Chapter 29 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 29

Question 1

Type: MCSA

A patient has a split S2 heart sound. Where would the nurse auscultate to best hear this sound?

1. 2nd intercostal space left of the sternum

2. 5th intercostal space midclavicular line

3. 3rd intercostal space right of the sternum

4. 4th intercostal space left midaxillary line

Correct Answer: 1

Rationale 1: A split S2 heart sound is heard best in the pulmonic area, which is the 2nd intercostal space left of the sternum.

Rationale 2: The 5th intercostal space midclavicular line is the mitral area. S1 is heard best at the mitral area.

Rationale 3: It would be more difficult to hear an S2 split to the right of the sternum.

Rationale 4: It would be difficult to hear an S2 split at the midaxillary line in the 4th intercostal space.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 2

Type: MCSA

A patient has a split S1 heart sound. How should the nurse explain this finding to the patient?

1. Your mitral and tricuspid valves are not closing at exactly the same time.

2. You probably have some calcification in the pulmonary valve that slows its closure.

3. Your aortic valve is closing more slowly than it should.

4. Your atrioventricular valves are not closing at exactly the same time.

Correct Answer: 1

Rationale 1: The S1 heart sound is caused by closure of the mitral and tricuspid valves. If they do not close at exactly the same time a splitting of the sound occurs.

Rationale 2: The pulmonary valve is not associated with the S1 heart sound.

Rationale 3: The aortic valve is not associated with the S1 heart sound.

Rationale 4: The atrioventricular valves are not associated with the S1 heart sound.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 3

Type: MCSA

The nurse is conducting a physical examination of a patients heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?

1. Left midclavicular line at the fifth intercostal space

2. Left sternal border at the fifth intercostal space

3. Right midclavicular line at the fifth intercostal space

4. Right sternal border at the third intercostal space

Correct Answer: 1

Rationale 1: S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart.

Rationale 2: The SI sound is audible at the left sternal border but would not be as loud as at another site.

Rationale 3: The S1 sound would not normally be audible at this site.

Rationale 4: The S1 sound would not normally be audible at the sternal border.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 4

Type: MCSA

While auscultating the patients heart sounds, the nurse hears an additional sound immediately following S2. The nurse would conduct further assessment for which condition?

1. Ventricular volume overload

2. Ventricular hypertrophy from hypertension

3. Atrial fibrillation

4. A stenotic aortic valve

Correct Answer: 1

Rationale 1: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop and results from conditions such as congestive heart failure (CHF) and mitral or tricuspid valve regurgitation.

Rationale 2: S4 immediately precedes S1 and can result from conditions such as hypertension-associated ventricular hypertrophy.

Rationale 3: S3 heart sounds are not associated with atrial fibrillation.

Rationale 4: Aortic stenosis is associated with S4 heart sounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 5

Type: MCSA

During the physical assessment of a patient on admission, the nurse auscultates a grade II midsystolic heart murmur. The nurse would conduct additional assessment for which condition?

1. Aortic stenosis

2. Mitral stenosis

3. Aortic regurgitation

4. Mitral regurgitation

Correct Answer: 1

Rationale 1: The murmur associated with aortic stenosis is a midsystolic, crescendo-decrescendo murmur.

Rationale 2: Mitral stenosis is characterized by a long, rumbling diastolic murmur.

Rationale 3: Aortic regurgitation is characterized by an early diastolic murmur.

Rationale 4: Mitral regurgitation results in a pansystolic murmur, or one that is heard throughout systole, not just at the midpoint.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 6

Type: MCSA

When palpating a thrill on the precordium, the nurse recognizes that this sign is associated with which cardiac condition?

1. Severe valve stenosis

2. Cardiomyopathy

3. Stenosis of the carotid arteries

4. Aortic aneurysm

Correct Answer: 1

Rationale 1: A palpable thrill over the precordium is indicative of valvular disorders such as stenosis.

Rationale 2: A thrill is not present merely when the heart is enlarged.

