Chapter 17 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 17

Question 1

Type: MCSA

The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The student nurse asks how the S1 heart sound is produced. Which of the following is the nurses best response?

1. It results from the closure of the semilunar valves.

2. It is heard when the aortic valve closes just slightly faster than the pulmonic valve.

3. It results from the closure of the atrioventricular valves.

4. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.

Correct Answer: 3

Rationale 1: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves.

Rationale 2: A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close.

Rationale 3: The S1 heart sound results from closure of the atrioventricular (AV) valves.

Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.

Global Rationale: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close. The S1 heart sound results from closure of the atrioventricular (AV) valves. The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.

Question 2

Type: HOTSPOT

The clients healthcare provider determines that the clients left ventricle is functioning adequately. Identify the left ventricle by drawing an arrow to it.

Screen Shot 2015-09-24 at 12.23.14 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale :

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.

Question 3

Type: FIB

The clients stroke volume is 72 ml/beat. The clients heart rate is 82 beats per minute.
What is the clients cardiac output?____________

Standard Text:

Correct Answer: 5904 mL per minute.

Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for 1 minute.
72 ml/ beat x 82 beats/ minute= 5904 mL/ minute

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.1: Identify the anatomy and physiology of the cardiovascular system.

Question 4

Type: HOTSPOT

The nurse is performing a cardiac assessment and prepares to palpate the clients heartbeat on the clients chest. Draw an arrow pointing to this area.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular system.

Question 5

Type: HOTSPOT

The nurse is reviewing the clients chart. The clients blood pressure has been consistently elevated over the last eight years. The client has been noncompliant with lifestyle changes and medication use designed to reduce the clients blood pressure. Today, the nurse is able to palpate a heave on the clients chest. Draw an arrow to the most likely location that the nurse is able to palpate the heave.

Screen Shot 2015-09-24 at 12.23.57 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.2: Recognize landmarks that guide assessment of the cardiovascular system.

Question 6

Type: MCMA

During the focused interview, the client answers the nurses questions. Which of the following statements by the client suggests that the client has an increased risk of developing cardiovascular disease?

Standard Text: Select all that apply.

1. I have been stressed out since my divorce last year.

2. Im what you call a Type C personality.

3. I went on this new diet because I gained 30 pounds in the last 9 months.

4. On my new diet, I can eat only grains and vegetables.

5. I think about my job all of the time.

Correct Answer: 1,3,4,5

Rationale 1: I have been stressed out since my divorce last year. Psychosocial problems and excessive stress can increase the clients risk for developing cardiovascular disease.

Rationale 2: Im what you call a Type C personality. Type A personalities tend to develop cardiovascular disease more often than people with other personality types.

Rationale 3: I went on this new diet because I gained 30 pounds in the last 9 months. Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain may accompany physical problems including systemic diseases such as diabetes, which increases this clients risk for developing cardiovascular disease.

Rationale 4: On my new diet, I can eat only grains and vegetables. The nurse must note if the client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject the client to potential complications. Muscle wasting may occur if the diet is deficient in protein. Lack of protein may compromise cardiac function.

Rationale 5: I think about my job all of the time. Stress increases the stimulation of the clients sympathetic nervous system and can increase the clients risk for developing cardiovascular disease.

Global Rationale: Psychosocial problems and excessive stress can increase the stimulation of the clients sympathetic nervous system, thereby increasing the clients risk for developing cardiovascular disease. Type A personalities tend to develop cardiovascular disease more often than people with other personality types. Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain may accompany physical problems including systemic diseases such as diabetes, which increases this clients risk for developing cardiovascular disease. The nurse must note if the client has been dieting to reduce weight. Many diets deplete valuable electrolytes and subject the client to potential complications. Muscle wasting may occur if the diet is deficient in protein. Lack of protein may compromise cardiac function.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.

Question 7

Type: MCSA

During the focused interview, the client makes the following statements. Which of the following statements indicates that the client has an increased risk of developing cardiovascular disease?

1. I was diagnosed with hypothyroidism about 5 years ago.

2. My doctor always tells me when I come in that my blood pressure is low.

3. I know my grandmother had diabetes, but every time it has been checked mine has been normal.

4. My total cholesterol has always been around 170.

Correct Answer: 1

Rationale 1: Hypothyroidism may increase the clients risk for developing cardiovascular disease.

Rationale 2: Hypertension, not hypotension, is associated with the development of cardiovascular disease.

