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begins with impulses generated by the
sinoatrial
node and circuited continuously over the
heart
Electrical Conduction of the Heart
*Sinoatrial (SA) node *
*Atrioventricular (AV) node*
- in posterior wall of the right atrium near
junction of superior and inferior vena
cava
- generates impulses at a *rate of 60-100
per minute*
- conducts them over both atria, causing
them to contract and send blood into the
ventricles
- functions as the *"pacemaker of the
heart"*
- in lower interatrial septum
- *slightly delays* incoming electrical impulses
- relays the impulse to the *AV bundle
(bundle of His)* in the upper interventricular septum
- generates impulses at a *rate of 40-60
per minute* if the SA node cannot function.
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- in myocardium of both ventricles
- causing them to contract almost simultaneously
*Purkinje fibers*
- blood flowing backward true valve
Re*gurg*itation
- filling and emptying of the heart's chambers
- has two phases: diastole and systole
*Cardiac cycle*
*Diastole*
- relaxation of the ventricles, known as
*filling*
- 2/3 of the cardiac cycle
- "atrial kick" - atria contract and complete emptying of blood into ventricles
*Systole*
- contraction of the ventricles, known as
*emptying*
- 1/3 of the cardiac cycle
- closing of AV valves - S1
- ventricles empty, pressure lower than at
aortha and pulmonary artery
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- closing of semilunar valves - S2 - end of
systole
- ventricles relax
*P wave:*
- diastole
- At depolarization;
- conduction of impulse throughout At.
*PR interval: *
- time from beginning of At depolarization
(diastole) to the beginning of Vt depolarization (systole)
*QRS complex: *
- presystole - systole
- Vt depolarization (At repolarization)
- conduction of the impulse throughout Vt
and triggering their contraction
ELECTROCARDIOGRAM
*RS:*
- *beginning of systole*
- isometric contraction
- four valves closed
- *S1*
*ST segment: *
- systole to relax to diastole
- from Vt depolarization to beginning of
Vt repolarization
*T wave: *
- systole to relax to diastole
- Vt repolarization;
- Vt at resting state (isometris relaxation)
- semilunar valves closed
- *S2*
*QT interval: *
- systole to relax
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- total time for Vt depolarization and repolarization
*U wave: *
- diastole
- final phase of ventricular repolarization.
*S1 - lub*
- *beginning of systole*
- each carotid pulsation
- AV valves closed
- heard best at apex (may be heard
over entire precordium)
- softer at the base and louder at the
apex
- split S1 heard over the apex may be S4
*S2 - dub*
- *beginning of diastole*
- semilunar valves (aortic and pulmonic)
closed
- closure of the pulmonic valve is delayed
by
inspiration, resulting in a split S2 sound
- laudest at the base
- *diastolic* filling sounds
*S3 and S4* - extra heart sounds
S3 - *ventricular gallop*
- ventricular vibration secondary to rapid
ventricular filling
- can be heard early in diastole, *after
S2* - ken-tuc-*ky*
- normal in in children, adolescents, and
young adults.
S4 - *atrial gallop*
- vibration secondary to ventricular
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Weber Health Assessment Ch. 21: Heart + Neck Vessels
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resistance (noncompliance) during atrial
contraction
- can be heard late in diastole, just *before S1* - *ten*-nes-see
- normal in well-conditioned athletes and
in older 40-50, especially after exercise.
- turbulent blood flow
- *swooshing or blowing sound* over precordium
- occurs with anemia, pregnancy, fever,
and hyperthyroidism
*Murmurs*
Conditions contribute:
(1) increased blood velocity,
(2) structural valve defects,
(3) valve malfunction,
(4) abnormal chamber openings (e.g.,
septal defect)
Types:
- Midsystolic
- Pansystolic
- Diastolic
- amount of blood pumped by ventricles
in 1 minute
*Cardiac output (CO)*
- stroke volume (SV) multiplied by heart
rate (HR):
SV × HR = CO
- normal adult cardiac output is 5 to 6
L/min.
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Weber Health Assessment Ch. 21: Heart + Neck Vessels
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- anterior surface of body overlying heart
and great vessels
*Precordium*
- sounds always travel in direction of
blood flow
*A*ll *P*eople *E*at *T*hree *M*eals
*Aortic area*
- S2
- 2nd ICS at R sternal border
- base of heart
*Areas of Auscultation*
*Pulmonic area*
- S2 is also loud
- 2nd / 3rd ICS at L sternal border
- base of heart
*Erb's point*
- 3rd to 5th ICS at L sternal border
- best place to hear murmur
*Tricuspid area*
- S1 loud
- 4th / 5th ICS at L lower sternal border
*Mitral / Apicel area*
- S1 is loudest here
- 5th ICS at the left midclavicular line
- apex of heart
- PMI - point of maximum impulse
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Weber Health Assessment Ch. 21: Heart + Neck Vessels
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- position yourself on Pt's right side
- Pt should be supine, with the upper
trunk elevated 30 degrees.
- for high-pitched sounds use diaphragm;
apply firmly
- for low-pitched sounds use bell; apply
lightly
*Heart Sound Auscultation Rules*
1. Listen heart's rate and rhythm.
2. Identify S1 and S2
3. Listen for extra heart sounds
4. Listen for murmurs
5. Listen with Pt in different positions
- closing eyes may enhance ability to
concentrate on auditory stimuli
- may be problem with palpation and auscultation of Apical impulse in obese Pts
or with barrel chest: increase distance
from the apex to precordium and coarsened tissues
Neck Vessels
*Common Carotid Arteries*
- extend from brachiocephalic trunk (R)
and aortic arch (L)
- in groove between trachea and sternocleidomastoid
- supply neck and head, including the
brain, with oxygenated blood
*Jugular Veins*
- internal JV lie deep and medial to the
sternocleidomastoid
- external JV more superficial, lie lateral
to sternocleidomastoid and above clavicle
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*Carotid Artery Pulse*
- centrally located arterial pulse
- close to heart, pulsation coincides
closely with ventricular systole
- good for assessing amplitude and contour
Pulse:
- reflects hemodynamics of the heart's
right side
Pressure:
- reflects right atrial (central venous)
pressure and right ventricular diastolic
filling pressure
- Right-sided heart failure raises pressure and volume, thus *raising* jugular
*Jugular Venous Pulse and Pressure*
venous pressure.
- Reduced left ventricular output or *reduced blood volume* *decreased* jugular venous pressure.
*Pulsus alternans* - regular rhythm
*Bisferiens pulse* - double systolic peak
*Increased pulse pressure* - large,
bounding pulse
*Slow upstroke* - small, weak pulse.
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*Angina - cardiac chest pain*
- sensation of squeezing around the
heart;
- steady, severe pain;
- sense of pressure
- may radiate to the left shoulder and
down the left arm or to the jaw
- dyspnea, diaphoresis, pallor, nausea,
palpitations, or tachycardia
- may be overlooked or misinterpreted as
gastrointestinal
- GI pain: occurs after meals and is relieved with antacids. Cardiac pain: occurs
anytime, is not relieved with antacids,
*worsens with activity*.
*Tachycardia *
- weak heart muscles,
- attempt by the heart to increase cardiac
output
*Palpitations *
- abnormality of the heart's conduction
system (arrhythmias)
- attempt by the heart to increase cardiac
output by increasing the heart rate
- may cause anxiety
*Fatigue *
- may result from compromised cardiac
output.
- if related to decreased cardiac output worse in the evening or as the day progresses,
- if related to depression - ongoing
throughout the day
*Dyspnea *
- congestive (L) heart failure,
- pulmonary disorders,
- coronary artery disease,
- myocardial ischemia,
- myocardial infarction
- may occur at rest, during sleep, or with
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mild,
moderate, or extreme exertion.
*Orthopnea *
- inability breathe while supine
- need to sit more upright to breath easyly
due to fluid accumelation in lungs - (L)
heart failure
*Paroxysmal nocturnal dyspnea*
- waking up from dispnea during night
- (R) heart failure due to redistribution of
fluid from ankles to the lungs when lies
down
*Sputum*
- fluid accumulation in the lungs from (L)
heart failure can cause cough up whiteor pink-tinged sputum
*Dizziness *
- decreased blood flow to the brain due
to
myocardial damage
- inner ear syndromes,
- decreased cerebral circulation,
- hypotension
Dizziness may put Pt at risk for falls.
*Nocturia*
- (R) heart failure with increased renal
perfusion during rest or recumbent positions
*Edema*
- in both lower extremities at night: (R)
heart failure due to reduction of blood
flow out of the heart, causing blood returning to the heart to back up in the
organs
*Dyslipidemia*
- elevation of plasma cholesterol develops atherosclerosis
- increases chance of fatty plaque formation in coronary vessels
- *greatest risk for the developing coronary
artery disease*
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*Acute rheumatic fever (ARF) and
Rheumatic heart disease (RHD)*
- result in bacterial infection and inflammation of all heart layers, impairing contraction and valvular function.
African American, Mexican Americans,
Native American, native Hawaiians, and
Risk for coronary cardiovascular disease
some Asian Americans have higher rates
compared to Caucasians
General Routine Screening
- Inspect jugular venous pulse
- Auscultate then palpate carotid arteries
- Inspect pulsation on anterior chest
- Palpate apical impulse
- Palpate for abnormal pulsations
- Auscultate S1 / S2
- Auscultate for extra saunds
- Auscultate for murmurs
Focused Specialty Assessment
- Evaluate jugular venous pressure
- Grade and identify sours of auscultated
murmurs
- Differentiate between specific split
sounds, rubs, snaps, and clicks
Observe the jugular *venous pulse*
- Pt in a supine position
- torso+head on the same plane, elevated 30-45 degrees
- turn Pt's head slightly to the left
- increase visualization of pulsations by
shadows from light source
- inspect suprasternal notch or area
around clavicles for pulsations
Abnormal:
*Fully distended jugular veins in torso >
45 degrees*:
- increased central venous pressure due
to R ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac
tamponade.
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- 30-45-60-90 elevate - shoul not be distended
Evaluate jugular *venous pressure*
Abnormal:
- distention, protrusion, or bulging: R
heart failure
- elevated venous pressure only during expiration: obstructive pulmonary disease
- elevated venous pressure only during
inspiration: *Kussmaul's sign* - in severe
constrictive pericarditis.
Auscultate carotid arteries
- in middle-aged or older Pt or suspected
cardiovascular disease
- *before palpating*
*Bruit*
- blowing or swishing sound caused
by turbulent blood flow through a narrowed
vessel,
- indicates occlusive arterial disease.
- if artery is > 2/3 occluded may not be
heard
- *inequality in R/L*:
arterial constriction or occlusion in one
carotid.
- *weak pulse*:
hypovilemia, shock, or decreased cardiac output.
Palpate *carotid arteries - pulse*
- *bounding, firm pulse*:
hypervolemia or increased cardiac output.
- *variations in strength from beat to beat
or with respiration*:
abnormal
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- *delayed upstroke* (compare to point of
maximum impulse PMI):
aortic stenosis.
- *loss of elasticity*:
arteriosclerosis
- *trills*:
narrowing of the artery
*Heaves or lifts*
- pulsations, other than the apical pulsation
- occur as the result of an enlarged ventricle from an overload of work
- Pt supine - by 1-2 fingers
- roll Pt to the left lateral position to better
feel impulse - by palmar surface
Palpate the apical impulse
Abnormal:
- absent: pulmonary emphysema (or
obese / large breast)
- >1-2 cm, displaced, more forceful, or of
longer duration: cardiac enlargement.
PULSE AMPLITUDE
0 Absent
1+ Weak, diminished (easy to obliterate)
2+ Normal (obliterate with moderate
pressure)
3+ Bounding (unable to obliterate or requires
firm pressure)
*Pulse deficit*
- differnce bw apical and peripheral pulse
- assess if irregular rhythm presents
- atrial fibrillation, atrial flutter, premature
ventricular contractions, and varying
degrees of heart block.
*Summation gallop*
- S3 and S4 pathologic sounds together
- *quadruple rhythm*
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- diffuse lifting left during systole at the
left lower sternal border
- retraction at the apex from the posterior
rotation of the left ventricle caused by the
oversized right ventricle
*Ventricular Lift / heave*
- right ventricular hypertrophy caused by
pulmonic valve disease, pulmonic hypertension and chronic ling desiase
*Ventricular Thrill palpated *
- palpated over 2nd an 3rd ICS
- severe aortic stenosis and systemic hypertension.
*Clicks*
- EXTRA HEART SOUNDS DURING
*SYSTOLE*
- high-frequency sounds heard just *after
S1 (ejection clicks)*
- produced by a functioning, but diseased, valve. - can occur in early or
mid-to-late systole
*Opening Snap (OS)*
- EXTRA HEART SOUNDS DURING
*DIASTOLE*
- opening of a stenotic or stiff mitral valve.
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highly complex
Consist of heart and blood vessels
Cardiovascular system
S+F of heart and vessels (3)
great vessels include (4)
-Heart located in mediastinum
Middle of thoracic cavity between lungs
-Precordium
Anterior chest area overlying the heart
and great vessels
Great vessels: large veins and arteries
leading directly to and from heart
sup/inf vena cava: return blood to right
atrium from upper/lower torsos
Pulmonary artery: exits right ventricle,bifurcates, carrying blood to lungs
Pulmonary veins: return oxygenated
blood to left atrium
Aorta: transports oxygenated blood from
left ventricle to body
SA node -> AV node -> Bundle of His
-> Bundle Branches L & R -> Purkinje
Fibers
Electrical conduction system pathway
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pace maker, generate impulse conducted over atria for simultaneous contraction
SA node
receive SA current, slightly delays impulse from atria, relaying to AV bundle
Av node:
av bundle transmit pimpulse to bundle
brnaches
Bundle of His (AV bundle)
transmit impulse to purkinje fibers
right/left bundle branches:
receive impulse in myocardium of ventricles, contracting almost simultaneously
Purkinje fibers:
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Electrical activity
-Measured and recorded by electrocardiography ECG/EKG
-Records polarization and depolarization
-includes phases: P, QRS, T, U
atrial depolarization, conduct impulse
through atria
p wave
ventricle depolarization, conduct impulse
through ventricles triggering contraction
QRS complex
ventricular repolarization/relaxation
T wave
may/may not be present, follows t wave
representing final phase of ventricular repolarization
U wave
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-Refers to fill and empty of heart
-Diastole: relaxation/filling
-Systole: contract and empty
Cardiac cycle (3)
Diastole (2)
Systole (2)
-AV valves open, ventricles relax, blood
rush to heart
-Atria contract, emptying blood to ventricles
-Pressure closes mitral/tricuspid valve to
close
First heart sounds lub
-Ventricles contract, aortic and pulmonary valves open
Blood ejects out of heart, leads to second
heart sound dub
-Produced when valve closes
-Lub (S1) dub(S2)
-Auscultate with stethoscope over precordium
Production of heart sounds (3)
-due to closure of AV, mitral, tricuspid
valves
-If 2 sounds, mitral valve closes first, followed by tricuspid valve
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first heart sound (2)
-Due to closure of aortic and pulmonic
valves
-Beginning of diastole
-If 2 sounds, split S2 due to closure of
aortic valve, then pulmonic valve
second heart sound (3)
Diastolic filling sounds: s3, s4
s3= ventricular gallop
s4 : atrial gallop
extra heart sounds (3)
murmurs (2)
-Swooshing or blowing sound
-Due to increase blood velocity, valve
malfunction, abnormal chamber openings (septal defects)
sepsis
extreme reaction to infection
septic shock
Shock caused by severe infection, usually a bacterial infection.
-murmurs are heard turbulent blood flow
within heart or near heart
difference between murmurs and bruit
-bruit is turbulent blood flow outside of
the heart in places like the carotid pulse
-Amount of blood pumped by ventricles
during given period of time
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-Determined by SV x HR
-normal amount is 5-6 L/min
cardiac output (3)
Amount of blood pumped from heart
each contraction
stroke volume
SV affected by (6)
-heart muscle compliance before contraction
-Pressure against which has to eject
blood during contraction
-Contraction synergy
-Ventricle compliance/distensibility
-Myocardial contractility
-Autonomic NS
-Centrally located
-Coincide close w ventricular systole
-Good for assessing pulse wave amplitude and contour
Carotid artery pulse (3)
Jugular venous pulse/pressure (2)
-2 sets: internal and external
-Determines hemodynamics of right side
of heart/level of pressure reflect right atrial pressure
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jugular venous components (3)
A wave: atrial pressure rise, atrial contraction
X descent and Y: right atrial fills, increase
vol and pressure
Y descent: right atrial empties, decrease
pressure
-US. hisp/black increase stiffness of
carotid arteries
-Hispanic = increase carotid diameter
with age
-Heart disease leading cause of death in
risk factors for coronary heart disall groups
ease/artery disease across cultures (6)
-Diabetes highest rate in hispanics
-LDL cholesterol: hispanic with highest
level
-Asians have lower rates on hypertension, obesity, diabetes, cholesterol
older adult considerations (2)
-Cautious to palpate neck vessels, atherosclerosis may cause obstruction/compression blocking circulation
-Apical impulse difficult to palpate due to
increased anteroposterior chest diameter
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HPI (4)
Use coldspa, chest pain? Can be cardiac, pulmonary, muscular, GI, angina
described as squeezing pain cardiac related
Tachycardia:palpitations
Does your heart beat faster? Seen in
tachycardia with weak heart muscles,
heart tries to increase CO
Heart skipping a beat? Palpitation occur
w abnormality of heart conduction system (arrhythmias)
Other symptoms
Fatigue? Due to compromised CO, related to decrease CO worsening in the
evening
Difficult breathing(dyspnea)? Result of
congestive heart failure, pulmonary disorder,CAD, MI
Personal Health history (3)
Diagnosed w heart defect/murmur? Congenital or acquired affect heart ability to
pump, low o2 supply to tissue
Monitor own HR/bp? Self monitor recommended for cardiotonic/antihypertensive
meds
Rheumatic fever? ARF and RHD significant public health concern
Family history
History of hypertension, MI, CHD? Genetic predisposition to develop heart disease
Lifestyle and health practices (3)
Smoke/stress? Increase risk of heart disease
Alc? Excessive intake of alc linked to
hypertension
Exercise? Sedentary lifestyle contribute
heart disease
Diet? Diet high in fat and cholesterol increase fatty plaque formation in coronary
vessels
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General routine screening
Inspect the jugular venous pulse.
Auscultate, then palpate carotid arteries.
Inspect pulsations on the anterior chest.
Palpate the apical impulse.
Palpate for abnormal pulsations.
Auscultate to identify S1 and S2.
Auscultate for extra heart sounds.
Auscultate for murmurs.
Focused specialty assessment
Evaluate jugular venous pressure.
Grade and identify source of auscultated
murmurs.
Differentiate between specific split
sounds, rubs, snaps, and clicks.
Prep client
Explain procedure, gown, client assume
diff position, provide modesty
equipment
Stethoscope
Small pillow
Penlight
Watch w second hand
2 cm rulers
gown/drape
Inspect jugular venous pulse: (2)
stand on right side of client at supine
position torso 45 degree, ask client to
turn head slightly left, shine light source
onto neck for pulsation visual, inspect
suprasternal notch, area around clavicle
-Jugular venous pulse not normally visible sitting upright
Inspect jugular venous pulse: abnormal-Fully distended veins indicate central
ities (2)
venous pressure result of right ventricular failure/pulmonary hypertension
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eval jugular venous pressure (3)
auscultate carotid arteries
Palpate carotid arteries: (3)
-watch distension of vein, normal to be
visible in supine, put supine position with
head bed 30, 45, 60 , 90 elevated, client
head turned away from side evaluated
-Jugular vein not distended, bulging, protruding at 45 or higher
-Distension, bulg, protrusion seen indicate right side heart failure
place bell over artery, ask client to hold
breath to not conceal sound w breath
No blowing, swishing
Bruit caused by turbulent blood flow
through narrowed vessel, indicate occlusive arterial disease
-each artery alternate with index and
middle finger pads, medial to sternocleidomastoid muscle on neck
-Pulse equal strong, 2+ or normal w no
variation, contour normally smooth and
rapid upstroke, less abrupt downstroke
-Pulse inequality indicate arterial constriction/occlusion in one carotid artery
-supine position 30-45 degree, stand
Inspect pulsations on anterior chest over clients right side look for apical impulse
heart: (3)
-Apical impulse may/maynot be visible
-Pulsations aka heaves = abnormal
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Palpate apical pulse: (3)
-remain right side, use 2 finger pad palpate apical impulse in mitral area, may
roll client to left side
-Apical impulse palpated may be 1-2 cm
in size, amplitude small
-Apical impulse impossible to palpate w
pulmonary emphysema
A serious disease that destroys lung tissue and causes breathing difficulties.
emphysema
Abnormal pulsation: (3)
Auscultate HR and rhythm: (3)
use palmar surface to palpate apex, L
sternal border, base
No pulsations/vibrations palpated
thrill/pulsation assoc w grade IV or higher
murmur
-Place diaphragm at apex
-Rate should be 60-100/min
-Bradycardia or tachycardia due to decrease CO
Radial and apical pulse rate identical
Auscultate for pulse rate deficit if irreguPulse deficit btw apical and peripheral inlar rhythm detected (2)
dicate atrial fibrillation, flutter, heart block
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S1 correspond w each carotid pulsation
= loudest at apex of heart, S2 followed after S1 immediate, loudest at heart base
Accentuated, diminished, or split S1/S2
Auscultate S1/S2 (2)
-Distinct sound heard in each area, loudest at apex
-Accentuated, diminished, varying split
Listen S1 (2)
Distinct sound heard in each area, loudest at base
Any split s2 heard in expiration
Listen s2 (2)
No sounds heard, physiologic s3 heart
sound is benign
Ejection sounds/clicks mid systolic click
associated w mitral valve prolapse
Auscultate extra heart sounds (2)
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Auscultate for murmurs (3)
murmur is swishing sound by turbulent
blood flow through heart valve/great vessels
No murmurs
Pathologic midsystolic, pansystolic, diastolic murmurs
Ask client to assume left lateral position,
use bell at apex
Auscultate w client assuming other posiS1 and s2 present
tions: (3)
S3 s4 or murmur of mitral stenosis may
reveal at left lateral position
Coronary heart disease
Include range of diseases
CAD, arrhythmias, heart infection, congenital heart defect, narrow/blocked bv
lead to:
Heart attack, chest pain, stroke, affecting
heart
heart attack/MI
a condition in which blood flow to part
of the heart muscle is blocked, causing
heart cells to die
goal of healthy people 2020
Improve CV health, quality of life through
prevent, detect treat
Screen for risk of heart disease (2)
-cholesterol, glucose level, bp, health
history, peripheral artery disease
-AHA recommend screen start at 20
years age bp, 45 check blood glucose
every 3 years
CHD Non modifiable risk factors
Age, gender, heredity
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Smoking, high blood cholesterol, triglycerides, hypertension, sedentary lifestyle,
obesity, overeight, diabetes
CHD Modifiable risk factors
factors contributing heart disease
Stress, excess alc, diet, nutrition, diabetes mellitus
Client education (7)
Stop smoke
Diet
Lower bp
Increase activity
Manage diabetes
Limit alc
Practice stress reducing
abnormal arterial pulse
Normal pulse
Weak pulse
Large bounding
Pulsus bisferiens
Pulsus alternans
Bigeminal pulse
Paradoxical pulse
ventricular impulses (4)
Lift
Thrill
Accentuated apical impulse
Lateral displaced apical impulse
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Abnormal heart rhythms (4)
Premature atrial/junctional contraction
Premature ventricular contractions
Sinus arrhythmia
Atrial fibrillation/atrial flutter
Extra heart sounds in systole clicks (3)
Aortic ejection click
Pulmonic ejection click
Midsystolic click
Extra heart sound in diastole (4)
Open snap
S3 third heart sound
S4 fourth heart sound
Summation gallop
Extra heart sound in both systole/diastole (3)
Pericardial friction rub
Patent ductus arteriosus
Venous hum
Heart murmurs (10) components
Characteristics
Timing
Intensity grade 1-6
Pitch
Quality
Location
Transmission
Ventilation and position
Shape or pattern (include pics)
Midsystolic, pansystolic, diastolic murmurs
midsystolic murmurs (5)
Innocent murmur
Physiologic murmur
Murmur pulmonic stenosis
Murmur aortic stenosis
Murmur hypertrophic cardiomyopathy
Pansystolic murmurs (3)
Murmur mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Diastolic murmurs (2)
Murmur of aortic regurgitation
Murmur mitral stenosis
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Cardiovascular
The ______ is highly complex consisting
of the heart a closed systems of blood
vessels.
A hollow muscular, four chambered organ located in the middle of the thoracic
cavity between the lungs. It has left and
right atria and ventricles
Heart
The heart is located in this spaced called
the ______.
Mediastinum
Precordium
The anterior chest area that overlies the
heart and great vessels is the ______.
Gas exchange
The right side of the heart pumps blood
to the lungs for ______ exchange (pulmonary circulation). The left side of the
heart pumps blood to the rest of the body
(systemic circulation).
Great vessels
The large veins and arteries leading directly to and away from the heart are
referred to as the ______ vessels.
The superior and inferior ______ is a
great vessel that return blood to the right
atrium from the upper and lower torso.
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Vena cava
Pulmonary artery
______ artery exits the right ventricle,
bifurcates, and carries blood to the lungs.
______ veins (two from each lung) return
oxygenated blood to the left atrium.
Pulmonary veins
______ transports oxygenated blood
from the left ventricle to the body.
