The patient is at moderate cardiovascular risk. The patient is at borderline cardiovascular risk.

The patient is at borderline cardiovascular risk. The ankle-brachial index (ABI) is an important tool that helps to identify whether the patient is at risk for peripheral vascular diseases such as peripheral artery disease (PAD). The ABI can be determined using the formula ABI = highest right or left average ankle pressure ( dorsalis pedis [DP] or posterior tibial [PT])/highest average right or left arm pressure. In this case, the patient's right ABI = 120/129 = 0.93. An ABI of 0.93 indicates that the patient is at borderline cardiovascular disorder risk. If the patient has an ABI ranging from 0.90 to 0.71, then the patient may have mild PAD. An ABI of 0.40 to 0.30 indicates severe PAD. An ABI of 0.70 to 0.41 indicates moderate PAD.

While performing peripheral vascular examination in a patient by using capillary refill, the nurse finds that the refill lasts for 5 seconds. What does the nurse interpret from this finding? The patient is at risk of hypoxia. The patient is at risk of hypovolemia. The patient is at risk of bilateral edema. The patient is at risk of peripheral vascular disease.

The patient is at risk of hypovolemia. The patient's capillary refill lasts for more than 2 seconds. It indicates decreased cardiac output and vasoconstriction. Decreased cardiac output may result in hypovolemic shock in the patient. Insufficient supply of oxygen or decreased hemoglobin content in the blood may result in hypoxia. The nurse cannot assess hypoxia in the patient by checking the capillary refill, so the nurse measures the site to evaluate bilateral edema. Capillary refill is not an indicator of bilateral edema. The nurse auscultates the site for a bruit to determine the presence of peripheral vascular disease in the patient. A capillary refill that lasts for more than 2 seconds is not associated with peripheral vascular disease.

The nurse is finding it difficult to locate an elderly patient's pulse. After palpating the patient's arm for some time, the nurse locates the pulse but notices it is obliterated on applying pressure. What do these findings indicate? The patient may have hyperthyroidism. The patient may have aortic valve stenosis. The patient may have aortic valve regurgitation. The patient may have decreased cardiac output. The patient may have peripheral arterial disease.

The patient may have aortic valve stenosis. The patient may have aortic valve regurgitation. The patient may have decreased cardiac output. The patient may have peripheral arterial disease.

The nurse is caring for a patient who has pain in the substernal region. The patients states, "I feel like some object is blocking my throat." After doing an assessment, the nurse finds that the pain may be caused by gastrointestinal complications. What condition may be causing the patient's symptoms? The patient may have cholecystitis. The patient may have pancreatitis. The patient may have esophageal spasms. The patient may have gastroesophageal reflux.

The patient may have esophageal spasms. The squeezing of the muscles of the esophagus may prevent food from reaching the stomach, leaving it stuck in the esophagus. This may lead to the feeling in the patient that some object is obstructing the throat or esophagus. This causes pain in the substernal region. These characteristics indicate that the patient has esophageal spasms. Cholecystitis is the inflammation of the gallbladder leading to the blockage of the cystic duct. Therefore, it causes pain in the epigastric region. Inflammation of the pancreas and upper abdominal pain is an early sign of pancreatitis. The pain associated with gastroesophageal reflux disease occurs in the retrosternal region, but not the substernal region.

While the nurse is performing a peripheral vascular examination, the patient says, "I wake up in the middle of the night because of sudden pain in my legs." What does the nurse infer from the patient's statement? The patient may have varicose veins. The patient may have Leriche syndrome. The patient may have arterial insufficiency. The patient may have restless leg syndrome.

The patient may have restless leg syndrome.

Which patients are at highest risk for developing cardiac disease? The patient with diabetes mellitus The patient with vitamin D deficiency The patient with vitamin A deficiency The patient with obesity The patient with carpal tunnel syndrome

The patient with diabetes mellitus The patient with vitamin D deficiency The patient with obesity Diabetes mellitus causes damage to the large blood vessels, which nourish the heart. Therefore, it increases risk of cardiac disease. Vitamin D deficiency decreases the levels of calcium and results in weakness of the heart muscle. Obesity leads to an increase in the cardiac output and cardiac workload. Vitamin A does not interfere with cardiac function; therefore, its deficiency may not lead to cardiac disease. Carpal tunnel syndrome is a musculoskeletal disorder; it does not affect cardiac function.