Rationale 3: Stenosis of the carotid arteries would produce a thrill palpable on the neck over the carotid arteries, not the precordium.

Rationale 4: Increased pulsations in the aortic area are indicative of an aortic aneurysm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 7

Type: MCSA

While completing the health history of a patient with a suspected cardiac disorder, the nurse would ask about which childhood illnesses?

1. Rheumatic fever and strep throat infections

2. Rubella and chickenpox

3. Asthma and bronchitis

4. Otitis media and respiratory syncytial virus (RSV)

Correct Answer: 1

Rationale 1: Rheumatic fever and streptococcal throat infections are caused by beta- hemolytic streptococci, which have a propensity to form growths and calcium deposits on the leaflets of heart valves.

Rationale 2: Rubella and chickenpox are not directly related to cardiac disorders.

Rationale 3: Asthma and bronchitis are not directly related to cardiac disorders.

Rationale 4: Otitis media and RSV are not directly related to cardiac disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-3

Question 8

Type: MCSA

When assessing the adult heart, the nurse expects to hear which heart sounds?

1. S1, then S2

2. S2, then S3

3. S3, then S4

4. S2, then S1

Correct Answer: 1

Rationale 1: The normal sequence of heart sounds is S1, then S2.

Rationale 2: S3 and S4 are considered abnormal heart sounds in adults.

Rationale 3: S3 and S4 are considered abnormal heart sounds in adults.

Rationale 4: The normal sequence of heart sounds is S1, then S2.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 9

Type: MCSA

The S1 heart sound corresponds to which physiological event?

1. Closure of the AV valves

2. Closure of the semilunar valves

3. Ejection of blood from the atria

4. The onset of relaxation

Correct Answer: 1

Rationale 1: S1 corresponds to the closure of the AV valves.

Rationale 2: Closure of the semilunar valves corresponds to S2.

Rationale 3: This sound is not associated with ejection of blood from just the atria.

Rationale 4: This sound is not associated with relaxation of the muscle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 10

Type: MCSA

When auscultating the chest of a 75-year-old patient who recently experienced a myocardial infarction (MI), the nurse hears an S3 heart sound immediately following S2. Because of these findings, the nurse would assess for which other condition?

1. Heart failure

2. Extension of the MI

3. Renal failure

4. Liver failure

Correct Answer: 1

Rationale 1: S3 immediately following S2 is called a ventricular gallop and is an indication of heart failure.

Rationale 2: Manifestations of MI extension include chest pain and positive laboratory findings (CPK-MB and troponin).

Rationale 3: Renal failure is a late complication of heart failure and is not manifested with an S3.

Rationale 4: Liver failure is not manifested with an S3.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 11

Type: MCSA

The patient presents to the emergency department (ED) complaining of chest pain, fatigue, and dyspnea. What is the nurses priority assessment?

1. Medications

2. Airway and oxygen status

3. Activity tolerance

4. Chest pain

Correct Answer: 2

Rationale 1: The patients medications will provide insight into past medical history but is not the priority assessment.

Rationale 2: The priority is to assess the patients airway and oxygen status, with the goal of maintaining an open airway and adequate oxygen levels.

Rationale 3: Assessment of activity tolerance will provide useful data, but this is not the priority assessment.

Rationale 4: Assessing the onset, location, duration, and description of the pain is the nurses second priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 12

Type: MCSA

A patient is admitted to the telemetry unit. Which nursing assessment has the highest priority for further investigation?

1. The patient complains of intermittent chest pain during mild exercise.

2. The patient has a history of urinary retention.

3. The patient complains of fatigue and dyspnea after walking up several flights of stairs.

4. The patients father has a history of smoking.

Correct Answer: 1

Rationale 1: A history of intermittent chest pain during mild exercise signals the highest need for further investigation into the patients cardiovascular status.

Rationale 2: The past history of urinary retention may be of concern if the patient will be receiving medications that could cause urinary retention or if surgery is planned, but should not be a high priority initially.