Aorta
The heart has four ______. Two upper
chambers, left and right atria, and two
lower chambers, right and left ventricles.
Chambers
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The right and left sides of the heart
are separated by a partition called the
______.
Septum
Atria, ventricles
______ (thicker walled) receive blood returning to the heart and pump blood into
the ______.
Atrioventricular (AV) valve
The entrance and exit of each ventricle
are protected by a one way valves that
direct the flow of blood through the heart
called the ______ valve. There are two:
tricuspid and bicuspid (mitral) valve.
The ______ is made of three cusps and
located between left atrium and left ventricle.
Tricuspid valve
Collagen fibers called ______ anchor the
AV valve flaps to papillary muscles within
the ventricles.
Chordae tendineae
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Semilunar valves
______ valves are at the exit of each
ventricle at the beginning of the great
veins. There are two of these valves: pulmonic and aortic valve. These valves are
open during ventricular contraction and
close from the pressure of blood when
ventricles relax.
______ is a tough, inextensible, loose-fitting, fibroserous sac that attaches to the
great vessels and surrounds the heart.
Pericardium
Parietal pericardium
A serous membrane lining, the ______
pericardium, secretes a small amount of
pericardial fluid that allows for smooth,
friction-free movement of the heart.
Epicardium
The ______ is a serous membrane that
covers the outer surface of the heart.
Myocardium
______ is the thickest layer of the heart,
made up of contractile cardiac muscle
cells.
Endocardium
______ is a thin layer of endothelial tissue that forms the innermost layer of the
heart and is continuous with the endothelial lining of blood vessels.
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Cardiac
Electrical conduction of the heart:
Cardiac muscle cells can spontaneously
generate an electric impulse and conduct it through the heart (myocardium).
This fills and empty chambers which is
called the ______ cycle.
Sinoartial (SA) node
______ (sinus) node is located on the
posterior wall of the right atrium near the
junction of the superior and inferior vena
cava. Rhythmicity, generates impulse (60
- 100/minute) that are conducted over
both atria, causing them to contract simultaneously, sending blood into ventricles. Pacemaker of hearet.
Atrioventricular (AV) node
______ node becomes activated when
the current from SA node is conducted
across atria. This node slightly delays incoming electrical impulses from the atria
and then relays the impulse to AV bundle
in the upper interventricular septum.
Purkinje fibers
Electrical impulse from AV nodes goes
to left bundle branches and the ______
fibers in the myocardium of both ventricles, causing them to contract almost at
the same time.
Bundle of his
______ of his takes over as the "pacemaker of heart" if SA node cannot function.
Electrocardiography
______ (EKG) is how electrical activity
can be measured and recorded which
can be detected on the surface of the
skin. Records depolarization and repolarization of the cardiac muscles.
The cardiac cycle has two phases:
______ (relaxation of ventricles, filling,
2/3 of cycle) and ______ (contraction of
the ventricles, emptying, 1/3 cycle).
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Diastole, systole
Atria
During diastole, AV valves are open and
ventricles are relaxed. Blood is rushing
into ______ called protodiastolic filling.
Near the end, it empties into ventricles
which is called presystole "Atrial kick".
AV valve
During systole, there is a large amount
of blood in ventricles, causing the pressure in the ventricles to be higher in the
atria. This causes ______ valves to shut.
Closure of the AV valves produces the
first heart sound which is the beginning
of systole. Also prevents backflow (regurgitation) into atria during ventricular
contraction.
Second
With ventricular emptying, the ventricular
pressure falls and the semilunar valves
close. This closure produces the ______
heart sound, which is the end of systole.
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1. During Diastole the relaxed
ventricles are
2. During Diastole the open
Tricuspid and Mitral Valves are
3. During Diastole
Blood flows into
the
ventricles
4. During Diastole the contract
atria
5. First heart Sound - Tricuspid and Mitral valve snap shut
S1 is....
6. During Systole
rises
pressure in the ventricles
7. During Systole
closed
briefly all valves are
8. During Systole ris- aortic and pulmonary
ing pressure causes ______ and
______ valves to
open
9. During Systole,
aorta and pulmonary artery
blood goes into the
10. Second heart
sound - S2
pressure falls and pulmonary valve and aortic valve
snap shut
11. A split S2 sound is effect of respiration; aortic valve closes before pulcaused by
monary valve
12.
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Subjective data
Chest Pain, Cough, Cyanosis/pallor, Diaphoresis, Dyscommon or conpnea, Edema, Fatigue, Heartburn, Nausea, Nocturia,
cerning symptoms Orthopnea, Pain or discomfort radiating to neck/ left
shoulder/ left arm/ back, Palpitations / skipped beat,
Paroxysmal nocturnal dyspnea
13. Orthopnea
sleep elevated to breathe better; GERD could be a
problem; should sleep at a 30 degree angle
14. Nocturnal Dyspnea Sudden waking and sitting up in the middle of the night
to breathe properly
15. Bedridden patients sacral; hands/periphery
often have edema
in the _________
area and in the
__________
16. Nocturia
waking to urinate at night; take diuretics in the morning
and limit fluid intake after 7pm
17. Past health history CAD, HTN, DM, stroke, obesity, pericarditis, murmurs,
- diseases/ condi- rheumatic fever, congenital heart disease
tions
18. past health history cholesterol level, triglicerides, stress test, ECG, chest
- tests and results xray, Cardiac Cath, CABG, stents, dopplers (peripheral
or venous), echocardiogram
19. Cardiac Catheteri- dye injected into femoral artery looking for blockages in
zation
the heart
20. echocardiogram
shows how the valves are pumping
21. stress test
looking for a change in ST wave while treadmill incline
is increased; indicates a blockage
22. family history
questions
did a family member die before age 40 or a parent before
age 60 cardiac related issue, CAD, HTN, DM, Strokes
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23. Lifestyle habits
questions
dietary adjustments, nutrition, smoking, alcohol use,
medications incl otc and herbal
24. Examining carotid Auscultate with bell of stethoscope - looking for a bruit arteries
means there is narrowing of the blood vessels; Palpate
- each side separately never together
25. Examining jugular Inspect jugular pulse, estimate jugular venous pressure,
veins
palpate for hepatojugular reflux
26. Jugular Venous
Distention
Jugular Venous Pressure - find angle of Louis at sternal
angle; compare with pulsation point at 30 degrees; s/b
3 cm or less above sternal angle; venous pressure
measured at > 3 cm is considered abnormal
27. Cardiac Assessment points
1. aortic - 2nd intercostal sp, rt
2. pulmonic - 2nd intercostal sp, left
3. erb's pt. - 3rd intercostal sp, left
4. tricuspid - 4th/5th intercostl sp, lft
5 mitral or apex - fifth intercostal sp, left midclavicular
line (apical)
28. what is considered if you can visually see the heart pulsing; if you palpate
an abnormal find- and feel a thrill (cat purring) = murmur
ing at the cardiac assessment
points?
29. inspection and pal- Inspect the anterior chest
pation - precordium Palpate the apical pulse
Palpate across the precordium
Percuss to outline cardiac borders
30. Abnormal Ventricu- Lift
lar Impulses
Thrill
Accentuated Apical Impulse
Laterally Displaced Apical Impulse
31. Auscultate the
rate and rhythm
heart sounds - note
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the __________ and
__________
32. ** Sinus arrhythmia always originates in the
SA node
33. Pulse deficit
difference between apical and radial pulse - use two
people
34. s1 louder than s2 at apex, base
the ___________
s2 louder than s1 at
the ___________
35. Listen to S1 and S2 separately
____________
heart sounds
Listen for exmurmurs
tra ________
__________
Listen for
_____________
36. Extra heart sounds diseased valves
occur due to
37. Systole extra heart clicks
sounds are
38. clicks indicate
a valve is functioning but diseased
39. Diastole S3 sound sounds like 'ken-tuck-y";
always heard closest to S2;
heard due to rapid fillingof ventricles
40. Diastole S4 sound always heard closest to S1 (before it)
41. Diastole Opening
Snap
always heard early in diastole;
very high pitched
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42. S3 occurs with
fluid overload, congestive heart failure, decreased myocardial contractility
43. S4 is a __________ ventricular filling;
_________ sound; vibrations of blood flowing rapidly into ventricle after
due to ...
atrial contraction;
occurs with....
due to decreased compliance of the ventricles;
occurs with HTN, CAD, acute MI
44. Heart murmur is
turbulent blood flow
45. characteristics of
heart murmur
sounds
timing in the cardiac cycle
intensity (volume, grading)
pitch
quality
shape/pattern
location (tricuspid? mitral?)
TRANSMISSION/RADIATES
position (lying down? sitting?)
46. Systolic Murmur:
Aortic Stenosis
Calcification of Valve
Restricts forward blood flow
increases left ventricular overload
left ventricular hypertrophy
47. *** Systolic Murmur: Pulmonic
Stenosis
Impeded blood flow across pulmonic valve; increasing
right ventricular afterload; ejection click after S1;
right ventricular hypertrophy
48. Systolic Murmur:
Mitral Regurgitation
backflow of blood into left atrium from left ventricle
Incompetent mitral valve stays slightly open
49. Systolic Murmur: backflow of blood from rt ventricle to rt atrium; tricuspid
Tricuspid Regurgi- valve not closing properly; ENGORGED NECK VEINS;
tation
pansystolic murmur
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1. The nurse performs an admission assessment -"Murmur heard over
on an adult client admitted through the ED
right carotid artery"
with a myocardial infarction. The nurse charts
-Does not need to be
"Swooshing sound heard over right carotid
corrected
artery." How should this documentation be cor- -"Split sound auscultatrected?
ed over right carotid
artery"
-*"Right carotid bruit
auscultated"*
Distinguishing a murmur from a bruit can
be challenging. Murmurs originate in the
heart or great vessels
and are usually louder
over the upper precordium and quieter near the
neck. Bruits are higher pitched, more superficial, and heard only over
the arteries. A gallop is
a generic term for an
additional heart sounds
heard besides the normal S1 and S2 sound.
P447
2. A nurse is assessing a client for possible dehy- *Observe for a decrease
dration. Which of the following should the nurse in venous jugular presdo?
sure*
Decrease in jugular venous pressure can occur with dehydration
secondary to a decrease in total blood
volume, so the nurse
should observe for a
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decrease in jugular venous pressure. Assessing the difference in the
apical and radial pulses would help the nurse
assess for pulse deficit.
Differences in the amplitude or rate of the
carotid pulse may indicate stenosis. A split S1
occurs when the left and
right ventricles contract
at different times (asynchronous contraction).
3. When auscultating the heart sounds of a client, *Accentuated*
a nurse notes that the S2 is louder than the S1. -Diminished
How should the nurse describe S2?
-Wide split
-Normal split
4. A nurse cares for a client who suffered a my*Inflammation of the
ocardial infarction 2 days ago. A high-pitched, pericardial sac*
scratchy, scraping sound is heard that increases -Increased pressure
with exhalation and when the client leans forwithin the ventricles
ward. The nurse recognizes this sound as a re- -Inability of the atria to
sult of what process occurring within the peri- contract
cardium?
-Incompetent mitral
valve
A high pitched, scratchy,
scraping sound that increases with exhalation
and when the client
leans forward is called
a pericardial friction rub.
This is caused by inflammation of the pericardial sac. Increased
pressure within the ven2/9
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tricles may cause a decrease in cardiac output.
Inability of the atria to
contract can be caused
by any problem that
causes the sinoatrial
node not to fire. An incompetent mitral valve
would cause a systolic
murmur. P458-459
5. The nurse assesses the client's pulses to be nor- O
mal. These would be documented how?
1+
*2+*
3+
Normal pulses are 2+.
Absent pulses are 0.
Weak pules are 1+. Increased pulses are are
3+. P448
6. What nursing diagnosis would be most appropri- Correct: *Ineffective tisate for a client admitted with heart failure?
sue perfusion*
Wrong: Impaired gas exchange
P440
7. The nursing instructor explains to a group of
students that what can shorten diastole?
*Increased HR*
-BP
-Filling pressure
-Decreased respirations
As the heart rate increases, the length of
diastole is shortened.
The respiratory rate,
blood pressure and fill-
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ing pressures do not
shorten diastole.
8. The nurse understands that when the sympathet- Correct response:
ic nervous system is stimulated what occurs? • Increased cardiac outSelect all that apply.
put
• Increased blood pressure
• Increased heart rate
Explanation:
When the sympathetic nervous system is
stimulated, epinephrine
and norepinephrine are
released which causes an increased heart
rate and cardiac output
and and increase in the
blood pressure. (less)
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing,
5th ed., Philadelphia:
Wolters Kluwer Health,
2014, Chapter 21: Heart
and Neck Vessels, pg.
422.
9. The nurse is providing teaching about cardiovas- *Smoking*
cular disease in a community setting. What risk *Cholesterol*
factors would the nurse identify to the group as *Blood pressure*
those they can modify through lifestyle choices? -Age
Select all that apply.
-Family history
10. When a patient is obese or has a thick chest wall, *Apical impulse*
what is difficult to palpate?
-Grade 4 murmur
-Sternal angle
-JVP
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11. The nurse assesses a hospitalized adult client *increased central veand observes that the client's jugular veins are nous pressure.*
fully extended. The nurse contacts the client's -pulmonary emphysephysician because the client's signs are indica- ma.
tive of
-diastolic murmurs.
-patent ductus arteriosus.
The level of the jugular venous pressure reflects right atrial (central
venous) pressure and,
usually, right ventricular diastolic filling pressure. Right-sided heart
failure raises pressure
and volume, thus raising jugular venous pressure. P439
12. The area known as Erb's point is the third site
for auscultation on the precordium. Where is it
located?
*3rd left rib space*
13. When evaluating the jugular venous pressure in *Right Atrium*
a patient with known coronary artery disease,
the nurse explains to the patient that the JVP
measures the pressure in the
14. A nurse provides prevention strategies to a
-*Walk briskly 30mins a
group of clients who are identified as at risk for day*
hypertension. Which strategies should the nurse -*Choose foods like bainclude? Select all that apply.
nanas and sweet potato*
-*Use low sodium seasoning to flavor food*
15. During the health history interview with a
40-year-old man, the nurse uses the genogram
to specifically assess for major family risk for
5/9
-*Heart attacks in his father and siblings*
-Weight patterns within
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cardiovascular disease by asking about which of his family
the following?
-Hypertension in his
grandparents
-Diabetes mellitus in his
extended family
Risk of developing heart
disease is increased if
one or more immediate
family members (parents or siblings) have
had an MI, hypertension, or high cholesterol.
16. A 58-year-old teacher presents with breathless- *Orthopnea*
ness with activity. The client has no chronic
-Tenesmus
conditions and does not take any medications, -Abdominal pain
herbs, or supplements. Which of the following -Hematochezia
symptoms is appropriate to ask about in the cardiovascular review of systems?
Orthopnea, which is
dyspnea that occurs
when lying down and
improves when sitting
up, is part of the cardiovascular review of systems and, if positive,
may indicate congestive
heart failure. P442
17. The nurse is conducting a health history with a -"Is the pain worse when
female client who reports upper back and jaw
you are lying down?"
pain. In order to assess the client's risk for a
-"Is the pain worse on
cardiac event, which question should the nurse exertion?"
ask first?
-*"Do you have any pain
or discomfort in your
chest?"*
-"Do you have cramping
pain?'
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The first question the
nurse asks should be
broad as this will encourage the client to
share more detail regarding the source of
the pain. Chest pain
is one of the most
serious and important
symptoms often signaling coronary artery disease, potentially leading to myocardial infarction. All of the other
options are more specific; these questions
should only be asked
when the nurse needs
to narrow the focus of
the cardiovascular examination. P440
18. Before the nurse begins the physical examina- -Ensure that the client
tion of a client with congestive heart failure, the lies flat for the examinaclient reports having to get up at night to void tion.
frequently. Which action should the nurse take in -*Inspect for dependent
response to the client's report?
edema.*
-Assess for thrills.
-Palpate the carotid
pulse.
Dependent edema results from sodium
and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of
noctouria results from
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the redistribution of fluid at night, forcing the
client to get up to
void more frequently.
The client should only
be told to lie flat for the
physical examination if
the client is hypovolemic
and the neck veins need
to be visualized. Palpation of the carotid pulse
is useful for determining whether a murmur
is systolic or diastolic.
Thrills are formed by the
turbulence of underlying
murmurs and are associated with other cardiac
conditions. P441
19. A 25-year-old client presents to the health care • *Smokes 5 cigarettes
clinic for a routine physical. Which lifestyle prac- daily for past 5 years*
tices in the client's history are most important • *Family history of heart
for the nurse to provide teaching in assisting the attack before age 50
client to reduce the risk for the development of years*
coronary heart disease? Select all that apply.
• *High stress job as a
financial analyst*
-Adds salt to foods regularly
-Exercise 30 mins 5X a
week
-Ten pounds over ideal
body weight
Risk factors for the
development of coronary heart disease for
this client include tobacco use, family his8/9
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tory of heart attack before age 50 years, and
a high-stress job. Exercise would tend to lower
the client's risk for heart
disease, not increase it.
Although the client is 10
pounds over his ideal
body weight, there is no
evidence that he is overweight or obese. Also,
although the client adds
salt to his food regularly, there is no indication
that he has high blood
pressure. P443
20. The nurse begins auscultating a client's heart 2nd intercostal space
sounds at the 2nd intercostal space right sternal left sternal border
border. Which location should the nurse assess
next?
21. What term is used to describe the degree of vas- *Afterload*
cular resistance to ventricular contraction?
22. While conducting a physical examination of
*Left-sided HF*
the cardiovascular system, the nurse hears fine -Hypertension
crackles on auscultation of the lungs. This find- -Dextrocardia
ing is most likely a manifestation of which prob- -Palpitations
lem?
??????????????????????
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1. Temporary heart
Angina
pain, resolving in
less than 20 minAngina is temporary heart pain, resolving in less than
utes, aggravated by 20 minutes. It can be aggravated by physical activity
physical activity and and stress, or there may be no triggers (unstable
stress is known as angina). This type of pain is not musculoskeletal, gaswhat?
trointestinal, or crushing.
2. Across the lifespan,
a nurse knows what
characteristic of the
female heart is consistently true?
Is normally smaller than the male heart
The total size of the heart is approximately that of
a clenched adult fist. The female heart is normally
smaller and weighs less than the male heart across
all age groups. The female heart does not consistently
beat more slowly than a male heart.
3. A client comes to
Shortness of breath
the emergency department reporting a Clients with heart failure may be short of breath from
sudden onset of dys- fluid accumulation in the pulmonary bed. Onset may
pnea. What finding be sudden with acute or chronic pulmonary edema.
is a manifestation of It is important to assess how much activity brings on
dyspnea?
dyspnea, such as rest, walking on a flat surface, or
climbing. The other options listed are distracters to the
question.
4. How should a nurse Assess for a difference between the apical and radial
assess a client for
pulse
pulse rate deficit?
The nurse should assess the pulse deficit by assessing the difference in the apical and radial pulse. Pulse
deficit is the difference between the apical and peripheral/radial pulses. Differences in the amplitude or rate
of the carotid pulse may indicate stenosis. A split S1
occurs when the left and right ventricles contract at
different times (asynchronous contraction). Decrease
in jugular venous pressure can occur with dehydration
secondary to a decrease in total blood volume but
does not cause a pulse deficit.
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5. The nurse prepares examining the neck
to perform a carexamining the face
diovascular exami- inspecting the hands and lower legs
nation. The nurse un- inspecting and palpating the precordium
derstands the components of this
examination include
(Select all that apply.)
6. While completing the Shortness of breath
cardiovascular system health history, Shortness of breath, also called orthopnea, is dyspa client reports dif- nea that occurs while the client is lying flat and imficulty falling asleep proves when the client sits up. The client would not exunless she is in
perience relief from chest pain, palpitations or edema
an upright position. by sitting upright. For this reason, these options are
Which of the follow- incorrect.
ing potential problems should the
nurse further investigate?
7. When auscultating Accentuated
the heart sounds of a
client, a nurse notes An accentuated S2 means that the S2 is louder than
that the S2 is loud- the S1. This occurs in conditions in which the aortic
er than the S1. How or pulmonic valve has a higher closing pressure. A
should the nurse de- diminished S2 means that the S2 is softer than the
scribe S2?
S1. This occurs in conditions in which the aortic or
pulmonic valves have decreased mobility. Normal split
S2 can be heard over the second or third left intercostal space; it is usually heard best during inspiration
and disappears during expiration. Wide split S2 is an
increase in the usual splitting that persists throughout
the entire respiratory cycle, and widens on expiration.
8. A nurse ausculBradycardia
tates a client's heart
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sounds and obtains
a rate of 56 beats
per minute. How
should this rate be
documented by the
nurse?
The proper documentation of this rate is bradycardia,
a rate less than 60 beats per minute. The normal adult
heart rate is 60 to 100 beats per minute. Tachycardia
is a heart rate above 100 beats per minute. This heart
rate is decreased, but this is not a proper documentation term.
9. A nurse cares for
Inflammation of the pericardial sac
a client who suffered a myocardial A high pitched, scratchy, scraping sound that increasinfarction 2 days
es with exhalation and when the client leans forward
ago. A high-pitched, is called a pericardial friction rub. This is caused by
scratchy, scraping
inflammation of the pericardial sac. Increased pressound is heard that sure within the ventricles may cause a decrease in
increases with excardiac output. Inability of the atria to contract can be
halation and when caused by any problem that causes the sinoatrial node
the client leans for- not to fire. An incompetent mitral valve would cause a
ward. The nurse rec- systolic murmur.
ognizes this sound
as a result of what
process occurring
within the pericardium?
10. In auscultating
a client's heart
sounds, a nurse
hears a swooshing sound over
the pre cordium.
The nurse recognizes this sound as
which of the following?
Murmur
Blood normally flows silently through the heart. There
are conditions, however, that can create turbulent
blood flow in which a swooshing or blowing sound may
be auscultated over the pre cordium; this sound is
known as a murmur. S1, the first heart sound, sounds
like "lub," and S2, the second heart sound, sounds like
"dubb." Ventricular gallop is a name for the third heart
sound, S3, which is not a swooshing sound over the
pre cordium.
11. Which of the follow- New onset chest pain
ing would the nurse
A new onset of chest pain would be an urgent situation.
3/6
(PrepU) Chapter 21: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_8q4blb
consider to be an ur- The blood pressure, oxygen saturation and heart rate
gent situation?
are within normal limits.
12. What nursing diag- Ineffective tissue perfusion
nosis would be most
appropriate for a
Heart failure can cause ineffective tissue perfusion
client admitted with which can lead to fatigue, pain and activity intolerance.
heart failure?
Impaired gas exchange would be more appropriate for
respiratory disorders
13. The nurse underIncreased cardiac output
stands that when the Increased blood pressure
sympathetic nervous Increased heart rate
system is stimulated
what occurs? Select When the sympathetic nervous system is stimulated,
all that apply.
epinephrine and norepinephrine are released which
causes an increased heart rate and cardiac output and
increase in the blood pressure.
14. The nurse is provid- Smoking
ing teaching about Cholesterol
cardiovascular dis- Blood pressure
ease in a community setting. What
Smoking, cholesterol and blood pressure can be conrisk factors would
trolled through lifestyle choices. Age and family history
the nurse identify
are non-modifiable risk factors.
to the group as
those they can modify through lifestyle
choices? Select all
that apply.
15. The bicuspid, or mi- between the left atrium and the left ventricle.
tral, valve is located
The bicuspid (mitral) valve is composed of two cusps
and is located between the left atrium and the left
ventricle.
16. The nurse is con"Do you have any pain or discomfort in your chest?"
ducting a health his4/6
(PrepU) Chapter 21: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_8q4blb
tory with a female
The first question the nurse asks should be broad
client who reports
as this will encourage the client to share more detail
upper back and jaw regarding the source of the pain. Chest pain is one
pain. In order to
of the most serious and important symptoms often
assess the client's signaling coronary artery disease, potentially leading
risk for a cardiac
to myocardial infarction. All of the other options are
event, which ques- more specific; these questions should only be asked
tion should the nurse when the nurse needs to narrow the focus of the
ask first?
cardiovascular examination.
17. While conducting a left-sided heart failure
physical examination of the carLeft-sided heart failure can cause fluid to leak into the
diovascular system, lungs, and as a result fine crackles can be heard from
the nurse hears fine the movement of fluid in the lungs on air exchange.
crackles on auscul- Auscultation of fine crackles is not a typical finding
tation of the lungs. associated with clients experiencing palpitations or
This finding is most hypertension. Dextrocardia is a condition in which the
likely a manifestaheart is situated on the right side. Fine crackles are
tion of which prob- not a characteristic feature of dextrocardia.
lem?
18. Before the nurse
Inspect for dependent edema.
begins the physical examination of a Dependent edema results from sodium and water reclient with conges- absorption through the kidneys, leading to extracellutive heart failure, the lar expansion. Increased frequency of nocturia results
client reports having from the redistribution of fluid at night, forcing the client
to get up at night
to get up to void more frequently. The client should
to void frequently.
only be told to lie flat for the physical examination if the
Which action should client is hypovolemic and the neck veins need to be
the nurse take in re- visualized. Palpation of the carotid pulse is useful for
sponse to the client's determining whether a murmur is systolic or diastolic.
report?
Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.
19. A nurse provides
prevention strategies to a group of
Walk briskly 30 minutes per day.
Choose foods like bananas and sweet potatoes.
Use a low sodium seasoning to flavor food.