While assessing a patient with acute asthma, the nurse concludes that the patient may have pulsus paradoxus. Which finding supports the nurse's conclusion? The patient's pulse is easily detectable under the fingertips. The patient's blood pressure falls to 100/70 mm Hg during inspiration. The patient's blood pressure falls to 90/60 mm Hg during expiration. The patient has a premature heartbeat followed by a normal heartbeat.

The patient's blood pressure falls to 100/70 mm Hg during inspiration. A patient with acute asthma will have pericardial effusion that compresses the heart, decreases cardiac output, and causes pulsus paradoxus. Pulsus paradoxus is associated with a fall in the blood pressure more than 10 mm Hg during inspiration. Therefore, a blood pressure of 100/70 mm Hg during inspiration indicates that the patient has pulsus paradoxus. The presence of an easily detectable pulse indicates that the patient has anxiety associated with increased blood flow. Pulsus paradoxus is associated with a fall in blood pressure during inspiration but not during expiration. The presence of a premature heartbeat followed by a normal beat indicates that the patient has pulsus bigeminus.

While assessing a patient, the nurse finds that the liver and the jugular vein have become enlarged. The nurse could best hear the soft and pansystolic heart murmur at the lower right and left sternal borders. Which disorder does the nurse suspect? Aortic stenosis Tricuspid stenosis Aortic regurgitation Tricuspid regurgitation

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

Which arteries are described as superficial and deep palmar arches? Ulnar artery Radial artery Plantar artery Femoral artery Popliteal artery

Ulnar artery Radial artery The brachial artery in the arm bifurcates into the ulnar and radial arteries immediately below the elbow. These arteries run distally and form two arches supplying oxygenated blood to the hand. Therefore, the ulnar and radial arteries are described as the superficial and deep palmar arches. The plantar, femoral, and popliteal arteries are associated with the leg, and they are not found in the upper extremities. These arteries are not described as superficial and deep palmar arches.

Which findings should the nurse observe in a patient with left ventricular hypertrophy? Visible apical heave Change in heart location Impalpable apical impulse Diameter of the heart 3.5 cm Higher jugular venous pressure

Visible apical heave Diameter of the heart 3.5 cm Left ventricular hypertrophy is the thickening of the myocardium of the left ventricle. Apical heave occurs due to pressure loading in the left ventricular hypertrophy. Left ventricular hypertrophy will not increase the diameter of the heart, so a diameter of 3.5 cm is normal. Left ventricular hypertrophy does not cause dilation of the heart. Impalpable apical impulse is the sign of pulmonary emphysema. In heart failure, jugular venous pressure increases, the location of the heart changes because of enlargement, and the diameter of the heart increases more than 4 cm.

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

Y descent There are five components of jugular venous pressure—A wave, C wave, X descent, V wave, and Y descent. Y descent indicates passive ventricular filling and opening of the tricuspid valve. A wave reflects atrial contraction due to the backward flow of blood to the vena cava. V wave occurs with passive atrial filling due to increase in pressure and volume in the right atria. X descent indicates atrial relaxation.

When would the nurse perform the abdominojugular test? When the nurse suspects heart failure When the nurse suspects premature ectopic beats When the nurse suspects obstructive coronary artery disease When the nurse distinguishes an innocent murmur from a pathologic murmur

suspects HF

The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient? Fifth interspace at around the left midclavicular line Second left interspace Second right interspace Left lower sternal border

xLeft lower sternal border Tricuspid regurgitation occurs in the patient with incompetent tricuspid valve. The tricuspid valve is present near the left lower sternal border. Therefore, the nurse can feel a palpable thrill in the left lower sternal border of the patient with tricuspid regurgitation. The nurse feels a palpable thrill in the fifth interspace around the left midclavicular line of a patient with mitral stenosis. The nurse can feel a palpable thrill in the second left interspace in the patient with pulmonic stenosis. The second right interspace is the area of the aortic valve. Therefore, the palpable thrill occurs in this area in the patient with aortic stenosis.