Rationale 3: Normal serum glucose levels indicate that the client does not currently have diabetes and so this clients risk is not necessarily increased.

Rationale 4: The clients total cholesterol level is within normal limits. High cholesterol levels would increase the clients risk for developing cardiovascular disease.

Global Rationale: Hypothyroidism may increase the clients risk for developing cardiovascular disease. Hypertension, not hypotension, is associated with the development of cardiovascular disease. Normal serum glucose levels indicate that the client does not currently have diabetes and so this clients risk is not necessarily increased. The clients total cholesterol level is within normal limits. High cholesterol levels would increase the clients risk for developing cardiovascular disease.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.

Question 8

Type: MCSA

The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction. Which of the following client statements would be unexpected?

1. I couldnt catch my breath.

2. My chest didnt actually ever hurt.

3. My wife said I looked like someone poured water all over me.

4. I got so sick to my stomach.

Correct Answer: 2

Rationale 1: Typically males who are experiencing a myocardial infarction will complain of dyspnea.

Rationale 2: Typically males who are experiencing a myocardial infarction will complain of chest pain that is prolonged, dull, and radiates to the shoulder or jaw. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without actual chest pain.

Rationale 3: In males, the pain of MI is often accompanied by diaphoresis.

Rationale 4: In males, the pain of MI is often accompanied by nausea.

Global Rationale: Typically males who are experiencing a myocardial infarction will complain of dyspnea, and chest pain that is prolonged, dull, and radiates to the shoulder or jaw. In males, the pain is often accompanied by diaphoresis and they may complain of nausea. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath or extreme fatigue, without actual chest pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.

Question 9

Type: MCSA

The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the clients coronary arteries. Which of the following questions by the nurse has the highest priority to help the nurse determine the clients most important risk factor for this condition?

1. Can you please tell me about the vitamins or supplements that you take?

2. Have you ever been diagnosed with rheumatic fever?

3. Do you smoke or are you exposed to secondhand smoke?

4. Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or echocardiogram, or a surgical procedure for a cardiovascular problem?

Correct Answer: 3

Rationale 1: Information about vitamin and supplement use is important but is not specifically related to atherosclerosis and coronary artery disease.

Rationale 2: A history of rheumatic fever can increase the clients risk for valvular problems but does not necessarily increase the clients risk for developing atherosclerosis and coronary artery disease.

Rationale 3: The most important question regarding this clients history and recent diagnosis is about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque.

Rationale 4: Diagnostic testing may help the nurse determine if there was a previous suspicion that the client had developed a cardiovascular problem, but is not specifically related to coronary artery disease and atherosclerosis.

Global Rationale: Information about vitamin and supplement use is important but is not specifically related to atherosclerosis and coronary artery disease. A history of rheumatic fever can increase the clients risk for valvular problems but does not necessarily increase the clients risk for developing atherosclerosis and coronary artery disease. The most important question regarding this clients history and recent diagnosis is about exposure to cigarettes smoke. The chemical contained in the cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque. The question regarding diagnostic testing may help the nurse determine if there was a previous suspicion that the client had developed a cardiovascular problem, but is not specifically related to coronary artery disease and atherosclerosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.3: Develop questions to be used when completing the focused interview.

Question 10

Type: MCMA

The nurse is preparing to assess the female clients cardiovascular system during the clients visit to the healthcare providers office. Which of the following items should the nurse have available in the room in order to complete the examination?

Standard Text: Select all that apply.

1. Ruler (metric)

2. Stethoscope

3. Lamp

4. Client gown and a drape

5. Doppler

Correct Answer: 1,2,3,4,5

Rationale 1: Ruler (metric). The nurse will require a metric ruler to determine distention of blood vessels.

Rationale 2: Stethoscope. The nurse will require a stethoscope to auscultate the clients heart and arteries.

Rationale 3: Lamp. The nurse will require a lamp or adequate lighting in the room for the inspection process of the assessment.

Rationale 4: Client gown and a drape. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure.

Rationale 5: Doppler. A Doppler device can be used to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse.

Global Rationale: The nurse will require a metric ruler to determine distention of blood vessels. The nurse will require a stethoscope to auscultate the clients heart and arteries. The nurse will require a lamp or adequate lighting in the room for the inspection process of the assessment. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure. A Doppler device can be used to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system.