5/6
(PrepU) Chapter 21: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_8q4blb
clients who are identified as at risk for
Encouraging physical activity, decreasing dietary inhypertension. Which take of sodium, and increasing dietary intake of potasstrategies should the sium, such as in bananas and sweet potato, are
nurse include? Se- lifestyle modifications that can promote sustaining a
lect all that apply.
healthy blood pressure. Excess alcohol consumption
is a modifiable lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages
should be limited from one to two per day. Dairy products tend to be high in cholesterol. Clients at risk for
hypertension should avoid increasing consumption of
these foods.
20. The nurse be2nd intercostal space left sternal border
gins auscultating a
client's heart sounds Since the nurse started at the base of the heart, the
at the 2nd intercostal next location to assess would be the 2nd intercostal
space right sternal space left sternal border. The 3rd left intercostal space
border. Which loca- would be assessed next and followed by the 4th intertion should the nurse costal space. The 5th left intercostal space midclavicassess next?
ular line would be assessed last.
21. During a cardiac ex- apex of the heart.
amination, the nurse
can best hear the S1 S1 may be heard over the entire precordium but is
heart sound by plac- heard best at the apex (left MCL, fifth ICS).
ing the stethoscope
at the client's
22. A nurse performs an No current medications or treatments
initial health history on a client adSubjective data is data collected from the client. No
mitted for new onset current medications or treatments is information the
of chest pain. Which nurse obtained from the client. Apical heart rate 70
data is considered beats per minute, no edema of extremities noted, and
subjective for the
apical impulse palpated at 5 intercostal space on left
cardiovascular sys- are examples of objective data collected by the nurse
tem?
upon physical examination.
6/6
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
1. The nurse performs an
Correct response: "Right carotid bruit auscultatadmission assessment on ed"
an adult client admitted
Explanation:
through the ED with a
Bruits are swooshing sounds similar to the
myocardial infarction. The sound of the blood pressure. They result from
nurse charts "Swooshturbulent blood flow related to atherosclerosis.
ing sound heard over
A bruit is audible when the artery is partially
right carotid artery." How obstructed. With complete obstruction, no bruit
should this documentation is audible, because no blood gets through. Disbe corrected?
tinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great
vessels and are usually louder over the upper
a) Does not need to be cor- precordium and quieter near the neck. Bruits
rected
are higher pitched, more superficial, and heard
b) "Murmur heard over
only over the arteries. Split sounds are not heard
right carotid artery"
over arteries. (less)
c) "Split sound ausculReference:
tated over right carotid
Weber, J., & Kelley, J. H. (2014). Health Assessartery"
ment in Nursing, 5th ed. Philadelphia: Wolters
d) "Right carotid bruit aus- Kluwer Health/Lippincott Williams & Wilkins,
cultated"
Chapter 21: Assessing Heart and Neck Vessels,
p. 431.
2. During an interview with
the nurse, a client complains of a fatigue that
seems to get worse in the
evening. Which of the following causes of fatigue
would explain this pattern?
Correct response: Decreased cardiac output
Explanation:
Fatigue may result from compromised cardiac
output. Fatigue related to decreased cardiac
output is worse in the evening or as the day progresses, whereas fatigue seen with depression
is ongoing throughout the day. Severe muscular
exertion and an upper respiratory infection may
be associated with fatigue, but not the pattern
a) Decreased cardiac out- mentioned in the scenario. (less)
put
Reference:
b) Depression
Weber, J.R., & Kelley, J.H. Health Assessment
c) Severe muscular exer- in Nursing, 5th ed., Philadelphia: Wolters Kluwtion
er Health/Lippincott Williams & Wilkins, 2014,
d) Upper respiratory infec- Chapter 21: Assessing Heart and Neck Vessels,
tion
p. 424.
1 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
3. In order to palpate an api- Correct response: left midclavicular line at the
cal pulse when perform- fifth intercostal space
ing a cardiac assessment, Explanation:
where should the nurse
The apical pulse is the point of maximal impulse
place the fingers?
and is located in the fifth intercostal space at the
left midclavicular line when the client is placed
a) left midclavicular line at in a sitting position. The apical impulse is palthe fifth intercostal space pated in the mitral area and therefore cannot be
b) right of the midclavic- palpated at the left midclavicular line at the third
ular line at the third inter- intercostal space, at right of the midclavicular
costal space
line at the third intercostal space and at right
c) left midclavicular line at of the midclavicular line at the fifth intercostal
the third intercostal space space. (less)
d) right of midclavicular
Reference:
line at the fifth intercostal Weber, J., & Kelley, J. H. (2014). Health Assessspace
ment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 432.
4. The client has been diagnosis with severe sepsis.
Which finding would indicate the client is experiencing low cardiac output?
Correct response: Tachycardia; hypotension
Explanation:
A low cardiac output would be exhibited by
tachycardia and hypotension.
Reference:
Weber, J., and Kelley, J. Health Assessment in
Nursing, 5th ed., Philadelphia: Wolters Kluwer
a) Bradycardia; hyperten- Health, 2014, Chapter 21: Assessing Heart and
sion
Neck Vessel, pg. 422.
b) Tachycardia; hypotension
c) Bradycardia; hypotension
d) Tachycardia; hypertension
5. Where are the heart and
great vessels located in
Correct response: The mediastinum, between
the lungs above the diaphragm
2 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
the human body?
Explanation:
The heart and great vessels are located in the
a) The mediastinum, bemediastinum between the lungs and above the
tween the lungs below the diaphragm from the center to the left of the thodiaphragm
rax. Therefore, the other options are incorrect.
b) The mediastinum, be(less)
tween the lungs above the Reference:
diaphragm
Weber, J., & Kelley, J. H. (2014). Health Assessc) The peritoneum, below ment in Nursing, 5th ed. Philadelphia: Wolters
the diaphragm
Kluwer Health/Lippincott Williams & Wilkins,
d) The peritoneum, above Chapter 21: Assessing Heart and Neck Vessels,
the diaphragm
p. 416.
6. A client is experiencing
Correct response: Blood pressure
decreased cardiac output. Explanation:
Which vital sign is priori- With decreased cardiac output, the heart pumps
ty for the nurse to monitor inadequate blood to meet the body's metabolic
frequently?
demands. The blood pressure is most important
to assess frequently. (less)
a) Heart rate
Reference:
b) Blood pressure
Weber, J., and Kelley, J. Health Assessment in
c) Respiratory rate
Nursing, 5th ed., Philadelphia: Wolters Kluwer
d) Temperature
Health, 2014, Chapter 21: Assessing Heart and
Neck Vessels, pg. 422.
7. During auscultation of the Correct response: Murmur
heart, the nurse notes
Explanation:
a swooshing sound. The A murmur is a swooshing sound caused by turnurse would document
bulent blood flow. Extra heart sounds could inthis as what?
clude a ventricular vibration. A flutter is a cardiac
rhythm. (less)
a) Murmur
Reference:
b) Extra sound
Weber, J., and Kelley, J. Health Assessment in
c) Flutter
Nursing, 5th ed., Philadelphia: Wolters Kluwer
d) Vibration
Health, 2014, Chapter 21: Assessing Heart and
Neck Vessels, pg. 422.
8. The area known as Erb's
point is the third site for
Correct response: 3rd left rib space
Explanation:
3 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
auscultation on the preThe 3rd left rib space is the third site for ausculcordium. Where is it locat- tation (Erb's point). The other options are dised?
tracters. (less)
Reference:
a) 3rd right rib space
Weber, J., & Kelley, J. H. (2014). Health Assessb) 4th left rib space
ment in Nursing, 5th ed. Philadelphia: Wolters
c) 3rd left rib space
Kluwer Health/Lippincott Williams & Wilkins,
d) 4th right rib space
Chapter 21: Assessing Heart and Neck Vessels,
p. 423.
9. A 58-year-old teacher pre- Correct response: Orthopnea
sents with breathlessness Explanation:
with activity. The client has Orthopnea, which is dyspnea that occurs when
no chronic conditions and lying down and improves when sitting up, is part
does not take any medof the cardiovascular review of systems and, if
ications, herbs, or supple- positive, may indicate congestive heart failure.
ments. Which of the follow- (less)
ing symptoms is appropri- Reference:
ate to ask about in the car- Weber, J., & Kelley, J. H. (2014). Health Assessdiovascular review of sys- ment in Nursing, 5th ed. Philadelphia: Wolters
tems?
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
a) Tenesmus
p. 425.
b) Abdominal pain
c) Orthopnea
d) Hematochezia
10. While completing the car- Correct response: Shortness of breath
diovascular system health Explanation:
history, a patient tells the The use of pillows to sleep helps determine if
nurse about using four pil- the patient is experiencing orthopnea or shortlows at night to sleep. The ness of breath when sleeping in the flat position.
nurse will use this infor- The use of pillows is not assessed for chest
mation to further assess pain, palpitations, or edema. (less)
which area?
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessa) Chest pain
ment in Nursing, 5th ed. Philadelphia: Wolters
b) Edema
Kluwer Health/Lippincott Williams & Wilkins,
4 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
c) Palpitations
d) Shortness of breath
Chapter 21: Assessing Heart and Neck Vessels,
p. 425.
11. The nurse understands
Correct response:
that when the sympathetic • Increased cardiac output
nervous system is stimu- • Increased blood pressure
lated what occurs? Select • Increased heart rate
all that apply.
Explanation:
When the sympathetic nervous system is stima) Increased cardiac out- ulated, epinephrine and norepinephrine are reput
leased which causes an increased heart rate
b) Decreased cardiac out- and cardiac output and and increase in the
put
blood pressure. (less)
c) Increased blood pres- Reference:
sure
Weber, J., and Kelley, J. Health Assessment in
d) Decreased blood pres- Nursing, 5th ed., Philadelphia: Wolters Kluwer
sure
Health, 2014, Chapter 21: Heart and Neck Vese) Increased heart rate
sels, pg. 422.
12. The nursing instructor is Correct response: A thrill
discussing assessment of Explanation:
the heart with students.
Thrills are vibrations detected on palpation. A
A student states that he
palpable, rushing vibration (thrill) is caused from
has a client with a rushing turbulent blood flow with incompetent valves,
vibration in the precordi- pulmonary hypertension, or septal defects. This
um that the student could vibration is usually in the location of the valve
feel and that it was in the in which it is associated. A thrust or a heave is
area of the pulmonic valve. a forceful thrusting on the chest. This is not a
What should the instructor normal finding. (less)
explain that the student is Reference:
feeling?
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
a) A thrill
Kluwer Health/Lippincott Williams & Wilkins,
b) A heave
Chapter 21: Assessing Heart and Neck Vessels,
c) A thrust
p. 432.
d) A normal finding
13. How does the nurse difCorrect response: Have the client hold his or her
ferentiate a pleural friction breath; if the rub persists, it is pericardial
5 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
rub from a pericardial fric- Explanation:
tion rub?
Pericardial friction rubs can be differentiated
from pleural friction rubs by having the client
a) Auscultate the base of hold the breath. If present without breathing,
the heart; if a rub is prethe rub is pericardial. Turning the client to the
sent, it is pericardial
right side and auscultating either the base of
b) Turn the client on the
the heart or the upper back do not differentiate
right side; if the rub per- between pericardial and pleural friction rubs.
sists, it is pericardial
(less)
c) Auscultate the upper
Reference:
back; if a rub is present, it Weber, J., & Kelley, J. H. (2014). Health Assessis pleural
ment in Nursing, 5th ed. Philadelphia: Wolters
d) Have the client hold his Kluwer Health/Lippincott Williams & Wilkins,
or her breath; if the rub per- Chapter 21: Assessing Heart and Neck Vessels,
sists, it is pericardial
p. 442.
14. Question: Understanding Correct response:
pressures in the left atri- aortic pressure is greater than ventricular presum, left ventricle, and aor- sure
ta is fundamental to unmitral valve closes producing S1
derstanding heart sounds. the atrium is empty and pressures in the ventriPlace the following in
cles increase slightly
order of pressures and
S3 and S4 may be heard if pathologic ventricusounds through one car- lar compliance
diac cycle.
ventricular pressure increases and forces the
opening of the aortic valve
aortic valve closes producing S2
1 aortic valve closes pro- Reference:
ducing S2
Weber, J., & Kelley, J. H. (2014). Health Assess2 mitral valve closes pro- ment in Nursing, 5th ed. Philadelphia: Wolters
ducing S1
Kluwer Health/Lippincott Williams & Wilkins,
3 S3 and S4 may be heard Chapter 21: Heart and Neck Vessels, p. 420.
if pathologic ventricular
compliance
4 ventricular pressure increases and forces the
opening of the aortic valve
5 aortic pressure is greater
than ventricular pressure
6 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
6 the atrium is empty and
pressures in the ventricles
increase slightly
15. A nurse auscultates a
client's carotid arteries,
finding the strength of
the pulse to be bounding.
Which score should the
nurse record?
a) 3+
b) 2+
c) 4+
d) 1+
Correct response: 4+
Explanation:
The strength of the pulse is evaluated on a scale
from 0 to 4 as follows: 0 = Absent; 1+ = Weak;
2+ = Normal; 3+ = Increased; 4+ = Bounding.
(less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment
in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014,
Chapter 21: Assessing Heart and Neck Vessels,
p. 431.
16. A client complains of dif- Correct response: Orthopnea
ficulty sleeping, stating he Explanation:
has to sit up with the help A client with heart failure may have fluid in their
of several pillows and can- lungs, making it difficult to breathe when lying
not breathe when lying flat. flat (orthopnea). An increased respiratory rate
This client has a condition is tachypnea. Sleep apnea is a condition where
known as what?
the client has periods of not breathing while
sleeping. Pneumonia does not present as dea) Tachypnea
scribed in the question. (less)
b) Orthopnea
Reference:
c) Pneumonia
Weber, J., & Kelley, J. H. (2014). Health Assessd) Sleep apnea
ment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 425.
17. What finding upon assessment would indicate
the client is experiencing
shock?
a) Temperature 99.5 F
Correct response: Systolic blood pressure 50
Explanation:
A systolic blood pressure of 50 would indicate
the client is experiencing shock. All other vital signs, while elevated do not indicate shock
(less)
7 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
b) Respiratory rate 24
Reference:
c) Heart rate 100
Weber, J., and Kelley, J. Health Assessment in
d) Systolic blood pressure Nursing, 5th ed., Philadelphia: Wolters Kluwer
50
Health, 2014, Chapter 21: Assessing Heart and
Neck Vessels, pg. 431.
18. Which characteristic of
Correct response: Displaced
the apical pulse should a Explanation:
nurse expect to find in the The nurse should expect to find a displaced
client diagnosed with left apical pulse for a client with left ventricular hyventricular hypertrophy? pertrophy. In ventricular hypertrophy, the apical
pulse may be larger than 1 to 2 cm, displaced,
a) Displaced
more forceful, or of longer duration. Bounding
b) Bounding
apical pulse is not a characteristic of ventricular
c) Diminished
hypertrophy. (less)
d) Normal
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment
in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014,
Chapter 21: Assessing Heart and Neck Vessels,
p. 433.
19. The nurse manager on a Correct response: Palpating carotid pulses sicardiac unit should immultaneously.
mediately intervenen when Explanation:
observing which staff
Caroid pulse palpation should be conducted by
nurse's assessment tech- feeling one side at a time; otherwise the client
nique?
my become dizzy or lightheaded. All other assessment techniques are correct. (less)
a) Palpation of the point of Reference:
maximum impluse on the Weber, J., and Kelley, J. Health Assessment in
chest.
Nursing, 5th ed., Philadelphia: Wolters Kluwer
b) Inspecting bilateral
Health, 2014, Chapter 21: Assessing Heart and
jugular veins.
Neck Vessels, pp. 438-439
c) Palpating carotid pulses
simultaneously.
d) Auscultaing all heart
sounds with the bell and
diaphragm.
8 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
20. What nursing diagnosis
Correct response: Ineffective tissue perfusion
would be most appropriate Explanation:
for a client admitted with Heart failure can cause ineffective tissue perfuheart failure?
sion which can lead to fatigue, pain and activity
intolerance. Impaired gas exchange would be
a) Impaired gas exchange more appropriate for respiratory disorders (less)
b) Acute pain
Reference:
c) Risk for denial
Weber, J., and Kelley, J. Health Assessment in
d) Ineffective tissue perfu- Nursing, 5th ed., Philadelphia: Wolters Kluwer
sion
Health, 2014, Chapter 21: Assessing Heart and
Neck Vessels, pg. 437.
21. Temporary heart pain, re- Correct response: Angina
solving in less than 20 min- Explanation:
utes, aggravated by phys- Angina is temporary heart pain, resolving in
ical activity and stress is less than 20 minutes. It can be aggravated by
known as what?
physical activity and stress, or there may be no
triggers (unstable angina). This type of pain is
a) Musculoskeletal
not musculoskeletal, gastrointestinal, or crushb) Crushing
ing. (less)
c) Gastrointestinal
Reference:
d) Angina
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 424.
22. The nurse is caring for a Correct response: Eat low-fat, low-cholesterol
client who has an elevat- meals
ed cholesterol level. To re- Explanation:
duce the mean total blood This client should follow a low-fat, low-cholescholesterol and LDL cho- terol diet. It would be inappropriate to teach the
lesterol levels, what would patient to eat high-protein or low-carbohydrate
be important to teach this meals. (less)
client?
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
a) Eat low-cholesterol,
Kluwer Health/Lippincott Williams & Wilkins,
low-carbohydrate meals
9 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
b) Eat high-protein, low-fat Chapter 21: Assessing Heart and Neck Vessels,
meals
p. 429.
c) Eat high-protein,
low-carbohydrate meals
d) Eat low-fat, low-cholesterol meals
23. While performing an
admission assessment,
the nurse auscultates a
high-pitched, scratching,
and grating sound at the
left lower sternal border.
The nurse should know
that this would be documented as what type of
sound?
a) Paradoxical sound
b) Split sound
c) Pericardial murmur
d) Pericardial friction rub
Correct response: Pericardial friction rub
Explanation:
The pericardial friction rub is the most important
physical sign of acute pericarditis. It may have
up to three components during the cardiac cycle
and is high pitched, scratching, and grating. It
can best be heard with the diaphragm of the
stethoscope at the left lower sternal border. The
pericardial friction rub is heard most frequently
during expiration and increases when the client
is upright and leaning forward. This is not a
paradoxical sound, a split sound, or a murmur.
(less)
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 442.
24. The client is experiencCorrect response: 1+ pulses
ing severe sepsis. What
Explanation:
assessment finding would The blood pressure, heart rate, and respiratory
the nurse expect?
rate are all within normal limit. Weak pulses
would be expected. (less)
a) 1+ pulses
Reference:
b) Blood pressure 140/80 Weber, J., and Kelley, J. Health Assessment in
c) Respiratory rate 14
Nursing, 5th ed., Philadelphia: Wolters Kluwer
d) Heart rate 88
Health, 2014, Chapter 21: Assessing Heart and
Neck Vessels, pg. 431.
25.
10 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
The nurse hears
Correct response: Bruits.
high-pitched swooshing Explanation:
sounds over the carotid
Distinguishing a murmur from a bruit can be
artery on the right side.
challenging. Murmurs originate in the heart or
What is this sound indica- great vessels and are usually louder over the
tive of?
upper precordium and quieter near the neck.
Bruits are higher pitched, more superficial, and
a) Gallops
heard only over the arteries. A gallop is a generb) Murmurs
ic term for an additional heart sounds heard
c) Bruits
besides the normal S1 and S2 sound. (less)
d) Normal findings
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 431.
26. A nurse auscultates a
Correct response: Bradycardia
client's heart sounds and Explanation:
obtains a rate of 56 beats The proper documentation of this rate is bradyper minute. How should
cardia, a rate less than 60 beats per minute.
this rate be documented by The normal adult heart rate is 60-100 beats per
the nurse?
minute. Tachycardia is a heart rate above 100
beats per minute. This heart rate is decreased
a) Bradycardia
but this is not a proper documentation term.
b) Normal
(less)
c) Decreased
Reference:
d) Tachycardia
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 433.
27. A nurse is assessing a
Correct response: Auscultate for split S1 at the
client for the presence of base and apex
asynchronous contraction Explanation:
in the heart. Which of the A split S1 occurs when the left and right venfollowing should the nurse tricles contract at different times (asynchronous
do?
contraction); thus, the nurse should auscultate
11 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
for split S1 at the base and apex to detect this
a) Check for pulse inequal- condition. Pulse deficit is detected by assessing
ity between right and left the difference in the apical and radial pulses. Difcarotid arteries
ferences in the amplitude or rate of the carotid
b) Assess for a difference pulse may indicate stenosis. Decrease in jugubetween the apical and ra- lar venous pressure can occur with dehydration
dial pulse
secondary to a decrease in total blood volume.
c) Auscultate for split S1 at (less)
the base and apex
Reference:
d) Observe for a decrease Weber, J. R., & Kelley, J. H. (2014). Health
in jugular venous pressure Assessment in Nursing, 5th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams &
Wilkins, Chapter 21: Assessing Heart and Neck
Vessels, p. 420.
28. A nurse is unable to pal- Correct response: Client has an increased chest
pate the apical impulse
diameter
on an older client. Which Explanation:
assessment data in the
The apical impulse may not be palpable in
client's history should the clients with increased anteroposterior diamenurse recognize as the rea- ters. Irregular heart rate should not interfere with
son for this finding?
the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse.
a) Heart rate is irregular
Heart enlargement would displace the apical
b) Client has an increased impulse but not cause it to be nonpalpable.
chest diameter
(less)
c) Respiratory rate is too Reference:
fast
Weber, J.R., & Kelley, J.H. Health Assessment
d) Heart enlargement is
in Nursing, 5th ed., Philadelphia: Wolters Kluwpresent
er Health/Lippincott Williams & Wilkins, 2014,
Chapter 21: Assessing Heart and Neck Vessels,
p. 433.
29. A client is admitted to
Correct response: Ineffective Tissue Perfusion
the health care facility
Explanation:
with reports of chest pain, The nurse assesses a decrease in the carotid
elevated blood pressure, pulses (1+ is considered weak) and a weak radiand shortness of breath
al pulse is present. The client also has a murmur.
with activity. The nurse pal- These findings allow the nurse to confirm the
12 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
pates the carotid arteries diagnosis of Ineffective Tissue Perfusion. There
as 1+ bilaterally and a weak are not enough criteria to confirm the diagnosis
radial pulse. A Grade 3 sys- of Impaired Breathing Pattern, Activity Intolertolic murmur is auscultat- ance, or Ineffective Health Maintenance. (less)
ed. Which nursing diagno- Reference:
sis can the nurse confirm Weber, J.R., & Kelley, J.H. Health Assessment
based on this data?
in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014,
a) Activity Intolerance
Chapter 21: Assessing Heart and Neck Vessels,
b) Impaired Breathing Pat- p. 437.
tern
c) Ineffective Health Maintenance
d) Ineffective Tissue Perfusion
30. How should a nurse asCorrect response: Assess for a difference besess a client for pulse rate tween the apical and radial pulse
deficit?
Explanation:
The nurse should assess the pulse deficit by
a) Auscultate for split S1 at assessing the difference in the apical and radial
the base and apex
pulse. Pulse deficit is the difference between the
b) Observe for a decrease apical and peripheral/radial pulses. Differences
in jugular venous pressure in the amplitude or rate of the carotid pulse may
c) Check for pulse inequal- indicate stenosis. A split S1 occurs when the left
ity between right and left and right ventricles contract at different times
carotid arteries
(asynchronous contraction). Decrease in jugud) Assess for a difference lar venous pressure can occur with dehydration
between the apical and ra- secondary to a decrease in total blood volume
dial pulse
but does not cause a pulse deficit. (less)
Reference:
Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck Vessels,
p. 434.
31. A nurse performs an initial health history on a
Correct response: No current medications or
treatments
13 / 14
Health Assessment: Assessing Heart and Neck Vessels
Study online at https://quizlet.com/_zfaj3
client admitted for new on- Explanation:
set of chest pain. Which
Subjective data is data collected from the client.
data is considered subjec- No current medications or treatments is infortive for the cardiovascular mation the nurse obtained from the client. Apical
system?
heart rate 70 beats per minute, no edema of
extremities noted, and apical impulse palpated
a) Apical heart rate 70
at 5 intercostal space on left are examples of
beats per minute
objective data collected by the nurse upon physb) Apical impulse palpated ical examination. (less)
at 5 intercostal space on Reference:
left
Weber, J., & Kelley, J. H. (2014). Health Assessc) No edema of extremities ment in Nursing, 5th ed. Philadelphia: Wolters
noted
Kluwer Health/Lippincott Williams & Wilkins,
d) No current medications Chapter 21: Assessing Heart and Neck Vessels,
or treatments
p. 424.
32. A nurse cares for a client Correct response: Inflammation of the pericarwho suffered a myocardial dial sac
infarction two (2) days ago. Explanation:
A high pitched, scratchy, A high pitched, scratchy, scraping sound is
scraping sound is heard heard that increase with exhalation and when
that increase with exhala- the client leans forward is called a pericardial
tion and when the client
friction rub. This is caused by inflammation of
leans forward. The nurse the pericardial sac. Increased pressure within
recognizes this sound as the ventricles may cause a decrease in cardiac
a result of what process
output. Inability of the atria to contract can be
occurring within the peri- caused by any problem that causes the sinoacardium?
trial node not to fire. An incompetent mitral valve
would cause a systolic murmur. (less)
a) Increased pressure
Reference:
within the ventricle
Weber, J., & Kelley, J. H. (2014). Health Assessb) Incompetent mitral
ment in Nursing, 5th ed. Philadelphia: Wolters
valve
Kluwer Health/Lippincott Williams & Wilkins,
c) Inflammation of the
Chapter 21: Assessing Heart and Neck Vessels,
pericardial sac
p. 442.
d) Inability of the atria to
contract
14 / 14
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
1.
