EAQ Ch 20

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

50

Which cardiac assessment findings are documented as normal? Select all that apply. -Absence of cardiac murmur -S2 is louder at the base of the heart -Accentuated first heart sound (S1) -Diminished second heart sound (S2) -Absence of equal and bilateral breath sounds

Absence of cardiac murmur S2 is louder at the base of the heart

Which findings are considered normal in a patient who is pregnant? Select all that apply. -Apical impulse sits higher -Increase in loudness of S1 -A slight left axis deviation -Harsh holosystolic murmur -Low-pitched diastolic rumble

Apical impulse sits higher Increase in loudness of S1 A slight left axis deviation

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

Auscultate with the diaphragm of a stethoscope.

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

Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line

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

Collagenous fibers that anchor the leaflets of the atrioventricular valves

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

Have the patient sit during the carotid artery assessment. Put the patient in a supine position to assess the precordium. Maintain a warm room temperature.

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

Left lower sternal border

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

Left ventricular dilation

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

Lie between the ventricles and the great vessels

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

Lifting impulse in the left sternal border

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

P wave

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

Palpable vibration in the chest

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

Pericarditis

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

Right bundle branch block

Which clinical findings would the nurse observe in the patient with mitral regurgitation? Select all that apply. -S1 is diminished. -S2 is accentuated. -Arterial pulse is diminished. -Apical impulse is observed lower. -Palpable thrill is observed during diastole.

S1 is diminished. S2 is accentuated. Apical impulse is observed lower.

Which heart sound occurs because of the closure of the semilunar valves? -First heart sound (S1) -Second heart sound (S2) -Third heart sound (S3) -Fourth heart sound (S4)

Second heart sound (S2)

Which condition causes the patient to have a diminished first heart sound of S1 because of more forceful atrial contractions? -Mitral stenosis -Atrial fibrillation -Severe hypertension -Right ventricular hypertrophy

Severe hypertension

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

Sharp, stabbing pain that worsens with deep breathing and a cough with hemoptysis

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

Sinoatrial node

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

Sitting Supine Left lateral recumbent

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

Superior vena cava

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

Sustained thrust of the ventricle of the heart

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

Third heart sound

Which statement describes the pericardium? -Muscular wall of the heart -Area of the chest overlying the heart -Tough, fibrous sac surrounding the heart -Thin layer of endothelial tissue lining the inner surface of the heart

Tough, fibrous sac surrounding the heart

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

Tricuspid regurgitation