Question 11

Type: MCMA

The nurse is preparing to assess the clients cardiovascular system. Which of the following positions will the nurse need to place the client in during the assessment?

Standard Text: Select all that apply.

1. Dorsal recumbent

2. Leaning forward

3. Right lateral position

4. Left lateral position

5. Sitting upright

Correct Answer: 1,2,4,5

Rationale 1: Dorsal recumbent. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position.

Rationale 2: Leaning forward. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the clients heart while the client is leaning forward.

Rationale 3: Right lateral position. This is not a common position to place the client in during this type of examination.

Rationale 4: Left lateral position. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best heard at the apical area with the client in the left lateral position.

Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client is in this position. This is the position the nurse should ask the client to assume when beginning chest auscultation.

Global Rationale: The nurse will most likely begin this examination with the client sitting upright. This is the position the nurse should ask the client to assume when beginning chest auscultation. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the clients heart while the client is leaning forward. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best heard at the apical area with the client in the left lateral position. Right lateral position is not a common position to place the client in during this type of examination.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.4: Explain client preparation for assessment of the cardiovascular system.

Question 12

Type: SEQ

The nurse is preparing to perform a cardiac assessment on a client. Rank the following pieces of the assessment in order of occurrence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Auscultation of the clients heart, apical pulse, and carotid arteries

Choice 2. Inspection of the clients head and neck, chest, abdomen, and extremities

Choice 3. Percussion of the clients chest

Choice 4. Palpation of the precordium and pulses

Correct Answer: 2,4,3,1

Rationale 1: The fourth of these steps is auscultation. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated.

Rationale 2: The first of these steps is inspection of the clients head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected.

Rationale 3: The third of these steps is percussion, which is conducted to determine the cardiac borders.

Rationale 4: The second of these steps is palpation. Palpation includes the precordium and carotid pulses.

Global Rationale: Physical assessment of the cardiovascular system follows an organized pattern. It begins with inspection of the clients head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected. Palpation includes the precordium and carotid pulses. Percussion of the chest is conducted to determine the cardiac borders. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular system.

Question 13

Type: MCMA

The student nurse is assessing the clients cardiovascular system while the experienced nurse observes. The employment of which of the following techniques by the student nurse indicate the need for further education?

Standard Text: Select all that apply.

1. The client complains of discomfort while lying flat. The student nurse auscultates the clients chest quickly while the client continues to lie flat.

2. The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line.

3. The student nurse examines the clients legs and notes that the clients hair is evenly distributed.

4. The student nurse gently palpates the clients carotid arteries simultaneously to determine pulse strength, rhythm, and rate.

5. The student nurse examines the clients hands and fingers and notes the presence of clubbing.

Correct Answer: 1,4

Rationale 1: The client complains of discomfort while lying flat. The student nurse auscultates the clients chest quickly while the client continues to lie flat. If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination.

Rationale 2: The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. This is normally where the point of maximal impulse can be palpated.

Rationale 3: The student nurse examines the clients legs and notes that the clients hair is evenly distributed. This is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem.

Rationale 4: The student nurse gently palpates the clients carotid arteries simultaneously to determine pulse strength, rhythm, and rate. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole.

Rationale 5: The student nurse examines the clients hands and fingers and notes the presence of clubbing. It is appropriate to examine the clients hands and fingers to determine the existence of peripheral circulatory problems.

Global Rationale: If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination. If the student nurse has determined the apical impulse to be located at the fifth intercostal space at the midclavicular line, this is normal. Examining the clients legs and noting that the clients hair is evenly distributed is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole. It is appropriate to examine the clients hands and fingers to determine the existence of peripheral circulatory problems.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.5: Describe the techniques required for assessment of the cardiovascular system.

Question 14

Type: HOTSPOT

The client has a history of rheumatic fever. Draw an arrow pointing to the layer of the heart that is most at risk for damage due to this infection.

Screen Shot 2015-09-24 at 12.25.31 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Strep infections can cause rheumatic fever. Rheumatic fever can damage the clients endocardium. The endocardium makes up the innermost layer of the heart and valve tissue.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 15

Type: MCSA

The nurse is percussing the clients anterior chest and notes a dull sound over an area where lung tissue is normally found. Which of the following would the nurse associate with this finding?

1. This is a normal finding.

2. The clients heart may be enlarged.

3. The client has developed a murmur.

4. The client has a pulse deficit.

Correct Answer: 2

Rationale 1: This is not a normal finding. When the nurse percusses over lung tissue, the sound should be described as resonant.