The nurse performs an admisCorrect response: "Right carotid bruit
sion assessment on an adult client auscultated"
admitted through the ED with a
Explanation:
myocardial infarction. The nurse Bruits are swooshing sounds similar
charts "Swooshing sound heard to the sound of the blood pressure.
over right carotid artery." How
They result from turbulent blood flow
should this documentation be cor- related to atherosclerosis. A bruit is
rected?
audible when the artery is partially
obstructed. With complete obstruction,
no bruit is audible, because no blood
a) Does not need to be corrected gets through. Distinguishing a murmur
b) "Murmur heard over right
from a bruit can be challenging. Murcarotid artery"
murs originate in the heart or great
c) "Split sound auscultated over vessels and are usually louder over the
right carotid artery"
upper precordium and quieter near the
d) "Right carotid bruit auscultat- neck. Bruits are higher pitched, more
ed"
superficial, and heard only over the arteries. Split sounds are not heard over
arteries. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 431.
2.
During an interview with the nurse, Correct response: Decreased cardiac
a client complains of a fatigue that output
seems to get worse in the evening. Explanation:
Which of the following causes of Fatigue may result from compromised
fatigue would explain this pattern? cardiac output. Fatigue related to decreased cardiac output is worse in
a) Decreased cardiac output
the evening or as the day progresses,
b) Depression
whereas fatigue seen with depression
c) Severe muscular exertion
is ongoing throughout the day. Severe
d) Upper respiratory infection
muscular exertion and an upper respi1 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
ratory infection may be associated with
fatigue, but not the pattern mentioned
in the scenario. (less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2014, Chapter 21:
Assessing Heart and Neck Vessels, p.
424.
3.
In order to palpate an apical pulse Correct response: left midclavicular
when performing a cardiac asline at the fifth intercostal space
sessment, where should the nurse Explanation:
place the fingers?
The apical pulse is the point of maximal impulse and is located in the fifth
a) left midclavicular line at the fifth intercostal space at the left midclavicintercostal space
ular line when the client is placed in a
b) right of the midclavicular line at sitting position. The apical impulse is
the third intercostal space
palpated in the mitral area and therec) left midclavicular line at the
fore cannot be palpated at the left midthird intercostal space
clavicular line at the third intercostal
d) right of midclavicular line at the space, at right of the midclavicular line
fifth intercostal space
at the third intercostal space and at
right of the midclavicular line at the fifth
intercostal space. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 432.
4.
The client has been diagnosis
Correct response: Tachycardia; hywith severe sepsis. Which finding potension
would indicate the client is experi- Explanation:
2 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
encing low cardiac output?
A low cardiac output would be exhibited by tachycardia and hypotension.
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessel, pg. 422.
a) Bradycardia; hypertension
b) Tachycardia; hypotension
c) Bradycardia; hypotension
d) Tachycardia; hypertension
5.
Where are the heart and great ves- Correct response: The mediastinum,
sels located in the human body? between the lungs above the diaphragm
a) The mediastinum, between the Explanation:
lungs below the diaphragm
The heart and great vessels are lob) The mediastinum, between the cated in the mediastinum between the
lungs above the diaphragm
lungs and above the diaphragm from
c) The peritoneum, below the di- the center to the left of the thorax.
aphragm
Therefore, the other options are incord) The peritoneum, above the di- rect. (less)
aphragm
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 416.
6.
A client is experiencing decreased Correct response: Blood pressure
cardiac output. Which vital sign is Explanation:
priority for the nurse to monitor With decreased cardiac output, the
frequently?
heart pumps inadequate blood to meet
the body's metabolic demands. The
a) Heart rate
blood pressure is most important to
b) Blood pressure
assess frequently. (less)
c) Respiratory rate
Reference:
d) Temperature
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadel3 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
phia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessels, pg. 422.
7.
During auscultation of the heart, Correct response: Murmur
the nurse notes a swooshing
Explanation:
sound. The nurse would document A murmur is a swooshing sound
this as what?
caused by turbulent blood flow. Extra
heart sounds could include a ventrica) Murmur
ular vibration. A flutter is a cardiac
b) Extra sound
rhythm. (less)
c) Flutter
Reference:
d) Vibration
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessels, pg. 422.
8.
The area known as Erb's point is
the third site for auscultation on
the precordium. Where is it located?
a) 3rd right rib space
b) 4th left rib space
c) 3rd left rib space
d) 4th right rib space
9.
Correct response: 3rd left rib space
Explanation:
The 3rd left rib space is the third site
for auscultation (Erb's point). The other
options are distracters. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 423.
A 58-year-old teacher presents
Correct response: Orthopnea
with breathlessness with activity. Explanation:
The client has no chronic condi- Orthopnea, which is dyspnea that octions and does not take any med- curs when lying down and improves
ications, herbs, or supplements. when sitting up, is part of the cardioWhich of the following symptoms vascular review of systems and, if posi4 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
is appropriate to ask about in
tive, may indicate congestive heart failthe cardiovascular review of sys- ure. (less)
tems?
Reference:
Weber, J., & Kelley, J. H. (2014).
a) Tenesmus
Health Assessment in Nursing, 5th
b) Abdominal pain
ed. Philadelphia: Wolters Kluwer
c) Orthopnea
Health/Lippincott Williams & Wilkins,
d) Hematochezia
Chapter 21: Assessing Heart and Neck
Vessels, p. 425.
10. While completing the cardiovascu- Correct response: Shortness of breath
lar system health history, a patient Explanation:
tells the nurse about using four pil- The use of pillows to sleep helps delows at night to sleep. The nurse termine if the patient is experiencing
will use this information to further orthopnea or shortness of breath when
assess which area?
sleeping in the flat position. The use of
pillows is not assessed for chest pain,
a) Chest pain
palpitations, or edema. (less)
b) Edema
Reference:
c) Palpitations
Weber, J., & Kelley, J. H. (2014).
d) Shortness of breath
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 425.
11. The nurse understands that when Correct response:
the sympathetic nervous system • Increased cardiac output
is stimulated what occurs? Select • Increased blood pressure
all that apply.
• Increased heart rate
Explanation:
a) Increased cardiac output
When the sympathetic nervous system
b) Decreased cardiac output
is stimulated, epinephrine and norepc) Increased blood pressure
inephrine are released which causes
d) Decreased blood pressure
an increased heart rate and cardiac
e) Increased heart rate
output and and increase in the blood
pressure. (less)
5 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Heart and Neck Vessels,
pg. 422.
12. The nursing instructor is disCorrect response: A thrill
cussing assessment of the heart Explanation:
with students. A student states
Thrills are vibrations detected on palthat he has a client with a rushing pation. A palpable, rushing vibration
vibration in the precordium that (thrill) is caused from turbulent blood
the student could feel and that it flow with incompetent valves, pulwas in the area of the pulmonic
monary hypertension, or septal devalve. What should the instructor fects. This vibration is usually in the
explain that the student is feeling? location of the valve in which it is associated. A thrust or a heave is a forceful
a) A thrill
thrusting on the chest. This is not a
b) A heave
normal finding. (less)
c) A thrust
Reference:
d) A normal finding
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 432.
13. How does the nurse differentiate a Correct response: Have the client hold
pleural friction rub from a pericar- his or her breath; if the rub persists, it
dial friction rub?
is pericardial
Explanation:
a) Auscultate the base of the
Pericardial friction rubs can be differheart; if a rub is present, it is peri- entiated from pleural friction rubs by
cardial
having the client hold the breath. If preb) Turn the client on the right side; sent without breathing, the rub is periif the rub persists, it is pericardial cardial. Turning the client to the right
c) Auscultate the upper back; if a side and auscultating either the base
6 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
rub is present, it is pleural
of the heart or the upper back do not
d) Have the client hold his or her differentiate between pericardial and
breath; if the rub persists, it is peri- pleural friction rubs. (less)
cardial
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 442.
14. Question: Understanding pressures in the left atrium, left ventricle, and aorta is fundamental
to understanding heart sounds.
Place the following in order of
pressures and sounds through
one cardiac cycle.
Correct response:
aortic pressure is greater than ventricular pressure
mitral valve closes producing S1
the atrium is empty and pressures in
the ventricles increase slightly
S3 and S4 may be heard if pathologic
ventricular compliance
ventricular pressure increases and
1 aortic valve closes producing S2 forces the opening of the aortic valve
2 mitral valve closes producing S1 aortic valve closes producing S2
3 S3 and S4 may be heard if patho- Reference:
logic ventricular compliance
Weber, J., & Kelley, J. H. (2014).
4 ventricular pressure increases Health Assessment in Nursing, 5th
and forces the opening of the aor- ed. Philadelphia: Wolters Kluwer
tic valve
Health/Lippincott Williams & Wilkins,
5 aortic pressure is greater than Chapter 21: Heart and Neck Vessels,
ventricular pressure
p. 420.
6 the atrium is empty and pressures in the ventricles increase
slightly
15. A nurse auscultates a client's
Correct response: 4+
carotid arteries, finding the
Explanation:
strength of the pulse to be bound- The strength of the pulse is evaluated
ing. Which score should the nurse on a scale from 0 to 4 as follows: 0 =
7 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
record?
Absent; 1+ = Weak; 2+ = Normal; 3+ =
Increased; 4+ = Bounding. (less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2014, Chapter 21:
Assessing Heart and Neck Vessels, p.
431.
a) 3+
b) 2+
c) 4+
d) 1+
16. A client complains of difficulty
sleeping, stating he has to sit up
with the help of several pillows
and cannot breathe when lying
flat. This client has a condition
known as what?
a) Tachypnea
b) Orthopnea
c) Pneumonia
d) Sleep apnea
Correct response: Orthopnea
Explanation:
A client with heart failure may have
fluid in their lungs, making it difficult to
breathe when lying flat (orthopnea). An
increased respiratory rate is tachypnea. Sleep apnea is a condition where
the client has periods of not breathing
while sleeping. Pneumonia does not
present as described in the question.
(less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 425.
17. What finding upon assessment
Correct response: Systolic blood preswould indicate the client is experi- sure 50
encing shock?
Explanation:
A systolic blood pressure of 50 would
a) Temperature 99.5 F
indicate the client is experiencing
b) Respiratory rate 24
shock. All other vital signs, while elec) Heart rate 100
vated do not indicate shock (less)
d) Systolic blood pressure 50
Reference:
8 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessels, pg. 431.
18. Which characteristic of the apical Correct response: Displaced
pulse should a nurse expect to
Explanation:
find in the client diagnosed with The nurse should expect to find a disleft ventricular hypertrophy?
placed apical pulse for a client with left
ventricular hypertrophy. In ventricular
a) Displaced
hypertrophy, the apical pulse may be
b) Bounding
larger than 1 to 2 cm, displaced, more
c) Diminished
forceful, or of longer duration. Boundd) Normal
ing apical pulse is not a characteristic
of ventricular hypertrophy. (less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2014, Chapter 21:
Assessing Heart and Neck Vessels, p.
433.
19. The nurse manager on a cardiac
unit should immediately intervenen when observing which staff
nurse's assessment technique?
Correct response: Palpating carotid
pulses simultaneously.
Explanation:
Caroid pulse palpation should be conducted by feeling one side at a time;
a) Palpation of the point of maxi- otherwise the client my become dizzy
mum impluse on the chest.
or lightheaded. All other assessment
b) Inspecting bilateral jugular
techniques are correct. (less)
veins.
Reference:
c) Palpating carotid pulses simul- Weber, J., and Kelley, J. Health Astaneously.
sessment in Nursing, 5th ed., Philadeld) Auscultaing all heart sounds
phia: Wolters Kluwer Health, 2014,
with the bell and diaphragm.
9 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
Chapter 21: Assessing Heart and Neck
Vessels, pp. 438-439
20. What nursing diagnosis would be Correct response: Ineffective tissue
most appropriate for a client ad- perfusion
mitted with heart failure?
Explanation:
Heart failure can cause ineffective tisa) Impaired gas exchange
sue perfusion which can lead to fab) Acute pain
tigue, pain and activity intolerance. Imc) Risk for denial
paired gas exchange would be more
d) Ineffective tissue perfusion
appropriate for respiratory disorders
(less)
Reference:
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessels, pg. 437.
21. Temporary heart pain, resolving in Correct response: Angina
less than 20 minutes, aggravated Explanation:
by physical activity and stress is Angina is temporary heart pain, reknown as what?
solving in less than 20 minutes. It can
be aggravated by physical activity and
a) Musculoskeletal
stress, or there may be no triggers
b) Crushing
(unstable angina). This type of pain is
c) Gastrointestinal
not musculoskeletal, gastrointestinal,
d) Angina
or crushing. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 424.
22.
10 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
The nurse is caring for a client who Correct response: Eat low-fat, low-chohas an elevated cholesterol level. lesterol meals
To reduce the mean total blood
Explanation:
cholesterol and LDL cholesterol This client should follow a low-fat,
levels, what would be important to low-cholesterol diet. It would be inteach this client?
appropriate to teach the patient to
eat high-protein or low-carbohydrate
meals. (less)
a) Eat low-cholesterol, low-carbo- Reference:
hydrate meals
Weber, J., & Kelley, J. H. (2014).
b) Eat high-protein, low-fat meals Health Assessment in Nursing, 5th
c) Eat high-protein, low-carbohy- ed. Philadelphia: Wolters Kluwer
drate meals
Health/Lippincott Williams & Wilkins,
d) Eat low-fat, low-cholesterol
Chapter 21: Assessing Heart and Neck
meals
Vessels, p. 429.
23. While performing an admission
Correct response: Pericardial friction
assessment, the nurse ausculrub
tates a high-pitched, scratching, Explanation:
and grating sound at the left lower The pericardial friction rub is the most
sternal border. The nurse should important physical sign of acute periknow that this would be docucarditis. It may have up to three commented as what type of sound?
ponents during the cardiac cycle and is
high pitched, scratching, and grating. It
a) Paradoxical sound
can best be heard with the diaphragm
b) Split sound
of the stethoscope at the left lower sterc) Pericardial murmur
nal border. The pericardial friction rub
d) Pericardial friction rub
is heard most frequently during expiration and increases when the client is
upright and leaning forward. This is not
a paradoxical sound, a split sound, or
a murmur. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
11 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
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Chapter 21: Assessing Heart and Neck
Vessels, p. 442.
24. The client is experiencing severe Correct response: 1+ pulses
sepsis. What assessment finding Explanation:
would the nurse expect?
The blood pressure, heart rate, and
respiratory rate are all within normal
a) 1+ pulses
limit. Weak pulses would be expected.
b) Blood pressure 140/80
(less)
c) Respiratory rate 14
Reference:
d) Heart rate 88
Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014,
Chapter 21: Assessing Heart and Neck
Vessels, pg. 431.
25. The nurse hears high-pitched
swooshing sounds over the
carotid artery on the right side.
What is this sound indicative of?
a) Gallops
b) Murmurs
c) Bruits
d) Normal findings
26.
12 / 48
Correct response: Bruits.
Explanation:
Distinguishing a murmur from a bruit
can be challenging. Murmurs originate
in the heart or great vessels and are
usually louder over the upper precordium and quieter near the neck. Bruits
are higher pitched, more superficial,
and heard only over the arteries. A gallop is a generic term for an additional
heart sounds heard besides the normal S1 and S2 sound. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 431.
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
A nurse auscultates a client's
Correct response: Bradycardia
heart sounds and obtains a rate of Explanation:
56 beats per minute. How should The proper documentation of this rate
this rate be documented by the
is bradycardia, a rate less than 60
nurse?
beats per minute. The normal adult
heart rate is 60-100 beats per minute.
a) Bradycardia
Tachycardia is a heart rate above 100
b) Normal
beats per minute. This heart rate is dec) Decreased
creased but this is not a proper docud) Tachycardia
mentation term. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 433.
27. A nurse is assessing a client
Correct response: Auscultate for split
for the presence of asynchronous S1 at the base and apex
contraction in the heart. Which of Explanation:
the following should the nurse do? A split S1 occurs when the left and right
ventricles contract at different times
a) Check for pulse inequality be- (asynchronous contraction); thus, the
tween right and left carotid arter- nurse should auscultate for split S1 at
ies
the base and apex to detect this conb) Assess for a difference bedition. Pulse deficit is detected by astween the apical and radial pulse sessing the difference in the apical and
c) Auscultate for split S1 at the
radial pulses. Differences in the amplibase and apex
tude or rate of the carotid pulse may
d) Observe for a decrease in jugu- indicate stenosis. Decrease in jugular
lar venous pressure
venous pressure can occur with dehydration secondary to a decrease in
total blood volume. (less)
Reference:
Weber, J. R., & Kelley, J. H.
(2014). Health Assessment in Nurs13 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
ing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 420.
28. A nurse is unable to palpate the
apical impulse on an older client.
Which assessment data in the
client's history should the nurse
recognize as the reason for this
finding?
a) Heart rate is irregular
b) Client has an increased chest
diameter
c) Respiratory rate is too fast
d) Heart enlargement is present
Correct response: Client has an increased chest diameter
Explanation:
The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate
should not interfere with the ability to
palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause
it to be nonpalpable. (less)
Reference:
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2014, Chapter 21:
Assessing Heart and Neck Vessels, p.
433.
29. A client is admitted to the health Correct response: Ineffective Tissue
care facility with reports of chest Perfusion
pain, elevated blood pressure, and Explanation:
shortness of breath with activiThe nurse assesses a decrease in the
ty. The nurse palpates the carotid carotid pulses (1+ is considered weak)
arteries as 1+ bilaterally and a
and a weak radial pulse is present. The
weak radial pulse. A Grade 3 sys- client also has a murmur. These findtolic murmur is auscultated. Which ings allow the nurse to confirm the dinursing diagnosis can the nurse agnosis of Ineffective Tissue Perfusion.
confirm based on this data?
There are not enough criteria to confirm the diagnosis of Impaired Breatha) Activity Intolerance
ing Pattern, Activity Intolerance, or In14 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
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b) Impaired Breathing Pattern
effective Health Maintenance. (less)
c) Ineffective Health Maintenance Reference:
d) Ineffective Tissue Perfusion
Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2014, Chapter 21:
Assessing Heart and Neck Vessels, p.
437.
30. How should a nurse assess a
client for pulse rate deficit?
Correct response: Assess for a difference between the apical and radial
pulse
a) Auscultate for split S1 at the
Explanation:
base and apex
The nurse should assess the pulse
b) Observe for a decrease in jugu- deficit by assessing the difference in
lar venous pressure
the apical and radial pulse. Pulse
c) Check for pulse inequality be- deficit is the difference between the
tween right and left carotid arter- apical and peripheral/radial pulses. Difies
ferences in the amplitude or rate of
d) Assess for a difference bethe carotid pulse may indicate stenotween the apical and radial pulse sis. A split S1 occurs when the left
and right ventricles contract at different times (asynchronous contraction).
Decrease in jugular venous pressure
can occur with dehydration secondary
to a decrease in total blood volume but
does not cause a pulse deficit. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 434.
31. A nurse performs an initial health Correct response: No current medicahistory on a client admitted for
tions or treatments
15 / 48
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Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
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new onset of chest pain. Which
Explanation:
data is considered subjective for Subjective data is data collected from
the cardiovascular system?
the client. No current medications or
treatments is information the nurse oba) Apical heart rate 70 beats per tained from the client. Apical heart rate
minute
70 beats per minute, no edema of
b) Apical impulse palpated at 5
extremities noted, and apical impulse
intercostal space on left
palpated at 5 intercostal space on left
c) No edema of extremities noted are examples of objective data collectd) No current medications or treat- ed by the nurse upon physical examiments
nation. (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 424.
32. A nurse cares for a client who
Correct response: Inflammation of the
suffered a myocardial infarction pericardial sac
two (2) days ago. A high pitched, Explanation:
scratchy, scraping sound is heard A high pitched, scratchy, scraping
that increase with exhalation and sound is heard that increase with exwhen the client leans forward. The halation and when the client leans
nurse recognizes this sound as a forward is called a pericardial friction
result of what process occurring rub. This is caused by inflammation of
within the pericardium?
the pericardial sac. Increased pressure
within the ventricles may cause a dea) Increased pressure within the crease in cardiac output. Inability of
ventricle
the atria to contract can be caused by
b) Incompetent mitral valve
any problem that causes the sinoatrial
c) Inflammation of the pericardial node not to fire. An incompetent mitral
sac
valve would cause a systolic murmur.
d) Inability of the atria to contract (less)
Reference:
Weber, J., & Kelley, J. H. (2014).
16 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
System
Study online at https://quizlet.com/_dt81kq
Health Assessment in Nursing, 5th
ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins,
Chapter 21: Assessing Heart and Neck
Vessels, p. 442.
33. During deep palpation of the ab- d
domen, the nurse identifies a soft,
nontender, solid mass extending 2
to 3 cm below the right costal margin. Which of the following would
be most appropriate?
A) Refer the client for medical follow-up.
B) Evaluate further for a problem
with the spleen.
C) Assess urinary output.
D) Document the position of the
liver.
34. When reviewing the medications a
currently taken by a 50-year-old
client who is complaining of constipation, teaching is indicated
when the nurse notes which medication?
A) Vitamin supplement with iron
B) Nonsteroidal anti-inflammatory
drug
C) Antidepressant
D) Hormone replacement
35. A group of students is preparc
ing for their clinical experience,
for which they are required to
demonstrate the techniques for
examining the abdomen. The stu17 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
Health Assessment Chapter 21: Peripheral Vascular System and Lymphati
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dents demonstrate understanding
of the proper sequence when they
demonstrate the techniques in
which order?
A) Palpate, percuss, inspect, auscultate
B) Auscultate, inspect, palpate,
percuss
C) Inspect, auscultate, percuss,
palpate
D) Percuss, inspect, auscultate,
palpate
36. Which strategy by the nurse would a
best facilitate palpation of a ticklish client's abdomen?
A) Have client place hand on the
abdomen with the nurse's hand on
top.
B) Press very firmly on the abdomen so the tickle sensation is
absent.
C) Distract the client with conversation about family while palpating the abdomen.
D) Place a small amount of lubricant on the skin so the nurse's fingers will slide more easily.
37. To promote relaxation of the ab- c
dominal muscles, which of the following would be most appropriate
for the nurse to do?
A) Encourage the client to hold his
or her breath.
B) Cover the client in a warm blanket.
18 / 48
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C) Place a pillow under both of the
client's knees.
D) Assure the client that painful
areas will not be examined.
38. A nurse suspects intra-abdominal c
bleeding in a client who was involved in a motor vehicle accident
3 days ago. Which finding would
the nurse most likely have noted?
A) Tenderness on palpation
B) Diastasis recti
C) Cullen's sign
D) Tympany on percussion
39. A young adult male who comes to d
the emergency department complaining of abdominal pain for the
past 3 days is suspected having a
ruptured appendix. The nurse auscultates the client's bowel sounds,
noting them to be which of the following?
A) Normoactive
B) Hyperactive
C) Hypoactive
D) Absent
40. The nurse is percussing a client's' c
liver and is assessing liver descent. The nurse would have the
client do which of the following?
A) Cough forcefully
B) Hold his or her breath
C) Breathe deeply
D) Perform the Valsalva maneuver
19 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
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41. A nurse determines that the liver a
span of an older adult male client
measures 6 cm. The nurse would
interpret this as indicating which
of the following?
A) It is a normal-sized liver.
B) The liver is larger than normal.
C) The liver is smaller than normal.
D) The liver has atrophied.
42. Which of the following would a
b
nurse suspect if dullness is percussed at the last interspace at the
anterior axillary line on deep inspiration?
A) Hepatomegaly
B) Splenomegaly
C) Abdominal mass
D) Intestinal air
43. While assessing a client's abc
domen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this
as most likely indicating which of
the following?
A) Hernia
B) Malignancy
C) Infection
D) Aneurysm
44. The nurse is preparing to assess b
the size of the aorta. The nurse
would palpate at which location?
A) Midline at the umbilicus
B) Deep epigastrium to the left of
midline
20 / 48
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C) Slightly above the suprapubic
area
D) Between the umbilicus and the
symphysis pubis
45. Which of the following would be d
most appropriate if a nurse palpates the abdomen and feels a
prominent, nontender, pulsating
6-cm mass above the umbilicus?
A) Refer the client to an oncologist.
B) Provide a dietician consult for
the client.
C) Counsel the client regarding
hernia repair.
D) Stop palpating and get medical
assistance.
46. A nurse is preparing to palpate
a client's spleen. Which position
would the nurse use to facilitate
palpation?
A) Sitting
B) Lying prone
C) Left side-lying
D) Right side-lying
d
47. A client's bladder is found to
b
be distended. At which location
would the nurse begin palpating?
A) At the umbilicus
B) At the symphysis pubis
C) In the right lower quadrant
D) In the left lower quadrant
48.
d
21 / 48
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Assessment of a client reveals
a distended abdomen with some
bulging of the flanks. Which test
would be most accurate in confirming nurse's suspicions?
A) Shifting dullness
B) Fluid wave
C) Abdominal x-ray
D) Ultrasound
49. The nurse is evaluating a new
nursing graduate's ability to perform a rebound tenderness test
for suspected appendicitis. The
nurse determines correct technique when the new graduate
is observed pressing deeply at
which anatomic location?
A) Right upper quadrant
B) Left upper quadrant
C) Right lower quadrant
D) Left lower quadrant
c
50. The nurse demonstrates the cor- d
rect technique for assessing the
psoas sign by which action?