Rationale 2: An enlarged heart emits a dull sound on percussion over a larger area than a heart of normal size.

Rationale 3: Murmurs can be determined during auscultation of the heart.

Rationale 4: A pulse deficit is present when the apical pulse is greater than the carotid pulse.

Global Rationale: This is not a normal finding. When the nurse percusses over lung tissue, the sound should be described as resonant. An enlarged heart emits a dull sound on percussion over a larger area than a heart of normal size. Murmurs can be determined during auscultation of the heart. A pulse deficit is present when the apical pulse is greater than the carotid pulse.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 16

Type: MCSA

The nurse is performing a cardiac assessment on a 70-year-old client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. The nurse suspects that the client may have developed which of the following problems?

1. Left ventricular hypertrophy

2. Aortic stenosis

3. Right ventricular volume overload

4. Enlarged left atrium

Correct Answer: 1

Rationale 1: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation.

Rationale 2: Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space.

Rationale 3: The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload.

Rationale 4: Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium.

Global Rationale: If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation. Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space. The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload. Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 17

Type: MCSA

A 39-year-old client has been admitted to the hospital with complaints of increasing fatigue. The history is remarkable for rheumatic fever as a child. The nurse hears a diastolic murmur at the apex when the client is in the left lateral position. The murmur is described as a rumble without radiation. This description is most consistent with:

1. tricuspid regurgitation.

2. mitral regurgitation.

3. mitral stenosis.

4. pulmonic stenosis.

Correct Answer: 3

Rationale 1: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, high-pitched, and may radiate.

Rationale 2: Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla.

Rationale 3: The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection.

Rationale 4: The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck.

Global Rationale: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, high-pitched, and may radiate. Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla. The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection. The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 18

Type: MCSA

During the cardiac assessment of a client, the nurse hears a loud rumbling during diastole that increases toward the end of the sound. This sound is heard with the bell of the stethoscope over the lower left sternal border. The nurse would suspect which of the following in this client?

1. Aortic stenosis

2. Tricuspid stenosis

3. Mitral regurgitation

4. Pulmonic stenosis

Correct Answer: 2

Rationale 1: The type of murmur heard with aortic stenosis occurs midsystole and is crescendo-decrescendo.

Rationale 2: The sound heard in this scenario is most likely a murmur related to tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases towards the end of the sound.

Rationale 3: With mitral regurgitation, the sound is heard in systole and is continuous.

Rationale 4: With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in the second intercostal space.

Global Rationale: The type of murmur heard with aortic stenosis occurs midsystole and is crescendo-decrescendo. The sound heard in this scenario is most likely a murmur related to tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases toward the end of the sound. With mitral regurgitation, the sound is heard in systole and is continuous. With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in the second intercostal space.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 19

Type: MCSA

The Intensive Care Unit nurse is performing a cardiac assessment on a newly admitted 72-year-old client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45 degree angle, and an enlarged liver. These findings are most consistent with which of the following disorders?

1. Pulmonary edema

2. Left-sided heart failure

3. Myocardial infarction

4. Right-sided heart failure

Correct Answer: 4

Rationale 1: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system.

Rationale 2: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system.

Rationale 3: Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction.

Rationale 4: With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement.

Global Rationale: Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction. With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 20

Type: MCSA

The nurse is assessing a client and notes a loud, blowing sound over the right carotid artery. The nurse would suspect the client has developed which of the following disorders?

1. Mitral stenosis

2. Aortic regurgitation

3. Atrial septal defect

4. Stricture of the carotid

Correct Answer: 4

Rationale 1: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis, there is often a murmur heard at the apical area with the client in left lateral position.

Rationale 2: Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal space.

Rationale 3: With an atrial septal defect, there is an opening between the right and left atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at the left sternal border at the second intercostal space.

Rationale 4: A bruit, which is a loud swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis.

Global Rationale: Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis, there is often a murmur heard at the apical area with the client in left lateral position. Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal space. With an atrial septal defect, there is an opening between the right and left atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at the left sternal border at the second intercostal space. A bruit, which is a loud swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 21

Type: MCMA

The nurse is caring for a client admitted with a grade 3 heart murmur heard during systole. The nurse would suspect which of the following cardiac conditions?

Standard Text: Select all that apply.

1. Mitral regurgitation

2. Mitral stenosis

3. Aortic stenosis

4. Pulmonic stenosis

5. Tricuspid stenosis

Correct Answer: 1,3,4

Rationale 1: Mitral regurgitation. A grade 3 murmur can be heard clearly and the nurse should be able to categorize the murmur easily. The murmur associated with mitral regurgitation can be heard during systole.

Rationale 2: Mitral stenosis. The murmur associated with mitral stenosis can be heard during diastole.

Rationale 3: Aortic stenosis. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with aortic stenosis.

Rationale 4: Pulmonic stenosis. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with pulmonic stenosis.

Rationale 5: Tricuspid stenosis. The murmur associated with tricuspid stenosis can be heard during diastole.

Global Rationale: The murmur associated with mitral regurgitation can be heard during systole. Midsystolic murmurs are associated with semilunar valve disorders. This murmur is heard during midsystole and this can be associated with pulmonic or aortic stenosis. The murmur associated with mitral or tricusid stenosis can be heard during diastole. The murmur associated with tricuspid stenosis can be heard during diastole.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 22

Type: MCMA

The nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases. The nurse would choose which of the following actions?

Standard Text: Select all that apply.

1. Refer the client to a plastic surgeon.

2. Document this finding as normal.

3. Document the finding and notify the healthcare provider.

4. Ask the client about any history of injuries to his ears.

5. Assess the clients risk factors for coronary artery disease.

Correct Answer: 3,4,5

Rationale 1: Refer the client to a plastic surgeon. The client may have an increased risk for developing coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon.

Rationale 2: Document this finding as normal. This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease.

Rationale 3: Document the finding and notify the healthcare provider. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases.

Rationale 4: Ask the client about any history of injuries to his ears. The nurse should determine if the client has sustained any injuries to the ears that could account for the bilateral earlobe creases.

Rationale 5: Assess the clients risk factors for coronary artery disease. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease.

Global Rationale: This is an abnormal finding and the client should be carefully monitored for the development of coronary artery disease. The nurse should document the finding, request information from the client regarding any injuries to the ears, and notify the healthcare provider about the presence of the bilateral earlobe creases. The nurse should assess the client for any other clinical manifestations and risk factors associated with coronary artery disease. At this point, the client does not need to be referred to a plastic surgeon.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.6: Differentiate normal from abnormal findings in physical assessment.

Question 23

Type: MCMA

The nurse is performing a cardiac assessment on a healthy elderly adult client. Which of the following findings may be expected when compared to when the client was middle-aged?

Standard Text: Select all that apply.

1. Systolic murmur

2. Increased cardiac output

3. Increased systolic blood pressure

4. Increased stroke volume

5. Slight decrease in heart rate

Correct Answer: 1,3,4,5

Rationale 1: Systolic murmur. Systolic murmurs become more common as people age, especially because of aortic stenosis.

Rationale 2: Increased cardiac output. In the healthy older adult, cardiac output remains relatively stable.

Rationale 3: Increased systolic blood pressure. The clients systolic blood pressure may increase.

Rationale 4: Increased stroke volume. Stroke volume may increase slightly when the client is at rest and during exercise.

Rationale 5: light decrease in heart rate. The healthy older adult may have an insignificant decrease in heart rate.

Global Rationale: Systolic murmurs become more common as people age, especially because of aortic stenosis. In the healthy older adult, cardiac output remains relatively stable. The older clients systolic blood pressure may increase. Stroke volume may increase slightly when the older client is at rest and during exercise. The healthy older adult may have an insignificant decrease in heart rate.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 24

Type: MCSA

The nurse is assessing a client who is 7 months pregnant. The nurse would document which of the following cardiac findings as normal in this client?

1. Increased systolic and diastolic blood pressures when standing

2. Point of maximal impulse palpated at fourth intercostal space and left of midclavicular line

3. Bradycardia

4. Diastolic murmur

Correct Answer: 2

Rationale 1: At this stage of the clients pregnancy, the blood pressure should be normal when compared to pre-pregnancy values.

Rationale 2: During pregnancy, the heart is displaced to the left and upward and so it would be normal to palpate the point of maximal impulse left of the midclavicular line at the fourth intercostal space.

Rationale 3: The pregnancy usually results in an increase in the clients heart rate from pre-pregnancy values.

Rationale 4: It is not normal to find a diastolic murmur.