A) Applying deep palpation pressure to the client's right lower
quadrant, then suddenly releasing
B) Tapping fingerpads over the
client's abdominal wall, feeling for
a floating mass
C) Flexing the client's right hip
and knee, rotating the hip internally and externally
D) Flexing the client's right hip, ap22 / 48
Health Assessment: Assessing Heart and Neck Vessels, Health Assessment Abdomen, Chapter 21: PVS and Lymphatic System Assessment,
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plying downward pressure on the
right thigh
51. When measuring abdominal girth b
in a client with ascites, the nurse
would place the client in which position?
A) Sitting
B) Standing
C) Supine
D) Prone
52. An instructor is explaining the var- a b c e
ious causes associated with abdominal distention. Which of the
following would the instructor include? Select all that apply.
A) Fat
B) Stool
C) Gas
D) Hernia
E) Fibroid tumors
53. After teaching a group of students c
about the important organs to
be assessed during an abdominal
assessment, the instructor determines that the teaching was successful when the students identify
which organ as the largest solid
organ in the body?
A) Pancreas
B) Spleen
C) Liver
D) Kidney
54.
b
23 / 48
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A client is experiencing parietal
abdominal pain. The nurse would
expect the client to describe the
pain as which type of sensation?
A) Dull
B) Steady
C) Cramping
D) Burning
55. A group of students is reviewc
ing information about the locations of various organs within the
abdomen. The students demonstrate understanding of the material when they identify which organ
as being found in the left upper
quadrant?
A) Gallbladder
B) Liver
C) Spleen
D) Head of pancreas
56. A nurse is describing viscera to a b d e f
group of nursing students in the
clinical area, differentiating solid
viscera from hollow viscera. Which
of the following would the nurse
describe as hollow viscera? Select
all that apply.
A) Liver
B) Stomach
C) Pancreas
D) Gallbladder
E) Small intestine
F) Urinary bladder
57.
a
24 / 48
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A client comes to the emergency
department complaining of pain
in the right lower quadrant. Rebound tenderness is present and
the nurse assesses the client for
referred rebound experiences. The
client experiences pain the right
lower quadrant. The nurse interprets this as which of the following?
A) Positive Rovsing's sign
B) Psoas sign
C) Obturator sign
D) Positive skin hypersensitivity
test
58. Assessment of a client's abdomen c
reveals a positive Murphy's sign.
Which of the following would the
nurse suspect?
A) Ascites
B) Appendicitis
C) Cholecystitis
D) Splenomegaly
59. The nurse is preparing to assess b
the abdomen of a client who is
complaining of abdominal pain.
Which statement by the nurse
would be most appropriate?
A) "I'm going to examine the area
where you're having pain first to
get a better picture of what's going
on."
B) "Before I get ready to examine
the painful area, I will let you know
in plenty of time."
25 / 48
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C) "You don't need to worry about
anything. I will make sure to be
very gentle during the exam."
D) "Since you're having pain in a
certain area, I won't have to do a
very thorough exam there."
60. A client is complaining of pain in a
the right upper quadrant and also
in the right shoulder. Which organ
would the nurse suspect as being
involved?
A) Gall bladder
B) Kidneys
C) Stomach
D) Pancreas
61. When inspecting a client's abdom- c
inal contour, the nurse observes
the abdomen to be sunken with the
lower edges of the ribs visible. The
nurse documents this as which of
the following?
A) Flat
B) Rounded
C) Scaphoid
D) Protuberant
62. A nurse is assessing a male
b
client's abdomen. Which of the following would lead the nurse to
suspect a problem?
A) Abdominal respiratory movements
B) Visible peristaltic waves
C) Symmetric appearance
D) No bulging with head raising
26 / 48
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63. 1. Leg pain or cramps
- PQRTSU
- Claudication?
- Claudication distance?
2. Skin changes on arms or legs
- varicose veins?
3. Swelling in arms of legs
- edema: bilateral or unilateral?
4. Lymph node enlargement
5. Medications
List the symptom areas to address during history-taking relating to the peripheral vascular system. (5)
64. Pain produced by decreased blood Define claudication.
flow during exercise but relieved
by rest
65. The number of blocks walked or Define claudication distance.
stairs climbed that produced pain
66. Dilated veins; swollen, twisted and Define varicose veins.
painful veins that have filled with
an abnormal collection of blood
67. Bilateral edema is caused by a
systemic problem
Differentiate between bilateral and unilateral edema.
Unilateral edema is caused by a
local problem or inflammation
68. 1. Skin - note colour of skin
List the steps for inspecting and palpat(consistent with background, even ing the arms. (6)
tone) and nail beds (160 degrees),
temperature (warm and equal bilaterally), texture (smooth, firm,
even) and turgor (ease of rising
and ability to return to place) ,
presence of lesions, edema or
27 / 48
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clubbing
2. Profile sign of nails - normal nail
bed angle of 160 degrees (detects
early clubbing)
3. Capillary refill - normal: colour
return in 1-2 seconds
4. Symmetry - symmetrical in size
5. Pulses (radial, ulnar and
brachial)
- noting rate (60-100bpm)
- rhythm (regular? irregular?)
- force (0-3+)
- equality (equal on both sides?)
- elasticity (stiff?)
6. Epitrochlear node - node is normally not palpable (enlarged = infection of the hand or forearm)
69. 0 = absent
1+ , weak
2+, normal
3+, increased, full, bounding
Fill in the grading scale for assessing
the force of an arterial pulse.
70. Acute infections: enlarged, warm, How will a lymph node feel with acute
tender, firm but freely moveable infections? chronic infection? cancer?
Chronic infections: clumped
Cancer: hard, unilateral, non-tender, fixed
71. 1. Skin and hair - note colour, hair List the steps for inspecting and palpatdistribution
ing the legs. (10) 1/2
2. Varicosities - venous pattern
normally flat and barely visible (inspect with patient standing)
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3. Symmetry - symmetrical in size
without swelling or atrophy (if
asymmetric, measure calf circumference) normal is < 1 cm difference)
4. Temperature - warm and equal
on both sides using dorsum of
hands
72. 5. Calf muscles - no tenderness
List the steps for inspecting and palpatupon compression (flex patients ing the arms. (10) continued
knee and gentle compress gastro
muscle against tibia)
6. Inguinal lymph nodes - normal
to find small, moveable, nontender
palpable nodes
7. Pulses (femoral, popliteal, posterior tibialis, dorsalis pedia) - note
rate, rhythm, force, equality
8. Edema - normally no indentation
upon release after 5 seconds on
firm pressure
9. Colour changes - either performed legs elevated of dangling
(elevational pallor or dependent
rubor = arterial insufficiency)
10. Strength, sensation, capillary
refill
- strength equal bilaterally
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- sensation as per neuro exam
- capillary refill 1-2 seconds max
73. Pain in calf when foot is sharply What is Homan's Sign?
dorsiflexed or compressed; signifies DVT; have poor sensitivity
74. White colour to skin upon eleva- Define elevational pallor.
tion of legs; signifies arterial insufficiency
75. Deep blue-red colour in the skin; Define dependent rubor.
signifies severe arterial insufficiency
76. 1+ Mild pitting, slight indentation, Fill in the description of the grading
no perceptible swelling of the leg scale for pitting edema.
2+ Moderate pitting, indentation,
subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks
swollen
4+ Very deep pitting, indentation
lasts a long time, leg is very
swollen
77. Used to detect weak peripheral
What is a Doppler Ultrasonic Stethopulses, to monitor blood pressure scope?
in infants or children or to measure a low blood pressure or blood
pressure in lower extremity
Magnifies pulsatile sounds from
blood vessels
30 / 48
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78. - Position the person in supine
Describe the technique for using the
- Legs externally rotated so you
Doppler ultrasonic stethoscope to decan reach the medial ankles easily tect peripheral
- Place some gel on the end of
pulses. (5)
transducer
- Place transducer over pulse site
@45 degree angle
- Apply very light pressure and locate the pulse
79. Modified Allen test is used to eval- What is the modified Allen Test? (1)
uate the adequacy of collateral cir- List the steps in performing the modiculation prior to cannulating the fied Allen test. (2)
radial artery;
(a) firmly occlude both the ulnar
and radial arteries of one hand
while the person makes a fist several times. This causes the hand to
blanch
(b) ask the person to open the
hand without hyperextending it;
then release pressure on the ulnar
artery while maintaining pressure
on the radial artery. Adequate circulation is suggested by a return
to the hands normal colour in approximately 2-5 seconds. You must
occlude the both arteries uniformly with 5kg (11lb) of pressure for
the test to be accurate.
80. Used to determine competency of What is the manual compression test
the valves in varicose veins
for varicosities (1) List the steps in performing the test. (2)
1. Place one hand on the lower part
pf the varicose vein and compress
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the vein with your other hand approximately 15-20 cm higher
2. Competent valves prevent a
wave transmission so that your
distal fingers feel no change
81. Used to determine the extent of
peripheral vascular disease
What is the ankle-brachial index (1)
List the steps in performing the test. (2)
1. Apply a regular blood pressure
cuff above the ankle and determine the systolic pressure in either the posterior tibial or dorsalis
pedis
2. Then divide that figure by the
systolic pressure in the arm
82. - lymph nodes palpable even when What are developmental considerahealthy
tions in infants and children. (2)
- lymphatic system well developed
at birth and highly active till puberty
83. - hormonal changes causes vaWhat are developmental considerasodilation = decreased BP
tions in pregnant women. (2)
- growing uterus obstructs
drainage from IVC (causing diffuse
bilateral pitting edema, varicose
veins and hemorrhoids)
84. - arteriosclerosis increases with What are developmental consideraage therefore increasing BP
tions in older adults. (3)
- pedal pulses difficult to palpate
- calf veins enlarge causing increased risk of DVT
85.
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- Episodic spasm of small arteries Define Raynaud's phenomenon. What
in the hand
are S/S? What triggers it? What are
- Pallor, cyanosis, redness in hand, causes?
pain, numbness
- Cold stress, vibration
- Smoking, medications
86. - Swelling due to blocked drainage Define lymphedema. What are S/S?
of lymph
What are causes?
- Unilateral swelling, non-pitting
edema
- Causes: removal or damage of
lymph nodes with breast cancer
treatment
87. Incompetent valves cause backup What is varicose veins
of blood and veins become dilated
88. A deep vein that is occluded by
What is deep vein thrombosis.
a thrombus (clot) which causes
inflammation, blockage or venous
return, cyanosis and edema
89. A buildup of fatty plaque on intima What is an arterial ischemic ulcer
plus hardening and calcification of
arterial wall causing ulcers at toes,
metatarsal heads, heels, and lateral ankles
90. Occurs after acute DVT or chronic What is a venous stasis ulcer
incompetent valves in deep veins;
causes increased venous pressure which then causes RBCs to
leak out of veins and into the skin;
RBCs break down and leave hemosiderin behind
33 / 48
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91. Location
Compare the characteristics of chronic
AI - deep muscle pain in calf or foot arterial insufficiency and venous insufVI - aching pain in calf or lower leg ficiency. (location, aggravation, relieving, signs, ulcer areas, ulcer characterAggravation
istics, ulcer name)
AI - claudication, elevation
VI - prolonged sitting/standing
Relieve
AI - rest, dangling
VI - elevation, walking
Signs
AI - coolness, pallor, dependent rubor, trophic skin
VI - frim brawny edema, thickened
skin, brown pigment
Ulcer areas
AI - toes, heels, lateral ankle
VI - medial malleolus
Ulcer characteristics
AI - pale, blackened base, well-defined edges, no bleeding
VI - bleeding, uneven edges
Ulcer name
AI - arterial (ischemic) ulcer
VI - venous (stasis) ulcer
92. Pallor
Coolness
Malnutrition
List the skin characteristics expected
with arterial insufficiency to the lower
leg.
93.
Differentiate between mild, moderate
and severe lymphedema.
34 / 48
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Mild: 1 to 3 cm asymmetry
Moderate: 3 to 5 cm assymetry
Severe: > 5 cm
94. - Leg pain or cramps
List the symptom areas to address dur- Skin changes on the arms or legs ing history taking relating to the periphswelling in the arms
eral vascular system.
- Lymph node enlargement
95. Which statement is true regarding The arterial system is a high-pressure
the arterial system?
system.
a. Arteries are large-diameter vessels.
b. The arterial system is a
high-pressure system.
c. The walls of arteries are thinner
than those of the veins.
d. Arteries can greatly expand to
accommodate a large blood volume increase.
96. The nurse is reviewing the blood Brachial
supply to the arm. The major artery
supplying the arm is the _____
artery.
a. Ulnar
b. Radial
c. Brachial
d. Deep palmar
97. The nurse is preparing to assess Lateral to the extensor tendon of the
the dorsalis pedis artery. Where is great toe
the correct location for palpation?
a. Behind the knee
b. Over the lateral malleolus
c. In the groove behind the medial
malleolus
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d. Lateral to the extensor tendon of
the great toe
98. A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse
recognizes that this description is
most consistent with _______ the
left leg.
a.
Venous obstruction of
b.
Claudication due to venous abnormalities in
c.
Ischemia caused by a partial
blockage of an artery supplying
d.
Ischemia caused by the complete
blockage of an artery supplying
ANS: C
Ischemia is a deficient supply of
oxygenated arterial blood to a tissue. A partial blockage creates
an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs
increase.
99. The nurse is reviewing venous
blood flow patterns. Which of
these statements best describes
the mechanism(s) by which venous blood returns to the heart?
a.
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Intraluminal valves ensure unidirectional flow toward the heart.
b.
Contracting skeletal muscles milk
blood distally toward the veins.
c.
High-pressure system of the heart
helps facilitate venous return.
d.
Increased thoracic pressure and
decreased abdominal pressure facilitate venous return to the heart.
ANS: A
Blood moves through the veins
by (1) contracting skeletal muscles that proximally milk the blood;
(2) pressure gradients caused by
breathing, during which inspiration makes the thoracic pressure
decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.
100. Which vein(s) is(are) responsible Superficial
for most of the venous return in
the arm?
a.
Deep
b.
Ulnar
c.
Subclavian
d.
Superficial
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Superficil
The superficial veins of the arms
are in the subcutaneous tissue
and are responsible for most of the
venous return.
101. A 70-year-old patient is scheduled
for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What
happens to my circulation when
this vein is removed? The nurse
should reply:
a.
Venous insufficiency is a common
problem after this type of surgery.
b.
Oh, you have lots of veinsyou wont
even notice that it has been removed.
c.
You will probably experience decreased circulation after the vein
is removed.
d.
This vein can be removed without
harming your circulation because
the deeper veins in your leg are in
good condition.
ANS: D
As long as the femoral and
popliteal veins remain intact, the
superficial veins can be excised
without harming circulation. The
other responses are not correct.
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102. The nurse is reviewing the risk factors for venous disease. Which of
these situations best describes a
person at highest risk for the development of venous disease?
a.
Woman in her second month of
pregnancy
b.
Person who has been on bed rest
for 4 days
c.
Person with a 30-year, 1 pack per
day smoking habit
d.
Older adult taking anticoagulant
medication
ANS: B
People who undergo prolonged
standing, sitting, or bed rest are
at risk for venous disease. Hypercoagulable (not anticoagulated) states and vein-wall trauma
also place the person at risk for
venous disease. Obesity and the
late months of pregnancy are also
risk factors.
103. he nurse is teaching a review class
on the lymphatic system. A participant shows correct understanding
of the material with which statement?
a.
Lymph flow is propelled by the
39 / 48
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contraction of the heart.
b.
The flow of lymph is slow, compared with that of the blood.
c.
One of the functions of the lymph
is to absorb lipids from the biliary
tract.
d.
Lymph vessels have no valves;
therefore, lymph fluid flows freely
from the tissue spaces into the
bloodstream.
ANS: B
The flow of lymph is slow, compared with flow of the blood.
Lymph flow is not propelled by
the heart but rather by contracting skeletal muscles, pressure
changes secondary to breathing,
and contraction of the vessel
walls. Lymph does not absorb
lipids from the biliary tract. The
vessels do have valves; therefore,
flow is one way from the tissue
spaces to the bloodstream.
104. When performing an assessment
of a patient, the nurse notices
the presence of an enlarged right
epitrochlear lymph node. What
should the nurse do next?
a.
Assess the patients abdomen, and
notice any tenderness.
b.
40 / 48
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Carefully assess the cervical
lymph nodes, and check for any
enlargement.
c.
Ask additional health history
questions regarding any recent
ear infections or sore throats.
d.
Examine the patients lower arm
and hand, and check for the presence of infection or lesions.
ANS: D
The epitrochlear nodes are located
in the antecubital fossa and drain
the hand and lower arm. The other
actions are not correct for this assessment finding.
105. A 35-year-old man is seen in
the clinic for an infection in his
left foot. Which of these findings
should the nurse expect to see
during an assessment of this patient?
a.
Hard and fixed cervical nodes
b.
Enlarged and tender inguinal
nodes
c.
Bilateral enlargement of the
popliteal nodes
d.
Pelletlike nodes in the supraclavicular region
41 / 48
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ANS: B
The inguinal nodes in the groin
drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.
106. The nurse is examining the
lymphatic system of a healthy
3-year-old child. Which finding
should the nurse expect?
a.
Excessive swelling of the lymph
nodes
b.
Presence of palpable lymph nodes
c.
No palpable nodes because of
the immature immune system of a
child
d.
Fewer numbers and a smaller size
of lymph nodes compared with
those of an adult
ANS: B
Lymph nodes are relatively large
in children, and the superficial
ones are often palpable even when
the child is healthy.
107. During an assessment of an older adult, the nurse should expect
to notice which finding as a normal physiologic change associated with the aging process?
a.
42 / 48
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Hormonal changes causing vasodilation and a resulting drop in
blood pressure
b.
Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
c.
Peripheral blood vessels growing
more rigid with age, producing a
rise in systolic blood pressure
d.
Narrowing of the inferior vena
cava, causing low blood flow and
increases in venous pressure resulting in varicosities
ANS: C
Peripheral blood vessels grow
more rigid with age, resulting in a
rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf
veins, not atrophy. The other options are not correct.
108. . A 67-year-old patient states that
he recently began to have pain in
his left calf when climbing the 10
stairs to his apartment. This pain
is relieved by sitting for approximately 2 minutes; then he is able
to resume his activities. The nurse
interprets that this patient is most
likely experiencing:
a.
Claudication.
43 / 48
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b.
Sore muscles.
c.
Muscle cramps.
d.
Venous insufficiency.
ANS: A
Intermittent claudication feels like
a cramp and is usually relieved by
rest within 2 minutes. The other responses are not correct.
109. A patient complains of leg pain
that wakes him at night. He states
that he has been having problems
with his legs. He has pain in his
legs when they are elevated that
disappears when he dangles them.
He recently noticed a sore on the
inner aspect of the right ankle.
On the basis of this health history
information, the nurse interprets
that the patient is most likely experiencing:
a.
Pain related to lymphatic abnormalities.
b.
Problems related to arterial insufficiency.
c.
Problems related to venous insufficiency.
d.
Pain related to musculoskeletal
abnormalities.
44 / 48
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ANS: B
Night leg pain is common in aging adults and may indicate the
ischemic rest pain of peripheral
vascular disease. Alterations in arterial circulation cause pain that
becomes worse with leg elevation
and is eased when the extremity is
dangled.
110. During an assessment, the nurse
uses the profile sign to detect:
a.
Pitting edema.
b.
Early clubbing.
c.
Symmetry of the fingers.
d.
Insufficient capillary refill.
ANS: B
The nurse should use the profile
sign (viewing the finger from the
side) to detect early clubbing.
111. he nurse is performing an assessment on an adult. The adults vital
signs are normal, and capillary refill time is 5 seconds. What should
the nurse do next?
a.
Ask the patient about a history of
frostbite.
b.
Suspect that the patient has ve45 / 48
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nous insufficiency.
c.
Consider this a delayed capillary
refill time, and investigate further.
d.
Consider this a normal capillary
refill time that requires no further
assessment.
ANS: C
Normal capillary refill time is less
than 1 to 2 seconds. The following
conditions can skew the findings:
a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
112. When assessing a patient, the
nurse notes that the left femoral
pulse as diminished, 1+/4+. What
should the nurse do next?
a.
Document the finding.
b.
Auscultate the site for a bruit.
c.
Check for calf pain.
d.
Check capillary refill in the toes.
ANS: B
If a pulse is weak or diminished
at the femoral site, then the nurse
should auscultate for a bruit. The
presence of a bruit, or turbulent
blood flow, indicates partial occlu46 / 48
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sion. The other responses are not
correct.
113. When performing a peripheral vascular assessment on a patient, the
nurse is unable to palpate the ulnar pulses. The patients skin is
warm and capillary refill time is
normal. Next, the nurse should:
a.
Check for the presence of claudication.
b.
Refer the individual for further
evaluation.
c.
Consider this finding as normal,
and proceed with the peripheral
vascular evaluation.
d.
Ask the patient if he or she has experienced any unusual cramping
or tingling in the arm.
ANS: C
Palpating the ulnar pulses is not
usually necessary. The ulnar pulses are not often palpable in the
normal person. The other responses are not correct.
114. he nurse is assessing the pulses
of a patient who has been admitted
for untreated hyperthyroidism. The
nurse should expect to find a(n)
_______ pulse.
a.
47 / 48
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Normal
b.
Absent
c.
Bounding
d.
Weak, thready
ANS: C
A full, bounding pulse occurs with
hyperkinetic states (e.g., exercise,
anxiety, fever), anemia, and hyperthyroidism. An absent pulse occurs with occlusion. Weak, thready
pulses occur with shock and peripheral artery disease.
48 / 48
PrepU ch. 21 assessing heart and neck vessels
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1. While completing the cardiovascu- b. Shortness of breath
lar system health history, a client re- Explanation:
ports difficulty falling asleep unless Shortness of breath, also called orshe is in an upright position. Which thopnea, is dyspnea that occurs while
of the following potential problems the client is lying flat and improves
should the nurse further investiwhen the client sits up. The client
gate?
would not experience relief from chest
pain, palpitations or edema by sitting
a.Chest pain
upright. For this reason, these options
b.Shortness of breath
are incorrect.
c.Palpitations
Reference:
d.Edema
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
2. A nurse is unable to palpate the api- a. Client has an increased chest dical impulse on an older client. Which ameter
assessment data in the client's his- Explanation:
tory should the nurse recognize as The apical impulse may not be palpathe reason for this finding?
ble in clients with increased anteroposterior diameters. Irregular heart
a.Client has an increased chest di- rate should not interfere with the abilameter
ity to palpate an apical impulse. Resb.Heart rate is irregular
piratory rate does not impact the apic.Respiratory rate is too fast
cal impulse. Heart enlargement would
d.Heart enlargement is present
displace the apical impulse but not
cause it to be nonpalpable.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 449
3. What finding upon assessment
would indicate the client is experiencing shock?
a.Systolic blood pressure 50
b.Heart rate 100
c.Respiratory rate 24
d.Temperature 99.5 F
1 / 28
a. Systolic blood pressure 50
Explanation:
A systolic blood pressure of 50 would
indicate the client is experiencing
shock. All other vital signs, while elevated do not indicate shock
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 448
PrepU ch. 21 assessing heart and neck vessels
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4. The nurse is providing teaching
-Smoking
about cardiovascular disease in a -Blood pressure
community setting. What risk fac- -Cholesterol
tors would the nurse identify to the Explanation:
group as those they can modify
Smoking, cholesterol and blood presthrough lifestyle choices? Select all sure can be controlled through
that apply.
lifestyle choices. Age and family history are non-modifiable risk factors.
-Smoking
Reference:
-Blood pressure
Weber, J.R., & Kelley, J.H., Health
-Cholesterol
Assessment in Nursing, 6th ed.,
-Family history
Philadelphia, Wolters Kluwer, 2018,
-Age
Chapter 21: Assessing Heart and
Neck Vessels.
5. A client has engorged jugular veins. a. right atrial pressure
What should this finding suggest to Explanation:
the nurse?
Jugular venous pressure (JVP) reflects right atrial pressure. Engorged
a.right atrial pressure
jugular veins are seen in right or
b.integrity of the aorta
left heart failure, pulmonary hypertenc.patency of carotid arteries
sion, tricuspid stenosis, and pericard.closure of the tricuspid valves
dial compression or tamponade. The
jugular veins are not used to estimate
the integrity of the aorta, patency of
carotid arteries, or the closure of the
tricuspid valves.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 439
6. When auscultating the heart sounds a. Accentuated
of a client, a nurse notes that the S2 Explanation:
is louder than the S1. How should An accentuated S2 means that the
the nurse describe S2?
S2 is louder than the S1. This occurs
in conditions in which the aortic or
a.Accentuated
pulmonic valve has a higher closing
b.Diminished
pressure. A diminished S2 means that
2 / 28
PrepU ch. 21 assessing heart and neck vessels
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c.Normal split
d.Wide split
the S2 is softer than the S1. This occurs in conditions in which the aortic
or pulmonic valves have decreased
mobility. Normal split S2 can be heard
over the second or third left intercostal
space; it is usually heard best during inspiration and disappears during expiration. Wide split S2 is an increase in the usual splitting that persists throughout the entire respiratory
cycle, and widens on expiration.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 436
7. The nurse is auscultating the heart
sounds of an adult client. To auscultate Erb point, the nurse should
place the stethoscope at the...
a.second intercostal space at the
right sternal border.
b.third to fifth intercostal space at
the left sternal border.
c.apex of the heart near the midclavicular line (MCL).
d.fourth or fifth intercostal space at
the left lower sternal border.
8. The nurse is conducting a health
history with a female client who
reports upper back and jaw pain.
In order to assess the client's risk
for a cardiac event, which question
should the nurse ask first?
b. third to fifth intercostal space at the
left sternal border.
Explanation:
Erb's point: Third to fifth intercostal
space at the left sternal border.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 438
a. "Do you have any pain or discomfort in your chest?"
Explanation:
The first question the nurse asks
should be broad as this will encourage the client to share more detail rea."Do you have any pain or discom- garding the source of the pain. Chest
fort in your chest?"
pain is one of the most serious and
b."Is the pain worse on exertion?" important symptoms often signaling
3 / 28
PrepU ch. 21 assessing heart and neck vessels
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c."Do you have cramping pain?'
d."Is the pain worse when you are
lying down?"
coronary artery disease, potentially
leading to myocardial infarction. All of
the other options are more specific;
these questions should only be asked
when the nurse needs to narrow the
focus of the cardiovascular examination.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
9. Before the nurse begins the physical a. Inspect for dependent edema.
examination of a client with conges- Explanation:
tive heart failure, the client reports Dependent edema results from sodihaving to get up at night to void
um and water reabsorption through
frequently. Which action should the the kidneys, leading to extracellular
nurse take in response to the client's expansion. Increased frequency of
report?
nocturia results from the redistribution of fluid at night, forcing the client
a.Inspect for dependent edema.
to get up to void more frequently. The
b.Ensure that the client lies flat for client should only be told to lie flat for
the examination.
the physical examination if the client
c.Palpate the carotid pulse.
is hypovolemic and the neck veins
d.Assess for thrills.
need to be visualized. Palpation of the
carotid pulse is useful for determining
whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are
associated with other cardiac conditions.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 441
10. During an interview with the nurse, c. Decreased cardiac output
a client complains of a fatigue that Explanation:
seems to get worse in the evening. Fatigue may result from compromised
Which of the following causes of fa- cardiac output. Fatigue related to de4 / 28
PrepU ch. 21 assessing heart and neck vessels
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tigue would explain this pattern?
a.Depression
b.Severe muscular exertion
c.Decreased cardiac output
d.Upper respiratory infection
creased cardiac output is worse in
the evening or as the day progresses,
whereas fatigue seen with depression
is ongoing throughout the day. Severe
muscular exertion and an upper respiratory infection may be associated
with fatigue, but not the pattern mentioned in the scenario.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
11. The nurse manager on a cardiac unit c. Palpating carotid pulses simultaneshould immediately intervene when ously.
observing which staff nurse's asExplanation:
sessment technique?
Carotid pulse palpation should be
conducted by feeling one side at a
a.Auscultating all heart sounds with time; otherwise the client my become
the bell and diaphragm.
dizzy or lightheaded. All other assessb.Palpation of the point of maximum ment techniques are correct.
impulse on the chest.
Reference:
c.Palpating carotid pulses simulta- Chapter 21: Assessing Heart and
neously.
Neck Vessels - Page 448
d.Inspecting bilateral jugular veins.
12. Which of the following would the
a. New onset chest pain
nurse consider to be an urgent sit- Explanation:
uation?
A new onset of chest pain would be an
urgent situation. The blood pressure,
a.New onset chest pain
oxygen saturation and heart rate are
b.Blood pressure 122/76
within normal limits.
c.Heart rate 88
Reference:
d.Oxygen saturation of 92%
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
13. The sinoatrial node of the heart is
located on the...
a.anterior wall of the left atrium.
5 / 28
d. posterior wall of the right atrium.
Explanation:
The sinoatrial (SA) node (or sinus
node) is located on the posterior wall
PrepU ch. 21 assessing heart and neck vessels
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b.anterior wall of the right atrium. of the right atrium near the junction of
c.upper intraventricular system.
the superior and inferior vena cava.
d.posterior wall of the right atrium. Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 433
14. A student is asked to define the
continuous rhythmic movement of
blood during contraction and relaxation of the heart. This best describes which of the following?
a.Cardiac circulation
b.Cardiac output
c.Cardiac cycle
d.Cardiac workload
c. Cardiac cycle
Explanation:
The continuous rhythmic movement
of blood during contraction and relaxation of the heart is the cardiac cycle.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 434
15. A nurse performs an initial health
b. No current medications or treathistory on a client admitted for new ments
onset of chest pain. Which data is Explanation:
considered subjective for the car- Subjective data is data collected from
diovascular system?
the client. No current medications or
treatments is information the nurse
a.Apical heart rate 70 beats per
obtained from the client. Apical heart
minute
rate 70 beats per minute, no edema
b.No current medications or treat- of extremities noted, and apical imments
pulse palpated at 5 intercostal space
c.No edema of extremities noted
on left are examples of objective data
d.Apical impulse palpated at 5 inter- collected by the nurse upon physical
costal space on left
examination.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 439-441
16. A 52-year-old man is skeptical about a. Smoking increases the heart's
the potentially harmful effect of his workload and contributes to atherosmoking on his heart, citing the fact sclerosis.
that both his father and grandfather Explanation:
lived long lives despite being life- Smoking increases cardiac work6 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
long smokers. Which of the following facts would underlie the explanation that the nurse provides the
client?
load and contributes to hypertension,
plaque build-up, and blood clots. It
does not directly affect contractility or
cardiac conduction, and it is not a
component of metabolic syndrome.
a.Smoking increases the heart's
Reference:
workload and contributes to athero- Chapter 21: Assessing Heart and
sclerosis.
Neck Vessels - Page 441
b.Smoking decreases the contractility of the myocardium and contributes to valvular disorders.
c.Smoking damages the cardiac
conduction system, resulting in dysrhythmias that are entirely preventable.
d.Smoking is a central component
of metabolic syndrome.
17. The nurse hears a distinctive first
heart sound while auscultating a
client's heart rate. What does this
heart sound represent?
a.the ending of diastole
b.the beginning of systole
c.opening of the mitral valve
d.closure of the aortic valve
b. the beginning of systole
Explanation:
Closure of the AV valves, mitral and
tricuspid, produces the first heart
sound, S1, which indicates the beginning of systole. The closure of the
atrial valve begins a cycle of diastole.
During systole, the left ventricle starts
to contract and ventricular pressure
rapidly exceeds left atrial pressure,
shutting the mitral valve. Aortic valve
closure produces the second heart
sound, S2.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 435
18. A client comes to the emergency de- a. Shortness of breath
partment reporting a sudden onset Explanation:
of dyspnea. What finding is a mani- Clients with heart failure may be short
festation of dyspnea?
of breath from fluid accumulation in
7 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
the pulmonary bed. Onset may be
sudden with acute or chronic pulmonary edema. It is important to assess how much activity brings on dyspnea, such as rest, walking on a flat
surface, or climbing. The other options listed are distracters to the question.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
a.Shortness of breath
b.Painful breathing
c.Rapid breathing
d.Inability to breathe
19. During the health history interview d. Heart attacks in his father and sibwith a 40-year-old man, the nurse
lings
uses the genogram to specifically Explanation:
assess for major family risk for car- Risk of developing heart disease is
diovascular disease by asking about increased if one or more immediate
which of the following?
family members (parents or siblings)
have had an MI, hypertension, or high
a.Hypertension in his grandparents cholesterol.
b.Weight patterns within his family Reference:
c.Diabetes mellitus in his extended Chapter 21: Assessing Heart and
family
Neck Vessels - Page 443
d.Heart attacks in his father and siblings
20. Which of the following assessment c. The intensity of the client's S1
findings would signal a pathophysi- varies between beats.
ological finding to the nurse?
Explanation:
S1 is usually louder than S2 at the
a.S1 is softer than S2 when the
apex, while the opposite can be true
nurse listens at the base of the
when listening at the base of the
client's heart.
heart. Normal physiological splitting
b.Auscultation at the client's apex of S2 is accentuated on inspiration
reveals that S1 is louder than S2.
and disappears on exhalation. Varyc.The intensity of the client's S1
ing intensity of S1 is associated with
varies between beats.
a heart block or arrhythmia.
d.S2 is split when the nurse asks the Reference:
8 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
client to inhale deeply but is not split Chapter 21: Assessing Heart and
on exhalation.
Neck Vessels - Page 457
21. While conducting a physical exami- a. left-sided heart failure
nation of the cardiovascular system, Explanation:
the nurse hears fine crackles on aus- Left-sided heart failure can cause flucultation of the lungs. This finding is id to leak into the lungs, and as a
most likely a manifestation of which result fine crackles can be heard from
problem?
the movement of fluid in the lungs
on air exchange. Auscultation of fine
a.left-sided heart failure
crackles is not a typical finding assob.palpitations
ciated with clients experiencing palpic.hypertension
tations or hypertension. Dextrocardia
d.dextrocardia
is a condition in which the heart is
situated on the right side. Fine crackles are not a characteristic feature of
dextrocardia.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018.
22. The nurse assesses the client's
c. 2+
pulses to be normal. How would the Explanation:
nurse document this information? On most scales, normal pulses are
recorded as 2+. Absent pulses are
a.0
0, weak pulses are 1+, full or someb.1+
what increased pulses are 3+, and a
c.2+
bounding pulse is a 4+.
d.4+
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 448
23. A client complains of difficulty
a. Orthopnea
sleeping, stating he has to sit up
Explanation:
with the help of several pillows and A client with heart failure may have
cannot breathe when lying flat. This fluid in their lungs, making it difficult
client has a condition known as
to breathe when lying flat (orthopwhat?
nea). An increased respiratory rate is
9 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
tachypnea. Sleep apnea is a condition
where the client has periods of not
breathing while sleeping. Pneumonia
does not present as described in the
question.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
a.Orthopnea
b.Tachypnea
c.Pneumonia
d.Sleep apnea
24. The nurse performs an admission c. "Right carotid bruit auscultated"
assessment on an adult client admit- Explanation:
ted through the ED with a myocardial infarction. The nurse ausculBruits are swooshing sounds similar
tates a swooshing sound over right to the sound of the blood pressure.
carotid artery. What phrase should They result from turbulent blood flow
the nurse use to correctly document related to atherosclerosis. A bruit is
this finding?
audible when the artery is partially
obstructed. Murmurs originate in the
a."Murmur heard over right carotid heart or great vessels and are usualartery"
ly louder over the upper precordium
b."Split sound auscultated over
and quieter near the neck. Bruits are
right carotid artery"
higher pitched, more superficial, and
c."Right carotid bruit auscultated" heard only over the arteries. Neither
d."S2 sound heard over right carotid split sounds nor an S2 is heard over
artery."
arteries.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 447
25. A nurse is working with a client who a. Myocardium
recently suffered a heart attack. As Explanation:
a result, the client has experienced The myocardium is the thickest laythe death of the muscle tissues that er of the heart and is made up of
make up the thickest layer of the
contractile cardiac muscle cells. The
heart. This layer of muscle is known pericardium is a tough, inextensible,
as which of the following?
loose-fitting, fibroserous sac that attaches to the great vessels and sura.Myocardium
rounds the heart. A serous mem10 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
b.Epicardium
c.Endocardium
d.Pericardium
brane lining, the parietal pericardium,
secretes a small amount of pericardial fluid that allows for smooth, friction-free movement of the heart. This
same type of serous membrane covers the outer surface of the heart and
is known as the epicardium. The endocardium is a thin layer of endothelial tissue that forms the innermost
layer of the heart and is continuous
with the endothelial lining of blood
vessels.
Reference:
Chapter 21: Assessing Heart and
Neck Vessels - Page 433
26. The client is noted to have a patho- b. An S3 gallop
logic change in ventricular comExplanation:
pliance. What information from the In older adults, an S3, sometimes
cardiac assessment would indicate termed "an S3 gallop," usually indithis?
cates a pathologic change in ventricular compliance.
a.A split S2
Reference:
b.An S3 gallop
Chapter 21: Assessing Heart and
c.A delayed S3
Neck Vessels - Page 436
d.A weak S4
27. When educating a client about
-Quit or do not start smoking
healthy habits relating to cardiovas- -Exercise regularly
cular health, it is important to in-Undergo regular cholesterol screenclude which of the following? Select ing
all that apply.
-Undergo regular screening for diabetes
-Quit or do not start smoking
Explanation:
-Exercise regularly
Important healthy habits to empha-Undergo regular cholesterol
size include following a low-fat diet,
screening
regularly exercising, undergoing reg-Eat a low-fiber diet
ular screening for diabetes and cholesterol, and quitting (or continuing
11 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
-Undergo regular screening for dia- not) smoking.
betes
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 443.
Chapter 21: Assessing Heart and
Neck Vessels - Page 443
28. The nurse hears high-pitched
a. Bruits
swooshing sounds over the carotid Explanation:
artery on the right side. What is this Distinguishing a murmur from a bruit
sound indicative of?
can be challenging. Murmurs originate in the heart or great vessels and
a.Bruits
are usually louder over the upper preb.Murmurs
cordium and quieter near the neck.
c.Normal findings
Bruits are higher pitched, more superd.Gallops
ficial, and heard only over the arteries.
A gallop is a generic term for an additional heart sounds heard besides the
normal S1 and S2 sound.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 447.
Chapter 21: Assessing Heart and
Neck Vessels - Page 447
29. The client asks the nurse what the a. Atrial depolarization
small P wave on her ECG indicates. Explanation:
What would the nurse answer?
The small P wave indicates atrial depolarization (duration up to 80 msec;
a.Atrial depolarization
PR interval 120 to 200 msec).
b.Ventricular depolarization
Reference:
c.Atrial repolarization
Weber, J.R., & Kelley, J.H., Health
d.Ventricular repolarization
Assessment in Nursing, 6th ed.,
12 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 434.
Chapter 21: Assessing Heart and
Neck Vessels - Page 434
30. The bicuspid, or mitral, valve is located...
a. between the left atrium and the left
ventricle.
Explanation:
a.between the left atrium and the left The bicuspid (mitral) valve is comventricle.
posed of two cusps and is located
b.between the right atrium and the between the left atrium and the left
right ventricle.
ventricle.
c.at the beginning of the ascending Reference:
aorta.
Weber, J.R., & Kelley, J.H., Health
d.at the exit of each ventricle near Assessment in Nursing, 6th ed.,
the great vessels.
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 432.
Chapter 21: Assessing Heart and
Neck Vessels - Page 432
31. While auscultating heart sounds,
b. Mitral stenosis
asking the client to turn onto a left Explanation:
lying position would help the nurse The left lateral position brings the
assess the presence of which of the left ventricle closer to the chest wall
following?
and accentuates a left-sided S3 or
S4 associated with mitral stenosis. A
a.Aortic murmurs
seated position accentuates an aortic
b.Mitral stenosis
murmur. The left lateral position does
c.The first heart sound
not accentuate the first heart sound
d.Atrial repolarization
or atrial repolarization.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 452.
13 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Chapter 21: Assessing Heart and
Neck Vessels - Page 452
32. During a cardiac examination, the c. apex of the heart.
nurse can best hear the S1 heart
Explanation:
sound by placing the stethoscope at S1 may be heard over the entire prethe client's...
cordium but is heard best at the apex
(left MCL, fifth ICS).
a.base of the heart.
Reference:
b.pulmonic valve area.
Weber, J.R., & Kelley, J.H., Health
c.apex of the heart.
Assessment in Nursing, 6th ed.,
d.second left interspace.
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 435.
Chapter 21: Assessing Heart and
Neck Vessels - Page 435
33. A nurse provides prevention strate- -Walk briskly 30 minutes per day.
gies to a group of clients who are -Use a low sodium seasoning to flavor
identified as at risk for hypertension. food.
Which strategies should the nurse -Choose foods like bananas and
include? Select all that apply.
sweet potatoes.
Explanation:
-Walk briskly 30 minutes per day.
Encouraging physical activity, de-Use a low sodium seasoning to fla- creasing dietary intake of sodium,
vor food.
and increasing dietary intake of
-Choose foods like bananas and
potassium, such as in bananas and
sweet potatoes.
sweet potato, are lifestyle modifica-Consume two to three glasses of tions that can promote sustaining a
red wine daily.
healthy blood pressure. Excess al-Increase consumption of dairy
cohol consumption is a modifiable
products.
lifestyle factor that can promote hypertension. Depending on gender, alcoholic beverages should be limited from one to two per day. Dairy
products tend to be high in cholesterol. Clients at risk for hypertension
should avoid increasing consumption
of these foods.
14 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 443.
Chapter 21: Assessing Heart and
Neck Vessels - Page 443
34. The nurse is palpating the apical im- b. Aortic stenosis, with pressure overpulse in a client with heart disease load of the left ventricle
and finds that the amplitude is dif- Explanation:
fuse and increased. Which of the fol- Pressure overload of the left ventricle,
lowing conditions could be a poten- as occurs in aortic stenosis, may retial cause of an increase in the am- sult in an increase in amplitude of the
plitude of the impulse?
apical impulse. The other conditions
should decrease amplitude of the apia.Hypothyroidism
cal impulse or not be palpable at all.
b.Aortic stenosis, with pressure
Reference:
overload of the left ventricle
Weber, J.R., & Kelley, J.H., Health
c.Mitral stenosis, with volume over- Assessment in Nursing, 6th ed.,
load of the left atrium
Philadelphia, Wolters Kluwer, 2018,
d.Cardiomyopathy
Chapter 21: Assessing Heart and
Neck Vessels, p. 448.
Chapter 21: Assessing Heart and
Neck Vessels - Page 448
35. A client is experiencing decreased d. Blood pressure
cardiac output. Which vital sign is Explanation:
priority for the nurse to monitor fre- With decreased cardiac output, the
quently?
heart pumps inadequate blood to
meet the body's metabolic demands.
a.Temperature
The blood pressure is most important
b.Respiratory rate
to assess frequently.
c.Heart rate
Reference:
d.Blood pressure
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
15 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Neck Vessels, p. 448.
Chapter 21: Assessing Heart and
Neck Vessels - Page 448
36. When auscultating a client's heart, a. Summation gallop
the nurse hears both S3 and S4.
Explanation:
What is this known as?
Presence of both S3 and S4 is referred to as a "summation gallop."
a.Summation gallop
Atrial kick is the additional flow of
b.Atrial kick
blood from the atrium to the ventricles
c.Ejection clicks
as the atrium contract. Ejection clicks
d.Diastolic clicks
are high-pitched sounds that occur at
the moment of maximal opening of
the aortic or pulmonary valves. They
are heard just after the S1 sound. Diastolic clicks can be found in clients
with mitral valve prolapse as the valve
does not close properly.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 451.
Chapter 21: Assessing Heart and
Neck Vessels - Page 451
37. The nurse is conducting a workshop a. Palpable
on the measurement of jugular ve- Explanation:
nous pulsation. As part of instruc- The carotid pulse is palpable; the
tion, the nurse tells the students to jugular venous pulsation is rarely palmake sure that they can distinguish pable. The carotid upstroke is norbetween the jugular venous pulsa- mally brisk, but may be delayed and
tion and carotid pulse. Which of the decreased as in aortic stenosis or
following characteristics is typical bounding as in aortic insufficiency.
of the carotid pulse?
Reference:
Weber, J.R., & Kelley, J.H., Health
a.Palpable
Assessment in Nursing, 6th ed.,
b.Soft, rapid, undulating quality
Philadelphia, Wolters Kluwer, 2018,
16 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
c.Pulsation eliminated by light pres- Chapter 21: Assessing Heart and
sure on the vessel
Neck Vessels, p. 447.
d.Level of pulsation changes with Chapter 21: Assessing Heart and
changes in position
Neck Vessels - Page 447
38. The nurse notes the client has weak a. Hypovolemia
pulses bilaterally. The nurse under- Explanation:
stands that this could indicate the A weak pulse can indicate hypovclient is experiencing what?
olemia, shock or decreased cardiac
output. Pulse inequality may india.Hypovolemia
cate a constriction or occlusion. Hyb.Occlusion
pervolemia would be manifested by
c.Hypervolemia
bounding pulses.
d.Constriction
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 448.
Chapter 21: Assessing Heart and
Neck Vessels - Page 448
39. A client with heart disease is a cur- -Advise to quit
rent cigarette smoker. What should -Arrange for follow-up
the nurse include when caring for -Assess willingness to quit
this client? Select all that apply.
-Assist with finding resources
Explanation:
-Advise to quit
The nurse can follow the 5 A's when
-Arrange for follow-up
assisting a client with smoking ces-Assess willingness to quit
sation. These A's include advising to
-Acknowledge dependence
quit, arranging for follow-up, assess-Assist with finding resources
ing the client's willingness to quit, and
assisting with finding resources. Acknowledging dependence is not an
intervention for smoking cessation.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
17 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Chapter 21: Assessing Heart and
Neck Vessels, p. 443.
Chapter 21: Assessing Heart and
Neck Vessels - Page 443
40. The nurse notes that a client's heart a. Sinus arrhythmia
rate increases with inspiration and Explanation:
slows down with expiration. How
In sinus arrhythmia, the heart rate
should the nurse document this
speeds up and slows down in a cycle,
finding?
usually becoming faster with inhalation and slower with expiration. Sinus
a.Sinus arrhythmia
bradycardia is a regular heart rhythm
b.Sinus bradycardia
that is a rate less than 60 beats per
c.Premature atrial contractions
minute. In premature atrial and vend.Premature ventricular contractricular contractions, a beat occurs
tions
earlier than the next expected beat
and is followed by a pause.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 457.
Chapter 21: Assessing Heart and
Neck Vessels - Page 457
41. When auscultating a client's heart a. Aortic and pulmonic
sounds, the nurse hears a louder S2 Explanation:
when listening at the 2nd intercostal The closure of the aortic and pulspace right sternal border. The nurse monic valves creates the second
determines that this finding is con- heart sound, which is heard louder
sistent with the closure of which
over the 2nd intercostal space right
heart valves?
sternal border. The closure of the tricuspid and mitral valves creates the
a.Aortic and pulmonic
first heart sound. The pulmonic and
b.Tricuspid and mitral
tricuspid valves do not close together.
c.Pulmonic and tricuspid
The mitral and aortic valves do not
d.Mitral and aortic
close together.
Reference:
18 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 436.
Chapter 21: Assessing Heart and
Neck Vessels - Page 436
42. The nurse is assessing a client di- a. Place the bell of the stethoscope
agnoses with mitral stenosis. Which over the apex with client on left side.
technique should the nurse use to Explanation:
listen to this condition?
This mid-diastolic murmur is associated with an opening snap and has
a.Place the bell of the stethoscope a low-pitched, rumbling quality. Heard
over the apex with client on left side. best with the bell over the apex with
b.Use the diaphragm of the stetho- the client turned to the left. The carotid
scope to listen over the right sternal arteries are auscultated one at a
border.
time for bruits. The 2nd left intercostal
c.With the client leaning forward, lis- space is the location to hear pulmonic
ten over the left carotid artery.
valve conditions.
d.With the client supine, place the Reference:
bell of the stethoscope on the 2nd Weber, J.R., & Kelley, J.H., Health
left intercostal space.
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 452.
Chapter 21: Assessing Heart and
Neck Vessels - Page 452
43. A new nurse on the telemetry unit is b. The time from firing of the sinoatrial
reviewing information about how to (SA) node to the beginning of depocorrectly read electrocardiograms. larization in the ventricle
The nurse is expected to know
Explanation:
that the PR interval represents what PR interval represents the time from
event?
the firing of the SA node to the beginning of ventricular depolarization
a.The spread of depolarization in the (includes a slight pause at the AV
atria
junction).
b.The time from firing of the sinoa- Reference:
19 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
trial (SA) node to the beginning of Weber, J.R., & Kelley, J.H., Health
depolarization in the ventricle
Assessment in Nursing, 6th ed.,
c.The spread of depolarization and Philadelphia, Wolters Kluwer, 2018,
sodium release in the ventricles to Chapter 21: Assessing Heart and
cause ventricular contraction
Neck Vessels, p. 434.
d.Relaxation of the ventricles and re- Chapter 21: Assessing Heart and
polarization of the cells
Neck Vessels - Page 434
44. The nurse assesses a client who has a. obstructive pulmonary disease
ventricular enlargement. The nurse Explanation:
palpates the left parasternal area but With obstructive pulmonary disease,
cannot feel the ventricle. Which un- a hyperinflated lung may prevent palderlying condition does this client pation of an enlarged right ventricle
likely have?
in the left parasternal area. The nurse
can more easily feel this high in the
a.obstructive pulmonary disease
epigastric region. Although the client
b.ischemic heart disease
may have an arrhythmia, an abnormal
c.arrhythmia
heartbeat, this would not prevent the
d.peripheral vascular disease
nurse from being able to palpate the
ventricle. Ischemic heart disease is a
condition in which there is reduced
blood flow to the heart. This would not
prevent the nurse from being able to
palpate the ventricle. Peripheral vascular disease results in a circulatory
problem that causes reduced blood
flow to the limbs. There would be no
reason for the nurse not to be able to
palpate the ventricle with this condition alone.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 446.
Chapter 21: Assessing Heart and
Neck Vessels - Page 446
20 / 28
PrepU ch. 21 assessing heart and neck vessels
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45. A nurse is assessing a client for pos- d. Observe for a decrease in jugular
sible dehydration. Which of the fol- venous pressure
lowing should the nurse do?
Explanation:
Decrease in jugular venous presa.Assess for a difference between sure can occur with dehydration secthe apical and radial pulse
ondary to a decrease in total blood
b.Check for pulse inequality bevolume, so the nurse should observe
tween right and left carotid arteries for a decrease in jugular venous presc.Auscultate for split S1 at the base sure. Assessing the difference in the
and apex
apical and radial pulses would help
d.Observe for a decrease in jugular the nurse assess for pulse deficit. Difvenous pressure
ferences in the amplitude or rate of
the carotid pulse may indicate stenosis. A split S1 occurs when the left and
right ventricles contract at different
times (asynchronous contraction).