Global Rationale: At this stage of the clients pregnancy, the blood pressure should be normal when compared to pre-pregnancy values. During pregnancy, the heart is displaced to the left and upward and so it would be normal to palpate the point of maximal impulse left of the midclavicular line at the fourth intercostal space. The pregnancy usually results in an increase in the clients heart rate from pre-pregnancy values. It is not normal to find a diastolic murmur.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 25

Type: MCSA

The nurse is assessing a full-term African American newborn that is 18 hours old. The nurse would document which of the following as a normal finding?

1. Lethargy

2. Heart rate 115120

3. Bulging of the precordium

4. Pale conjunctiva

Correct Answer: 2

Rationale 1: The infant should be easily aroused and alert.

Rationale 2: The heart rate of a newborn initially may be as high as 175180 beats per minute but should decrease over the next 6 to 8 hours to about 115120 beats per minute.

Rationale 3: Precordial bulging should always be evaluated and is never considered a normal finding.

Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the babys race.

Global Rationale: The infant should be easily aroused and alert. The heart rate of a newborn initially may be as high as 175180 beats per minute but should decrease over the next 6 to 8 hours to about 115120 beats per minute. Precordial bulging should always be evaluated and is never considered a normal finding. The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the babys race.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 26

Type: MCSA

The nurse notes the pregnant clients blood pressure has dropped from 122/70 taken during her second month of pregnancy to 118/64 during her fifth month of pregnancy. Which of the following actions by the nurse is most appropriate?

1. Assess for signs of hemorrhage.

2. Document the blood pressure as a normal finding .

3. Consult the healthcare provider.

4. Tell the client to come in the next day so the nurse can recheck her blood pressure.

Correct Answer: 2

Rationale 1: This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage.

Rationale 2: During pregnancy, there is a substantial increase in cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels.

Rationale 3: The healthcare provider does not need to be consulted because this is a normal finding.

Rationale 4: The client does not need to return to have her blood pressure checked on the following day.

Global Rationale: This small drop in blood pressure is expected and the nurse does not need to assess the client for signs of hemorrhage. During pregnancy, there is a substantial increase in cardiac workload secondary to the increase in blood volume. Despite this, the systolic and diastolic blood pressures may decrease during the first half of pregnancy. This is secondary to the peripheral vasodilatation. During the second half of the pregnancy, the blood pressure will return to previous pre-pregnancy levels. The healthcare provider does not need to be consulted because this is a normal finding. The client does not need to return to have her blood pressure checked on the following day.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 17.7: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 27

Type: MCSA

The student nurse is speaking with a nurse regarding the objectives of Healthy People 2020. Which of the following statements by the student nurse indicates that the student nurse requires further education regarding these objectives?

1. Parents of school-aged children really need to be educated about the importance of treating strep throat.

2. African Americans really need to be educated about the symptoms associated with hypertension.

3. People who smoke are twice as likely to die from a heart attack when compared to those who dont smoke.

4. African Americans can benefit greatly from education aimed at increasing their understanding about the importance of exercise.

Correct Answer: 2

Rationale 1: It is appropriate to educate parents of school-aged children about the importance of screening for and treating strep in their children. This can help prevent rheumatic fever and the valvular problems that are associated with this infection.

Rationale 2: African Americans can benefit from blood pressure screening activities. Hypertension is often present without any symptoms so education about symptoms will not be particularly beneficial.

Rationale 3: Smokers have double the mortality rate from myocardial infarction than nonsmokers.

Rationale 4: The impact of hypertension, diabetes, and obesity is particularly noted in African Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes.

Global Rationale: It is appropriate to educate parents of school-aged children about the importance of screening for and treating strep in their children. This can help prevent rheumatic fever and the valvular problems that are associated with this infection. African Americans can benefit from blood pressure screening activities. Hypertension is often present without any symptoms so education about symptoms will not be particularly beneficial. Smokers have double the mortality rate from myocardial infarction than nonsmokers. The impact of hypertension, diabetes, and obesity is particularly noted in African Americans. Exercise can reduce the risks for cardiovascular disease by promoting healthy weight, maintaining healthy blood pressure, and reducing the risk for development of diabetes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the cardiovascular system.

Question 28

Type: MCMA

The client is 3 months pregnant. The nurse recently reviewed the objectives of Healthy People 2020 regarding pregnant women. Which of the following statements by the client indicates adequate education has occurred according to the objectives?

Standard Text: Select all that apply.