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018.
46. When auscultating the heart, the
nurse is most likely to hear a diastolic murmur after which heart
sound?
a.S1
b.S2
c.Preload
d.Afterload
21 / 28
b. S2
Explanation:
Diastolic murmurs occur during filling,
from the end of S2 to the beginning
of the next S1, when the mitral and
tricuspid valves are open and the aortic and pulmonic valves are closed.
Preload is an indicator of how much
blood will be forwarded to and ejected from the ventricles. The heart has
to pump against the high blood pressures in the arteries and arterioles.
This pressure in the great vessels is
termed afterload. Preload and afterload are not heart sounds but volume
and pressure indicators.
Reference:
Weber, J.R., & Kelley, J.H., Health
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 451.
Chapter 21: Assessing Heart and
Neck Vessels - Page 451
47. The client is known to have a bundle c. Wide splitting
branch block that delays activation Explanation:
of the right ventricle as a result of
a recent myocardial infarction (MI). Wide splitting occurs when a bunWhat would the nurse expect to hear dle branch block delays activation of
when auscultating the client's heart the right ventricle. It also can hapsounds?
pen when stenosis of the pulmonic
valve or pulmonary hypertension dea.Arrhythmia
lays emptying of the right ventricle.
b.An opening snap
The nurse would not expect to ausc.Wide splitting
cultate an arrhythmia since it is a red.S3 sound
flection of heart rate. An opening snap
indicates that the mitral valve is mobile and "snaps" during early diastole
from high atrial pressure, such as with
mitral stenosis. Blood rushes into ventricles abnormally resistant to filling,
distending the ventricular walls and
causing vibration that results in a S3
sound.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 437.
Chapter 21: Assessing Heart and
Neck Vessels - Page 437
48. A nurse auscultates the heart rate
of a young male and notices that
22 / 28
c. Sinus arrhythmia
Explanation:
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
the rate speeds with inspiration and A heart rate that speeds with inspislows with exhalation. S1 and S2 are ration and slows with exhalation is
normal. The nurse recognizes this as termed sinus arrhythmia. This is ofwhat dysrhythmia?
ten a normal rhythm in young children
and well-conditioned athletes. Premaa.Premature ventricular contracture ventricular contractions and pretions
mature atrial contractions occur earb.Atrial fibrillation
lier than expected. Atrial fibrillation
c.Sinus arrhythmia
causes the ventricles to beat irregud.Premature atrial contractions
larly.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 449.
Chapter 21: Assessing Heart and
Neck Vessels - Page 449
49. The nurse is caring for a client who b. Low-fat, low-cholesterol meals
has an elevated cholesterol level. To Explanation:
reduce the mean total blood choThis client should follow a low-fat,
lesterol and low-density lipoprotein low-cholesterol diet. It would be in(LDL) cholesterol levels, what diet appropriate to teach the client to
should the nurse discuss with the eat high-protein or low-carbohydrate
client?
meals since they are not the focus of
the management of elevated cholesa.High-protein, low-fat meals
terol levels.
b.Low-fat, low-cholesterol meals
Reference:
c.High-protein, low-carbohydrate
Weber, J.R., & Kelley, J.H., Health
meals
Assessment in Nursing, 6th ed.,
d.Low-cholesterol, low-carbohyPhiladelphia, Wolters Kluwer, 2018,
drate meals
Chapter 21: Assessing Heart and
Neck Vessels, p. 443.
Chapter 21: Assessing Heart and
Neck Vessels - Page 443
50. A nurse is assessing a client for the c. Auscultate for split S1 at the base
presence of asynchronous contrac- and apex
23 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
tion in the heart. Which of the follow- Explanation:
ing should the nurse do?
A split S1 occurs when the left
and right ventricles contract at difa.Assess for a difference between ferent times (asynchronous contracthe apical and radial pulse
tion); thus, the nurse should ausculb.Check for pulse inequality betate for split S1 at the base and apex
tween right and left carotid arteries to detect this condition. Pulse deficit
c.Auscultate for split S1 at the base is detected by assessing the differand apex
ence in the apical and radial pulses.
d.Observe for a decrease in jugular Differences in the amplitude or rate of
venous pressure
the carotid pulse may indicate stenosis. Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood
volume.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels.
51. A client is admitted to the health
d. Ineffective Tissue Perfusion
care facility with reports of chest
Explanation:
pain, elevated blood pressure, and The nurse assesses a decrease in
shortness of breath with activity.
the carotid pulses (1+ is considered
The nurse palpates the carotid arter- weak) and a weak radial pulse is preies as 1+ bilaterally and a weak radi- sent. The client also has a murmur.
al pulse. A Grade 3 systolic murmur These findings allow the nurse to conis auscultated. Which nursing diag- firm the diagnosis of Ineffective Tisnosis can the nurse confirm based sue Perfusion. There are not enough
on this data?
criteria to confirm the diagnosis of Impaired Breathing Pattern, Activity Ina.Impaired Breathing Pattern
tolerance, or Ineffective Health Mainb.Activity Intolerance
tenance.
c.Ineffective Health Maintenance
Reference:
d.Ineffective Tissue Perfusion
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
24 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Chapter 21: Assessing Heart and
Neck Vessels.
52. An adult client tells the nurse that a. high serum level of low-density
his father died of a massive coro- lipoproteins.
nary attack at the age of 65. The
Explanation:
nurse should explain to the client
Dyslipidemia presents the greatest
that one of the risk factors for coro- risk for the developing coronary artery
nary heart disease is...
disease. Elevated cholesterol levels
have been linked to the development
a.high serum level of low-density
of atherosclerosis.
lipoproteins.
Reference:
b.low-carbohydrate diets.
Weber, J.R., & Kelley, J.H., Health
c.high serum level of high-density Assessment in Nursing, 6th ed.,
lipoproteins.
Philadelphia, Wolters Kluwer, 2018,
d.diets that are high in antioxidant Chapter 21: Assessing Heart and
vitamins.
Neck Vessels, p. 443.
Chapter 21: Assessing Heart and
Neck Vessels - Page 443
53. An adult client visits the clinic and b. angina.
tells the nurse that she feels chest Explanation:
pain and pain down her left arm. The Angina (cardiac chest pain) is usually
nurse should refer the client to a
described as a sensation of squeezphysician for possible...
ing around the heart; a steady, severe
pain; and a sense of pressure. It may
a.congestive heart failure.
radiate to the left shoulder and down
b.angina.
the left arm or to the jaw.
c.palpitations.
Reference:
d.acute anxiety reaction.
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 440.
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
54. The nurse is reviewing a client's
c. 6
cardiac output. The nurse identifies Explanation:
25 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
which cardiac output as being within Normal cardiac out put ranges from
the normal?
5-8 L/min.
Reference:
a.2
Weber, J.R., & Kelley, J.H., Health
b.4
Assessment in Nursing, 6th ed.,
c.6
Philadelphia, Wolters Kluwer, 2018,
d.8
Chapter 21: Assessing Heart and
Neck Vessels, p. 436.
Chapter 21: Assessing Heart and
Neck Vessels - Page 436
55. Which is true of a third heart sound c. It is caused by rapid deceleration of
(S3)?
blood against the ventricular wall.
a.It marks atrial contraction.
Explanation:
b.It reflects normal compliance of The S3 gallop is caused by rapid dethe left ventricle.
celeration of blood against the venc.It is caused by rapid deceleration tricular wall. S4 is heard with atrial
of blood against the ventricular wall. contraction and is absent in atrial fibd.It is not heard in atrial fibrillation. rillation for this reason. It usually indicates a stiff or thickened left ventricle
as in hypertension or left ventricular
hypertrophy.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 458.
Chapter 21: Assessing Heart and
Neck Vessels - Page 458
56. When evaluating the jugular venous a. right atrium
pressure in a client with known coro- Reference:
nary artery disease, the nurse ex- Weber, J.R., & Kelley, J.H., Health
plains to the client that the JVP mea- Assessment in Nursing, 6th ed.,
sures the pressure in the...
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
a.right atrium
Neck Vessels, p. 446.
26 / 28
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
b.left atrium
c.right ventricle
d.left ventricle
Chapter 21: Assessing Heart and
Neck Vessels - Page 446
57. Which of the following would put the -Dizziness
client at risk for falls? Select all that -Hypotension
apply.
-Confusion
-Dizziness
-Hypotension
-Confusion
-Palpitations
-Diaphoresis
Explanation:
Dizziness, hypotension and confusion may put the client at risk for falls.
Palpitations and diaphoresis does not
increase fall risk.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 440.
Chapter 21: Assessing Heart and
Neck Vessels - Page 440
58. The nursing instructor explains to
a group of students that what can
shorten diastole?
a.Increased heart rate
b.Decreased respirations
c.Filling pressures
d.Blood pressure
27 / 28
a. Increased heart rate
Explanation:
Diastole is the phase of the cardiac
cycle in which the ventricles relax
and fill with blood. As the heart rate
increases, the length of diastole is
shortened. The respiratory rate, blood
pressure and filling pressures do not
shorten diastole.
Reference:
Weber, J.R., & Kelley, J.H., Health
Assessment in Nursing, 6th ed.,
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
Neck Vessels, p. 434.
PrepU ch. 21 assessing heart and neck vessels
Study online at https://quizlet.com/_9gjs1j
Chapter 21: Assessing Heart and
Neck Vessels - Page 434
59. The nurse on the cardiac unit is
a. They more than double the risk of
caring for a client who thinks he
cardiac disease.
was having a myocardial infarction
when he came to the emergency de- Explanation:
partment. When reviewing laborato- The risk of a cardiovascular event
ry data on this client, the nurse notes more than doubles with an elevatthat all tests are within normal limits ed cholesterol and C-reactive protein
except for the cholesterol and C-re- level.
active protein, both of which are elevated outside the normal range. The Reference:
nurse should be aware of what fact Weber, J.R., & Kelley, J.H., Health
relating to elevated cholesterol and Assessment in Nursing, 6th ed.,
C-reactive protein?
Philadelphia, Wolters Kluwer, 2018,
Chapter 21: Assessing Heart and
a.They more than double the risk of Neck Vessels, p. 443.
cardiac disease.
Chapter 21: Assessing Heart and
b.They have no direct correlation
Neck Vessels - Page 443
with increased risk of cardiac disease.
c.They are both sensitive and specific to heart failure.
d.They are clinical proof that the
client had a coronary event.
28 / 28
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
1. An adult client tells the nurse that his father high serum level of low-dendied of a massive coronary attack at the age sity lipoproteins.
of 65. The nurse should explain to the client Explanation:
that one of the risk factors for coronary heart Dyslipidemia presents the
disease is
greatest risk for the developing coronary artery disease.
a) high serum level of high-density lipopro- Elevated cholesterol levels
teins.
have been linked to the deb) high serum level of low-density lipopro- velopment of atheroscleroteins.
sis.
c) diets that are high in antioxidant vitamins.
d) low-carbohydrate diets.
2. The client is experiencing severe sepsis.
What assessment finding would the nurse
expect?
a) Blood pressure 140/80
b) Respiratory rate 14
c) Heart rate 88
d) 1+ pulses
1+ pulses
Explanation:
The blood pressure, heart
rate, and respiratory rate are
all within normal limit. Weak
pulses would be expected.
3. The nurse notes the client has weak puls- Hypovolemia
es bilaterally. The nurse understands that
this could indicate the client is experiencing Explanation:
what?
A weak pulse can indicate hypovolemia, shock or
a) Hypovolemia
decreased cardiac output.
b) Constriction
Pulse inequality may indic) Hypervolemia
cate a constriction or ocd) Occlusion
clusion. Hypervolemia would
be manifested by bounding
pulses.
4. When a patient is obese or has a thick chest Apical impulse
wall, what is difficult to palpate?
Explanation:
a) Sternal angle
Obesity or a thick chest wall
b) Grade 4 murmur
makes palpation of the apical
1 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
c) Apical impulse
d) JVP
impulse difficult.
Weber, J. R., & Kelley, J.
H. (2014). Health Assessment in Nursing, 5th ed.
Philadelphia: Wolters Kluwer
Health/Lippincott Williams &
Wilkins, Chapter 21: Assessing Heart and Neck Vessels,
p. 429.
5. A nurse performs an initial health history on No current medications or
a client admitted for new onset of chest pain. treatments
Which data is considered subjective for the
cardiovascular system?
Explanation:
Subjective data is data cola) Apical heart rate 70 beats per minute
lected from the client. No
b) Apical impulse palpated at 5 intercostal current medications or treatspace on left
ments is information the
c) No current medications or treatments
nurse obtained from the
d) No edema of extremities noted
client. Apical heart rate 70
beats per minute, no edema
of extremities noted, and apical impulse palpated at 5 intercostal space on left are
examples of objective data
collected by the nurse upon
physical examination
6. A nurse is unable to palpate the apical im- Client has an increased
pulse on an older client. Which assessment chest diameter
data in the client's history should the nurse Explanation:
recognize as the reason for this finding?
The apical impulse may not
be palpable in clients with
a) Respiratory rate is too fast
increased anteroposterior dib) Heart rate is irregular
ameters. Irregular heart rate
c) Heart enlargement is present
should not interfere with the
d) Client has an increased chest diameter ability to palpate an apical impulse. Respiratory rate
2 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
does not impact the apical
impulse. Heart enlargement
would displace the apical impulse but not cause it to be
nonpalpable. pg 433
7. Where are the heart and great vessels locat- The mediastinum, between
ed in the human body?
the lungs above the diaphragm
a) The peritoneum, below the diaphragm
b) The mediastinum, between the lungs
Explanation:
above the diaphragm
The heart and great vesc) The peritoneum, above the diaphragm
sels are located in the med) The mediastinum, between the lungs be- diastinum between the lungs
low the diaphragm
and above the diaphragm
from the center to the left
of the thorax. Therefore, the
other options are incorrect.
pg416
8. What nursing diagnosis would be most ap- Ineffective tissue perfusion
propriate for a client admitted with heart failure?
Explanation:
Heart failure can cause
a) Ineffective tissue perfusion
ineffective tissue perfusion
b) Risk for denial
which can lead to fac) Acute pain
tigue, pain and activity ind) Impaired gas exchange
tolerance. Impaired gas exchange would be more appropriate for respiratory disorders pg437
9. The nurse has assessed the heart sounds recognize that this finding is
of an adolescent client and detects the pres- normal in adolescents.
ence of an S3 heart sound at the beginning
of the diastolic pause. The nurse should in- Explanation:
struct the client that she should
A physiologic S3 heart sound
is a benign finding coma) restrict exercise and strenuous activities. monly heard at the begin3 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
b) be referred to a cardiologist for further
evaluation.
c) be examined again in 6 months.
d) recognize that this finding is normal in
adolescents.
ning of the diastolic pause
in children, adolescents, and
young adults. pg435
10. During an interview with the nurse, a client Decreased cardiac output
complains of a fatigue that seems to get
worse in the evening. Which of the follow- Explanation:
ing causes of fatigue would explain this pat- Fatigue may result from comtern?
promised cardiac output. Fatigue related to decreased
a) Severe muscular exertion
cardiac output is worse in
b) Decreased cardiac output
the evening or as the day
c) Upper respiratory infection
progresses, whereas fatigue
d) Depression
seen with depression is ongoing throughout the day. Severe muscular exertion and
an upper respiratory infection may be associated with
fatigue, but not the pattern
mentioned in the scenario pg
424
11. What is located at the right and left 2nd inter- Base of the heart
costal spaces next to the sternum?
Explanation:
a) Base of the heart
The right ventricle narrows
b) Pulmonary vein
as it rises to meet the pulc) Apex of the heart
monary artery just below the
d) Aortic valve
sternal angle. This is called
the "base of the heart" and
is located at the right and left
2nd intercostal spaces next
to the sternum. pg423
12. The anterior chest area that overlies the
heart and great vessels is called the
4 / 30
precordium.
Explanation:
The anterior chest area that
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
a) myocardium.
b) precordium.
c) endocardium.
d) epicardium.
overlies the heart and great
vessels is called the precordium. p. 416.
13. The nurse assesses a hospitalized adult
increased central venous
client and observes that the client's jugular pressure.
veins are fully extended. The nurse contacts Explanation:
the client's physician because the client's The level of the jugular vesigns are indicative of
nous pressure reflects right
atrial (central venous) presa) diastolic murmurs.
sure and, usually, right venb) pulmonary emphysema.
tricular diastolic filling presc) patent ductus arteriosus.
sure. Right-sided heart faild) increased central venous pressure.
ure raises pressure and volume, thus raising jugular venous pressure
pg 424
14. The area known as Erb's point is the third
site for auscultation on the precordium.
Where is it located?
a) 4th right rib space
b) 4th left rib space
c) 3rd left rib space
d) 3rd right rib space
15. During the health history interview with
a 40-year-old man, the nurse uses the
genogram to specifically assess for major
family risk for cardiovascular disease by
asking about which of the following?
a) Diabetes mellitus in his extended family
b) Heart attacks in his father and siblings
c) Weight patterns within his family
d) Hypertension in his grandparents
5 / 30
3rd left rib space
Correct
Explanation:
The 3rd left rib space is
the third site for auscultation
(Erb's point). The other options are distracters. pg 423
Heart attacks in his father
and siblings
Explanation:
Risk of developing heart disease is increased if one
or more immediate family
members (parents or siblings) have had an MI, hypertension, or high cholesterol.
pg426
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
16. The nurse is reviewing a client's cardiac out- 6
put. The nurse identifies which cardiac out- Explanation:
put as being within the normal?
Normal cardiac out put
ranges from 5-8 L/min.
a) 2
pg. 422.
b) 4
c) 6
d) 8
17. A nurse is working with a client who recently Myocardium
suffered a heart attack. As a result, the client Correct
has experienced the death of the muscle tis- Explanation:
sues that make up the thickest layer of the The myocardium is the thickheart. This layer of muscle is known as which est layer of the heart and is
of the following?
made up of contractile cardiac muscle cells. The peria) Myocardium
cardium is a tough, inextensib) Endocardium
ble, loose-fitting, fibroserous
c) Epicardium
sac that attaches to the great
d) Pericardium
vessels and surrounds the
heart. A serous membrane
lining, the parietal pericardium, secretes a small amount
of pericardial fluid that allows for smooth, friction-free
movement of the heart. This
same type of serous membrane covers the outer surface of the heart and is
known as the epicardium.
The endocardium is a thin
layer of endothelial tissue
that forms the innermost layer of the heart and is continuous with the endothelial lining of blood vessels. pg417
18. A client complains of difficulty sleeping,
Orthopnea
stating he has to sit up with the help of sev- Explanation:
6 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
eral pillows and cannot breathe when lying A client with heart failure may
flat. This client has a condition known as
have fluid in their lungs, makwhat?
ing it difficult to breathe when
lying flat (orthopnea). An ina) Tachypnea
creased respiratory rate is
b) Sleep apnea
tachypnea. Sleep apnea is
c) Pneumonia
a condition where the client
d) Orthopnea
has periods of not breathing while sleeping. Pneumonia does not present as described in the question. pg
425
19. The nurse is providing teaching about car- • Cholesterol
diovascular disease in a community setting. • Blood pressure
What risk factors would the nurse identify to • Smoking
the group as those they can modify through Correct
lifestyle choices? Select all that apply.
Explanation:
Smoking, cholesterol and
a) Blood pressure
blood pressure can be
b) Age
controlled through lifestyle
c) Smoking
choices. Age and family hisd) Family history
tory are non-modifiable risk
e) Cholesterol
factors.
pg 429
20. Upon assessment of a client's pulse, a nurse Presence of an S3
notices that the amplitude of the pulse
Explanation:
varies between beats. Which other finding Changes in the amplitude (or
should the nurse assess for in this client? strength) of a client's pulse
from beat to beat is called
a) Presence of an S3
pulsus alternans. This is usub) Changes on expiration
ally seen in heart failure.
c) Split S2 on inspiration
The nurse should assess the
d) Diminished heart sounds
client for the presence of an
S3 and an S4, which indicate a noncompliant ventricle. Diminished heart sounds
can be present in an obese
7 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
client or with hypovolemia,
shock, or decreased cardiac
output. A pulse that changes
with respirations is called a
paradoxical pulse and seen
in cardiac tamponade or obstructive lung disease. A split
S2 does not change the amplitude of a client's pulse.
pg438
21. The semilunar valves are located
at the exit of each ventricle
at the beginning of the great
a) at the beginning of the ascending aorta. vessels.
b) at the exit of each ventricle at the begin- Explanation:
ning of the great vessels.
The semilunar valves are loc) between the left atrium and the left ven- cated at the exit of each ventricle.
tricle at the beginning of the
d) between the right atrium and the right
great vessels.p416
ventricle
22. A nurse experiences difficulty with palpation Ask the client to assume the
of the apical impulse on the pre cordium.
left lateral position
What is an appropriate action by the nurse? Explanation:
If unable to locate the apia) Try using one finger of the dominant hand cal impulse, ask the client to
to locate the pulse
turn to the left lateral posib) Use the stethoscope to auscultate
tion. This displaces the heart
c) Instruct the client to cough and attempt towards the left chest wall
again
and relocates the apical imd) Ask the client to assume the left lateral pulse farther to the left. Usposition
ing one finger is appropriate after locating the pulse
for a more accurate palpation. Coughing will not assist
in location of the apical impulse. The nurse should locate the apical impulse by
8 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
palpation before auscultating
heart sounds. pg433
23. A client is admitted to the health care facility Ineffective Tissue Perfusion
with reports of chest pain, elevated blood Correct
pressure, and shortness of breath with ac- Explanation:
tivity. The nurse palpates the carotid arteries The nurse assesses a deas 1+ bilaterally and a weak radial pulse.
crease in the carotid pulsA Grade 3 systolic murmur is auscultated. es (1+ is considered weak)
Which nursing diagnosis can the nurse con- and a weak radial pulse
firm based on this data?
is present. The client also
has a murmur. These finda) Activity Intolerance
ings allow the nurse to conb) Impaired Breathing Pattern
firm the diagnosis of Ineffecc) Ineffective Tissue Perfusion
tive Tissue Perfusion. There
d) Ineffective Health Maintenance
are not enough criteria to
confirm the diagnosis of Impaired Breathing Pattern, Activity Intolerance, or Ineffective Health Maintenance. pg
437
24. The nurse hears high-pitched swooshing
Bruits
sounds over the carotid artery on the right Explanation:
side. What is this sound indicative of?
Distinguishing a murmur
from a bruit can be challenga) Bruits
ing. Murmurs originate in the
b) Normal findings
heart or great vessels and
c) Gallops
are usually louder over the
d) Murmurs
upper precordium and quieter near the neck. Bruits are
higher pitched, more superficial, and heard only over
the arteries. A gallop is a
generic term for an additional
heart sounds heard besides
the normal S1 and S2 sound.
pg 431
9 / 30
Chapter 21 Heart and Neck Vessels
Study online at https://quizlet.com/_2lme7r
25. When auscultating the heart sounds of a
Accentuated
client, a nurse notes that the S2 is louder
Explanation:
than the S1. How should the nurse describe An accentuated S2 means
S2?
that the S2 is louder than
the S1. This occurs in cona) Normal split
ditions in which the aortic or
b) Wide split
pulmonic valve has a highc) Diminished
er closing pressure. A did) Accentuated
minished S2 means that the
S2 is softer than the S1.
This occurs in conditions in
which the aortic or pulmonic
valves have decreased mobility. Normal split S2 can
be heard over the second
or third left intercostal space;
it is usually heard best during inspiration and disappears during expiration. Wide
split S2 is an increase in the
usual splitting that persists
throughout the entire respiratory cycle, and widens on
expiration pg 421
26. The nurses the stethoscope at the second Pulmonic
and third left intercostal space close to the
sternum to assess what heart sound?
Explanation:
The aortic is assessed at
a) Right ventricular
the right second intercostal
b) Pulmonic
space to apex of heart. The
c) Aortic
pulmonic is assessed at the
d) Left ventricular
second and third left intercostal spaces close to
sternum. The Left ventricular area is assessed at the
second to fifth intercostal
spaces, extending from the
left sternal border to the
10 / 30
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left mid-clavicular line. Right
ventricular area is assessed
at the second to fifth intercostal spaces, centered over
the sternum.
27. A client is experiencing decreased cardiac Blood pressure
output. Which vital sign is priority for the
Explanation:
nurse to monitor frequently?
With decreased cardiac output, the heart pumps inada) Blood pressure
equate blood to meet the
b) Temperature
body's metabolic demands.
c) Respiratory rate
The blood pressure is most
d) Heart rate
important to assess frequently.
28. An adult client tells the nurse that his father high serum level of low-dendied of a massive coronary attack at the age sity lipoproteins.
of 65. The nurse should explain to the client
that one of the risk factors for coronary heart Explanation:
disease is
Dyslipidemia presents the
greatest risk for the developa) low-carbohydrate diets.
ing coronary artery disease.
b) high serum level of high-density lipopro- Elevated cholesterol levels
teins.
have been linked to the dec) diets that are high in antioxidant vitamins. velopment of atherosclerod) high serum level of low-density lipopro- sis.
teins.
29. The nurse is auscultating the heart sounds third to fifth intercostal space
of an adult client. To auscultate Erb point, the at the left sternal border.
nurse should place the stethoscope at the
a) third to fifth intercostal space at the left Explanation:
sternal border.