1. I never got my rubella vaccination so Ive been staying away from my niece who has rubella.

2. I stopped taking Accutane for my acne before we started trying to get pregnant.

3. I have been so careful about taking my insulin now that Im pregnant.

4. I have just one glass of wine each evening.

5. I had to change to a different medication to prevent my seizures before we got pregnant.

Correct Answer: 1,2,3,5

Rationale 1: I never got my rubella vaccination so Ive been staying away from my niece who has rubella. Pregnant females who have not had or been immunized against rubella must avoid contraction of the virus during the first trimester of pregnancy.

Rationale 2: I stopped taking Accutane for my acne before we started trying to get pregnant. The use of Accutane during pregnancy can increase the risk of having a child with congenital heart defects.

Rationale 3: I have been so careful about taking my insulin now that Im pregnant. Females with diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation of the diabetes before and in early pregnancy can reduce the risk.

Rationale 4: I just have one glass of wine each evening. It is not appropriate to drink alcohol during pregnancy because it increases the risk of having a child with birth defects.

Rationale 5: I had to change to a different medication to prevent my seizures before we got pregnant. Some anti-seizure medications can increase the risk of having a child with a heart defect.

Global Rationale: Pregnant females who have not had or been immunized against rubella must avoid contraction of the virus during the first trimester of pregnancy. The use of Accutane during pregnancy can increase the risk of having a child with congenital heart defects. Females with diabetes mellitus have an increased risk of having a child with a heart defect. Careful regulation of the diabetes before and in early pregnancy can reduce the risk. It is not appropriate to drink alcohol during pregnancy because it increases the risk of having a child with birth defects. Some anti-seizure medications can increase the risk of having a child with a heart defect.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.8: Discuss the objectives in Healthy People 2020 as they relate to the cardiovascular system.

Question 29

Type: MCMA

The Emergency Department nurse determines that the client may be having a myocardial infarction. Which of the following pieces of information indicate that the client is experiencing an acute cardiovascular problem?

Standard Text: Select all that apply.

1. Blood pressure has dropped from normal and is 90/52.

2. Apical heart rate is 114 beats per minute.

3. Skin is flushed and warm.

4. Respiratory rate is 28 per minute.

5. The client is complaining of a headache.

Correct Answer: 1,2,4

Rationale 1: Blood pressure has dropped from normal is 90/52. This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring.

Rationale 2: Apical heart rate is 114 beats per minute. The client is tachycardic and this is indicative of an acute cardiovascular problem.

Rationale 3: Skin is flushed and warm. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem.

Rationale 4: Respiratory rate is 28 per minute. This client is tachypneic and this is associated with an acute cardiovascular problem.

Rationale 5: The client is complaining of a headache. A headache is not necessarily a symptom of an acute cardiovascular problem.

Global Rationale: This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring. The client is tachycardic and this is indicative of an acute cardiovascular problem. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem. This client is tachypneic and this is associated with an acute cardiovascular problem. A headache is not necessarily a symptom of an acute cardiovascular problem.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical assessment of the cardiovascular system.

Question 30

Type: MCSA

The client has been admitted to the Coronary Care Unit with a myocardial infarction. Which of the following statements by the client indicate that adequate learning has occurred?

1. Im just sick to my stomach because I ate something that didnt agree with me.

2. I think I must have given myself a little too much insulin this morning.

3. Ive been breathing fast and my hearts been racing because my hearts not working right.

4. Just give me something for the nausea and I can go home.

Correct Answer: 3

Rationale 1: The client believes that the nausea is unrelated to an acute cardiovascular event such as a myocardial infarction.

Rationale 2: The client believes that his symptoms are related to hypoglycemia and will require education about the seriousness of his heart condition.

Rationale 3: The client is correct when he states that his heart is not working well and his respiratory rate and heart rate are up because of it.

Rationale 4: The client will be unable to go home until after he is stabilized and medically fit to return home.

Global Rationale: The client does not understand the importance of the symptoms that he is experiencing. The client believes that the nausea is unrelated to an acute cardiovascular event such as a myocardial infarction. The client believes that his symptoms are related to hypoglycemia and will require education about the seriousness of his heart condition. The client is correct when he states that his heart is not working well and his respiratory rate and heart rate are up because of it. The client will be unable to go home until after he is stabilized and medically fit to return home.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17.9: Apply critical thinking in selected simulations related to physical assessment of the cardiovascular system.

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