Erb's point: Third to fifth interb) fourth or fifth intercostal space at the left costal space at the left sterlower sternal border.
nal border
c) second intercostal space at the right sternal border.
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d) apex of the heart near the midclavicular
line (MCL).
30. The anterior chest area that overlies the
heart and great vessels is called the
precordium.
Explanation:
The anterior chest area that
overlies the heart and great
vessels is called the precordium.
a) precordium.
b) endocardium.
c) epicardium.
d) myocardium.
31. A nurse is unable to palpate the apical im- Client has an increased
pulse on an older client. Which assessment chest diameter
data in the client's history should the nurse
recognize as the reason for this finding?
Explanation:
The apical impulse may not
a) Respiratory rate is too fast
be palpable in clients with
b) Heart rate is irregular
increased anteroposterior dic) Client has an increased chest diameter ameters. Irregular heart rate
d) Heart enlargement is present
should not interfere with the
ability to palpate an apical impulse. Respiratory rate
does not impact the apical
impulse. Heart enlargement
would displace the apical impulse but not cause it to be
nonpalpable.
32. A nurse auscultates the heart of a client with Atrial contractions heard as
hypertension for the past ten (10) years. With vibrations against stiff walled
the client in the left lateral position, the nurse ventricles
hears a heart sound that occurs just before Explanation:
S1. The nurse recognizes this sound as what Long-standing hypertension
pathological process?
causes stiffening of the ventricles. This produces an S4
a) Atrial contractions heard as vibrations
heart sound, heard best with
against stiff walled ventricles
the bell of the stethoscope
b) Abnormal contraction of the ventricles
over the apical area with the
due to a conduction delay
client in a supine or left lat12 / 30
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c) Turbulence within the ventricles caused
by rapid filling
d) Splitting of S2 that does not disappear
with expiration
eral position. The sound is
produced as the atria contract and produce vibrations
from blood flow into stiff
walled ventricles. Abnormal
contraction of the ventricles
due to a conduction delay
would produce a split S1. Turbulence within the ventricles
caused by rapid filling is an
acute finding and most often
the result of acute heart failure. Splitting of S2 that does
not disappear with expiration
is suggestive of heart disease.
33. How does the nurse differentiate a pleural
friction rub from a pericardial friction rub?
Have the client hold his or
her breath; if the rub persists,
it is pericardial
a) Turn the client on the right side; if the rub
persists, it is pericardial
Explanation:
b) Have the client hold his or her breath; if Pericardial friction rubs can
the rub persists, it is pericardial
be differentiated from pleurc) Auscultate the upper back; if a rub is
al friction rubs by having the
present, it is pleural
client hold the breath. If pred) Auscultate the base of the heart; if a rub sent without breathing, the
is present, it is pericardial
rub is pericardial. Turning the
client to the right side and
auscultating either the base
of the heart or the upper back
do not differentiate between
pericardial and pleural friction rubs
34. A 52-year-old man is skeptical about the po- Smoking increases the
tentially harmful effect of his smoking on
heart's workload and conhis heart, citing the fact that both his father tributes to atherosclerosis.
and grandfather lived long lives despite be13 / 30
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ing lifelong smokers. Which of the following Explanation:
facts would underlie the explanation that the Smoking increases cardiac
nurse provides the client?
workload and contributes
to hypertension, plaque
a) Smoking is a central component of meta- build-up, and blood clots. It
bolic syndrome.
does not directly affect conb) Smoking damages the cardiac conduc- tractility or cardiac conduction system, resulting in dysrhythmias that tion, and it is not a compoare entirely preventable.
nent of metabolic syndrome.
c) Smoking increases the heart's workload
and contributes to atherosclerosis.
d) Smoking decreases the contractility of
the myocardium and contributes to valvular
disorders.
35. A client comes to the emergency department Shortness of breath
reporting a sudden onset of dyspnea. What
finding is a manifestation of dyspnea?
Explanation:
Clients with heart failure may
a) Painful breathing
be short of breath from flub) Rapid breathing
id accumulation in the pulc) Inability to breathe
monary bed. Onset may be
d) Shortness of breath
sudden with acute or chronic
pulmonary edema. It is important to assess how much
activity brings on dyspnea,
such as rest, walking on a
flat surface, or climbing. The
other options listed are distracters to the question.
36. The nurse is assessing a client diagPlace the bell of the stethonoses with mitral stenosis. Which technique scope over the apex with
should the nurse use to listen to this condi- client on left side.
tion?
This mid-diastolic murmur is
a) With the client leaning forward, listen over associated with an opening
the left carotid artery.
snap and has a low-pitched,
b) Place the bell of the stethoscope over the rumbling quality. Heard best
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apex with client on left side.
with the bell over the apex
c) With the client supine, place the bell of
with the patient turned to the
the stethoscope on the 2nd left instercostal left. The carotid arteries are
space.
auscultated one at a time
d) Use the diaphragm of the stethoscope to for bruits. The 2nd left interlisten over the right sternal border.
costal space is the location
to hear pulmonic valve conditions.
37. A nurse auscultates a very loud murmur that Grade 5
occurs throughout systole and can be heard
with the stethoscope partly off the chest.
Explanation:
How should the nurse grade this murmur? A very loud murmur that can
be heard with the stethoa) Grade 6
scope partly off the chest is
b) Grade 2
graded as Grade 5. A Grade
c) Grade 1
1 is very faint and a Grade 6
d) Grade 5
can be heard with the stethoscope entirely off the chest.
A Grade 2 is quiet but heard
immediately on placing the
stethoscope on the chest.
38. What is the most important physical sign of Pericardial friction rub
acute pericarditis?
Explanation:
A pericardial friction rub is
a) Elevated white cell count
the most important physical
b) Intense pain
sign of acute pericarditis. It
c) Murmur heard over the left sternal border may have up to three comd) Pericardial friction rub
ponents during the cardiac
cycle and is high pitched,
scratching, and grating. It
can best be heard with the diaphragm of the stethoscope
at the left lower sternal border. The pericardial friction
rub is heard most frequently during expiration and increases when the patient is
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upright and leaning forward.
Acute pericarditis, elevated
white cell count, and a murmur heard over the left sternal border would not be the
primary physical sign of the
condition
39. The nurse is planning to auscultate a feask the client to hold her
male adult client's carotid arteries. The nurse breath.
should plan to
Explanation:
Place the bell of the stethoa) ask the client to breathe normally.
scope over the carotid artery
b) ask the client to hold her breath.
and ask the client to hold
c) place the diaphragm of the stethoscope his or her breath for a moover the artery.
ment so that breath sounds
d) palpate the arteries before auscultation. do not conceal any vascular
sounds.
40. A nurse is assessing a client for possible
Observe for a decrease in
dehydration. Which of the following should jugular venous pressure
the nurse do?
Explanation:
a) Check for pulse inequality between right Decrease in jugular venous
and left carotid arteries
pressure can occur with deb) Auscultate for split S1 at the base and
hydration secondary to a deapex
crease in total blood volume,
c) Observe for a decrease in jugular venous so the nurse should observe
pressure
for a decrease in jugular
d) Assess for a difference between the api- venous pressure. Assessing
cal and radial pulse
the difference in the apical
and radial pulses would help
the nurse assess for pulse
deficit. Differences in the amplitude or rate of the carotid
pulse may indicate stenosis.
A split S1 occurs when the
left and right ventricles con-
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tract at different times (asynchronous contraction).
41. During a cardiac examination, the nurse can apex of the heart.
best hear the S1 heart sound by placing the
stethoscope at the client's
Explanation:
S1 may be heard over the ena) second left interspace.
tire precordium but is heard
b) apex of the heart.
best at the apex (left MCL,
c) pulmonic valve area.
fifth ICS).
d) base of the heart.
42. While assessing an older adult client, the
associated with occlusive arnurse detects a bruit over the carotid artery. terial disease.
The nurse should explain to the client that a Explanation:
bruit is
A bruit, a blowing or swishing sound caused by turbua) heard when the artery is almost totally
lent blood flow through a naroccluded.
rowed vessel is indicative of
b) a normal sound heard in adult clients.
occlusive arterial disease.
c) a wheezing sound.
d) associated with occlusive arterial disease.
43. A nurse cares for a client who suffered a my- Inflammation of the pericarocardial infarction two (2) days ago. A high dial sac
pitched, scratchy, scraping sound is heard
that increase with exhalation and when the Explanation:
client leans forward. The nurse recognizes A high pitched, scratchy,
this sound as a result of what process oc- scraping sound is heard that
curring within the pericardium?
increase with exhalation and
when the client leans forward
a) Inability of the atria to contract
is called a pericardial fricb) Increased pressure within the ventricle tion rub. This is caused by
c) Inflammation of the pericardial sac
inflammation of the pericard) Incompetent mitral valve
dial sac. Increased pressure
within the ventricles may
cause a decrease in cardiac
output. Inability of the atria
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to contract can be caused
by any problem that causes
the sinoatrial node not to fire.
An incompetent mitral valve
would cause a systolic murmur.
44. A student is asked to define the continuous Cardiac cycle
rhythmic movement of blood during conExplanation:
traction and relaxation of the heart. This best The continuous rhythmic
describes which of the following?
movement of blood during
contraction and relaxation of
a) Cardiac cycle
the heart is the cardiac cycle.
b) Cardiac output
c) Cardiac workload
d) Cardiac circulation
45. A 58-year-old teacher presents with breath- Orthopnea
lessness with activity. The client has no
chronic conditions and does not take any Explanation:
medications, herbs, or supplements. Which Orthopnea, which is dyspof the following symptoms is appropriate to nea that occurs when lying
ask about in the cardiovascular review of
down and improves when sitsystems?
ting up, is part of the cardiovascular review of systems
a) Abdominal pain
and, if positive, may indicate
b) Orthopnea
congestive heart failure
c) Hematochezia
d) Tenesmus
46. During assessment, the nurse notes an irregular rhythm. What should the nurse do
next?
a) Assess for a pulse deficit.
b) Document finding.
c) Notify the physician.
d) Reposition the client and reassess.
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Assess for a pulse deficit.
Explanation:
If an irregular rhythm is identified, the nurse should check
for a pulse deficit. The information should then be documented and the physician
can be notified. There is no
need to reposition the client.
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47. A 25-year-old optical technician comes to Mitral
the clinic for evaluation of fatigue. As part of
the physical examination, the nurse listens Explanation:
to her heart and hears a murmur only at
Mitral valve sounds are usuthe cardiac apex. Which valve is most likely ally heard best at and around
to be involved based on the location of the the cardiac apex.
murmur?
a) Pulmonic
b) Mitral
c) Aortic
d) Tricuspid
48. The nursing instructor is discussing assess- A thrill
ment of the heart with students. A student
states that he has a client with a rushing
Explanation:
vibration in the precordium that the student Thrills are vibrations detectcould feel and that it was in the area of the ed on palpation. A palpable,
pulmonic valve. What should the instructor rushing vibration (thrill) is
explain that the student is feeling?
caused from turbulent blood
flow with incompetent valves,
a) A heave
pulmonary hypertension, or
b) A thrill
septal defects. This vibration
c) A normal finding
is usually in the location of
d) A thrust
the valve in which it is associated. A thrust or a heave
is a forceful thrusting on the
chest. This is not a normal
finding.
49. A nurse recognizes that the second heart Closure of the semilunar
sound, S2, is produced by which cardiac ac- valves
tion?
Explanation:
a) Closure of the atrioventricular (AV) valves Closure of the semilunar
b) Isometric contraction
valves, which are the aortic
c) Closure of the semilunar valves
and pulmonic valves, causes
d) Ventricular contraction
the second heart sound, S2.
The closure of these valves
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signals the end of systole.
Isometric contraction occurs
when all valves are closed,
which occurs just before systole, in which no sound is
produced. Closure of the AV
valves produces the S1 heart
sound, which is the beginning of systole. Ventricular
contraction is the occurrence
of systole, which produces
not sound but causes ejection of blood from the ventricles.
50. When educating a client about healthy
Quit or do not start smoking
habits relating to cardiovascular health, it is • Exercise regularly
important to include which of the following? • Undergo regular cholesSelect all that apply.
terol screening
• Undergo regular screening
a) Undergo regular cholesterol screening
for diabetes
b) Exercise regularly
Explanation:
c) Eat a low-fiber diet
Important healthy habits to
d) Undergo regular screening for diabetes emphasize include following
e) Quit or do not start smoking
a low-fat diet, regularly exercising, undergoing regular
screening for diabetes and
cholesterol, and quitting (or
continuing not) smoking.
51. A nurse expects to find which abnormal
Midsystolic click
heart sound in a client diagnosed with mitral
valve prolapse?
Explanation:
The nurse would expect to
a) Venous hum
find a midsystolic click on
b) Midsystolic click
auscultation in the client dic) Ventricular gallop
agnosed with mitral valve
d) Opening snap
prolapse. A ventricular gallop is the third heart sound
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and is associated with decreased myocardial contractility, myocardial failure, congestive heart failure, and volume overload of the ventricle. A venous hum is a benign sound caused by turbulence of blood in the jugular veins. An opening snap is
heard with the opening of a
stenotic or stiff mitral valve.
52. Across the lifespan, a nurse knows that the Is normally smaller than the
female heart
male heart
Explanation:
a) Is normally smaller than the male heart The total size of the heart
b) Is normally larger than a male heart
is approximately that of a
c) Normally beats slower than a male heart clenched adult fist. The fed) Weighs more than a male heart
male heart is normally smaller and weighs less than the
male heart across all age
groups.
53. The nurse performs an admission assess- "Right carotid bruit auscultatment on an adult client admitted through the ed"
ED with a myocardial infarction. The nurse Explanation:
charts "Swooshing sound heard over right Bruits are swooshing sounds
carotid artery." How should this documenta- similar to the sound of the
tion be corrected?
blood pressure. They result
from turbulent blood flow related to atherosclerosis. A
a) "Right carotid bruit auscultated"
bruit is audible when the
b) "Murmur heard over right carotid artery" artery is partially obstructed.
c) "Split sound auscultated over right
With complete obstruction,
carotid artery"
no bruit is audible, because
d) Does not need to be corrected
no blood gets through. Distinguishing a murmur from
a bruit can be challenging. Murmurs originate in the
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heart or great vessels and
are usually louder over the
upper precordium and quieter near the neck. Bruits are
higher pitched, more superficial, and heard only over the
arteries. Split sounds are not
heard over arteries.
54. A nurse is working with a client who recently Myocardium
suffered a heart attack. As a result, the client
has experienced the death of the muscle tis- Explanation:
sues that make up the thickest layer of the The myocardium is the thickheart. This layer of muscle is known as which est layer of the heart and is
of the following?
made up of contractile cardiac muscle cells. The peria) Pericardium
cardium is a tough, inextensib) Epicardium
ble, loose-fitting, fibroserous
c) Endocardium
sac that attaches to the great
d) Myocardium
vessels and surrounds the
heart. A serous membrane
lining, the parietal pericardium, secretes a small amount
of pericardial fluid that allows for smooth, friction-free
movement of the heart. This
same type of serous membrane covers the outer surface of the heart and is
known as the epicardium.
The endocardium is a thin
layer of endothelial tissue
that forms the innermost layer of the heart and is continuous with the endothelial
lining of blood vessels
55. The bicuspid, or mitral, valve is located
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between the left atrium and
the left ventricle.
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a) between the left atrium and the left ventricle.
Explanation:
b) between the right atrium and the right
The bicuspid (mitral) valve is
ventricle.
composed of two cusps and
c) at the exit of each ventricle near the great is located between the left
vessels.
atrium and the left ventricle
d) at the beginning of the ascending aorta.
56. In order for the nurse to assess jugular ve- The head of the bed raised
nous pressure (JVP), the client should be in 60 degrees
which of the following positions?
Explanation:
Jugular venous pressure rea) The head of the bed raised 30 degrees
flects pressure in the right
b) The head of the bed raised 90 degrees
atrium or central venous
c) The head of the bed raised 60 degrees
pressure. With the head of
d) The client lying supine
the bed positioned at 60 degrees, the nurse can measure the jugular venous pressure because the "top" of
the internal jugular vein is
now visible, so the vertical distance from the sternal angle or right atrium
can be measured. With the
head of the bed positioned
at 30 degrees, the jugular venous pressure cannot
be measured because venous undulation is above the
jaw and therefore, not visible. With the head of the
bed positioned at 90 degrees, the veins are barely
discernible above the clavicle, making measurement
impossible. The jugular venous pressure cannot be
measured with the client in a
supine position because the
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head needs to be elevated
slightly in order to bring the
vein into view
57. The nurse on the cardiac unit is caring for a They more than double the
patient who thinks he was having a
risk of cardiac disease.
myocardial infarction when he came to the
emergency department. When reviewing
Explanation:
laboratory data on this patient, the nurse
The risk of a cardiovascunotes that all tests are within normal limlar event more than doubles
its except for the cholesterol and C-reacwith an elevated cholesterol
tive protein, both of which are elevated out- and C-reactive protein level.
side the normal range. The nurse should be
aware of what fact relating to elevated cholesterol and C-reactive protein?
a) They have no direct correlation with increased risk of cardiac disease.
b) They more than double the risk of cardiac
disease.
c) They are both sensitive and specific to
heart failure.
d) They are clinical proof that the patient had
a coronary event.
58. The nurse is conducting a workshop on the Palpable
measurement of jugular venous pulsation.
As part of instruction, the nurse tells the stu- Explanation:
dents to make sure that they can distinguish The carotid pulse is palpabetween the jugular venous pulsation and ble; the jugular venous pulcarotid pulse. Which of the following charac- sation is rarely palpable. The
teristics is typical of the carotid pulse?
carotid upstroke is normally brisk, but may be delayed
a) Pulsation eliminated by light pressure on and decreased as in aortic
the vessel
stenosis or bounding as in
b) Soft, rapid, undulating quality
aortic insufficiency
c) Level of pulsation changes with changes
in position
d) Palpable
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59. The P-wave phase of an electrocardiogram conduction of the impulse
(ECG) represents
throughout the atria.
a) conduction of the impulse throughout the Explanation:
atria.
The P wave indicates atrial
b) ventricular polarization.
depolarization; conduction of
c) ventricular repolarization.
the impulse throughout the
d) conduction of the impulse throughout the atria.
ventricles.
Reference:
p. 419.
60. The nursing instructor explains to a group of Increased heart rate
students that what can shorten diastole?
Explanation:
a) Decreased respirations
As the heart rate increasb) Filling pressures
es, the length of diastole
c) Increased heart rate
is shortened. The respiratory
d) Blood pressure
rate, blood pressure and filling pressures do not shorten
diastole.
61. A patient with prehypertension is in the clin- regular exercise for at least
ic for counseling. All lifestyle modifications 30 minutes a day
are important in preventing or managing hy- Regular exercise provides
pertension. Which modification would be the many benefits, including lowbest to implement first for this patient?
ering the risk of hypertension
a) weight loss to BMI under 25 kg/m2
Reference:
b) elimination of alcohol consumption
429.
c) smoking cessation
d) regular exercise for at least 30 minutes a
day
62. A nurse is assessing a client for the pres- Check for pulse inequality
ence of stenosis in the carotid arteries.
between right and left carotid
Which of the following should the nurse do? arteries
a) Check for pulse inequality between right Explanation:
and left carotid arteries
The nurse should check for
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b) Observe for a decrease in jugular venous pulse inequality between the
pressure
right and left carotid arterc) Assess for a difference between the api- ies, because differences in
cal and radial pulses
the amplitude or rate of the
d) Auscultate for split S1 at the base and
carotid pulse may indicate
apex
stenosis. Pulse deficit is detected by assessing the difference in the apical and radial pulses. A split S1 occurs
when the left and right ventricles contract at different
times (asynchronous contraction). Decrease in jugular
venous pressure can occur
with dehydration secondary
to a decrease in total blood
volume
63. A new nurse on the telemetry unit is review- The time from firing of the
ing information about how to correctly read sinoatrial (SA) node to the
electrocardiograms. The nurse is expected beginning of depolarization
to know that the PR interval represents what in the ventricle
event?
Explanation:
a) The time from firing of the sinoatrial (SA) PR interval represents the
node to the beginning of depolarization in time from the firing of the
the ventricle
SA node to the beginning
b) The spread of depolarization in the atria of ventricular depolarization
c) Relaxation of the ventricles and repolar- (includes a slight pause at
ization of the cells
the AV junction).
d) The spread of depolarization and sodium
release in the ventricles to cause ventricular
contraction
64. Which is true of a third heart sound (S3)?
a) It is not heard in atrial fibrillation.
b) It marks atrial contraction.
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It is caused by rapid deceleration of blood against the
ventricular wall.
Explanation:
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c) It reflects normal compliance of the left The S3 gallop is caused by
ventricle.
rapid deceleration of blood
d) It is caused by rapid deceleration of blood against the ventricular wall.
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
65. The client asks the nurse what the small P The small P wave indicates
wave on her ECG indicates. What would the atrial depolarization (duranurse answer?
tion up to 80 msec; PR interval 120 to 200 msec).
a) Atrial repolarization
b) Atrial depolarization
Reference:
c) Ventricular repolarization
p. 419.
d) Ventricular depolarization
66. Which statement describes the correct tech- Auscultate to determine the
nique by a nurse for use of a stethoscope to heart rate and if the rhythm is
auscultate the chest for heart sounds?
normal
Explanation:
a) Listen with the bell for the high pitched The nurse should focus on
sounds of normal S1S2
one sound at a time when
b) Auscultate to determine the heart rate
auscultating the precordium.
and if the rhythm is normal
Start by determining the rate
c) Elevate the head of bed until the examiner and rhythm. The examiner
can comfortably reach the client
should stand at the client's
d) Stand at the client's left side and perform right side to perform the asthe entire assessment from this position
sessment. The client should
be lying in the supine positions with the head of the
bed elevated at 30 degrees.
The diaphragm of the stethoscope is used to listen for the
high pitched should of nor-
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mal heart sounds.
pg 423
67. When auscultating the heart, the nurse is
S2
most likely to hear a diastolic murmur after
which heart sound?
Explanation:
The "lub" sound of S1 signals
a) S1
the beginning of ventricular
b) Preload
systole, whereas the "dub"
c) S2
sound of S2 signals the end
d) Afterload
of systole and beginning of
diastole. Systole occurs between S1 and S2, whereas diastole occurs between
S2 and the next S1. Preload
is an indicator of how much
blood will be forwarded to
and ejected from the ventricles. The heart has to pump
against the high blood pressures in the arteries and arterioles. This pressure in the
great vessels is termed afterload. Preload and afterload
are not heart sounds but volume and pressure indicators.
68. An adult client visits the clinic and tells the angina.
nurse that she feels chest pain and pain
down her left arm. The nurse should refer the Explanation:
client to a physician for possible
Angina (cardiac chest pain)
is usually described as
a) congestive heart failure.
a sensation of squeezing
b) angina.
around the heart; a steady,
c) acute anxiety reaction.
severe pain; and a sense of
d) palpitations.
pressure. It may radiate to
the left shoulder and down
the left arm or to the jaw.
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Chapter 21 Heart and Neck Vessels
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69. The nurse is preparing to assess the cardio- apical pulse.
vascular system of an adult client with emphysema. The nurse anticipates that there Explanation:
may be some difficulty palpating the client's The apical impulse may
be impossible to palpate in
a) jugular veins.
clients with pulmonary emb) carotid arteries.
physema.
c) apical pulse.
pg 433
d) breath sounds.
70. A nurse understands that the cardiac event Closure of the mitral and trithat signals the beginning of systole and
cuspid valves
produces the first heart sound is what?
Explanation:
The beginning of systole oca) Contraction of the ventricles
curs when the pressure in
b) Closure of the aortic and pulmonic valves the ventricles exceeds the
c) Closure of the mitral and tricuspid valves pressure in the atrium, causd) Relaxation of the ventricles
ing the mitral and tricuspid valves to close. This closure produces the first heart
sound (S1). The ventricles
contract and empty of the
blood volume, which causes
the pressure to drop and the
aortic and pulmonic valves
close. This produces the second heart sound (S2). Relaxation and contraction of
the ventricles do not produce
heart sounds.
71. When auscultating a client's heart sounds, Aortic and pulmonic
the nurse hears a louder S2 when listening
at the 2nd intercostal space right sternal bor- Explanation:
der. The nurse determines that this finding The closure of the aortic and
is consistent with the closure of which heart pulmonic valves creates the
valves?
second heart sound, which is
heard louder over the 2nd intercostal space right sternal
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Chapter 21 Heart and Neck Vessels
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a) Tricuspid and mitral
b) Aortic and pulmonic
c) Mitral and aortic
d) Pulmonic and tricuspid
border. The closure of the tricuspid and mitral valves creates the first heart sound.
The pulmonic and tricuspid
valves do not close together.
The mitral and aortic valves
do not close together.
72. When auscultating the heart sounds of a
Accentuated
client, a nurse notes that the S2 is louder
Explanation:
than the S1. How should the nurse describe An accentuated S2 means
this heart sound? S2 is:
that the S2 is louder than
the S1. This occurs in cona) Accentuated
ditions in which the aortic or
b) Wide Split
pulmonic valve has a highc) Diminished
er closing pressure. A did) Normal Split
minished S2 means that the
S2 is softer than the S1.
This occurs in conditions in
which the aortic or pulmonic
valves have decreased mobility. Normal Split S2 can
be heard over the second
or third left intercostal space;
it is usually heard best during inspiration and disappears during expiration. Wide
Split S2 is an increase in the
usual splitting that persists
throughout the entire respiratory cycle and widens on
expiration
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