Rationale 3: This complaint may need further investigation, but it also may not be significant, depending on how many flights of stairs the patient climbs and whether chest pain or discomfort develops.

Rationale 4: The fathers history of smoking is relevant based on secondhand smoke exposure but is not the priority assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 13

Type:

MCSA

A patient presents to the medical-surgical unit confused and with a blood pressure of 90/50. Which assessment findings would support the nurses concern that the patient has low cardiac output?

1. Skin tenting (poor turgor) and heart rate 102

2. Pallor and peripheral edema

3. Bounding peripheral pulses and pulse oximeter reading 90%

4. Prolonged capillary refill and diminished peripheral pulses

Correct Answer: 4

Rationale 1: Poor skin turgor and a heart rate of 102 could indicate dehydration.

Rationale 2: Pallor can be an indication of poor cardiac output; however, there are several causes of peripheral edema other than poor cardiac output, so this finding is not definitive.

Rationale 3: Bounding peripheral pulses indicates good output, although perhaps a rapid heart rate. Oxygen saturation of 90% is on the low side, but accompanied by bounding pulses does not indicate poor output.

Rationale 4: The patient with low cardiac output will have signs of poor circulation, such as prolonged capillary refill and diminished peripheral pulses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 14

Type: MCSA

A patient comes to the health clinic asking for advice on lowering her risk of heart disease. What is the nurses best response to this request?

1. Conduct a physical exam and discuss the findings.

2. Review the patients previous medical record and determine risks from that information.

3. Discuss the patients perceived area of health risks.

4. Conduct a health history and physical exam to determine the areas of risk and use these findings to educate the patient.

Correct Answer: 4

Rationale 1: Conducting a physical exam would discover some risk factors, but it is not inclusive of the health history.

Rationale 2: Using the patients old medical record may disclose some risk factors, but it would not include any recent concerns.

Rationale 3: Discussing the patients perceived area of health risks is important but will be unlikely to capture all health risks.

Rationale 4: A thorough health history and physical exam should disclose a patients risk factors. Modifiable risk factors can be evaluated and discussed with the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-2

Question 15

Type: MCSA

A patient presents with complaints of intermittent chest pain. The nurse assesses that the patient holds a high-stress job and is a Type A personality. How can the nurse best explain the importance of reducing cardiac risk factors?

1. Some stress is healthy for the heart. If constant chest pain develops, you need to have it investigated.

2. Stress is an everyday occurrence and should be managed by resting frequently.

3. Type A personalities tend to seek out higher-stress jobs. Maybe you should seek different employment.

4. The exposure to chronic stress increases the workload for the heart. Managing stress in a healthy manner will help decrease the risk factors for cardiovascular disease.

Correct Answer: 4

Rationale 1: Intermittent chest pain can be an early indication of upcoming problems and should be investigated. Delay could be detrimental.

Rationale 2: Stress is a common occurrence, but resting is not the best advice for this patient.

Rationale 3: Type A personalities may tend to seek out higher-stress jobs, but instead of advising the patient to change jobs, a better suggestion would be to employ stress-reduction techniques.

Rationale 4: Current and previous job stresses can contribute to an increased risk for cardiovascular disease by increasing the workload on the heart. Stress is unavoidable, so the patient should find healthy ways to manage stress.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-3

Question 16

Type: MCSA

The nurse is assessing a patients heart and believes a pericardial friction rub is present, but it is very faint. Which technique might help the nurse hear this sound more clearly?

1. Have the patient turn the head to the right.

2. Have the patient hold the breath while the nurse is listening.

3. Press the stethoscope tighter against the patients skin.

4. Have the patient lean on the overbed table.

Correct Answer: 4

Rationale 1: Turning the patients head to the side will not make this sound easier to hear.

Rationale 2: Having the patient hold the breath will help differentiate this sound from a pericardial rub but will not make the sound easier to hear.

Rationale 3: Pressing the stethoscope harder against the skin will be uncomfortable for the patient and will not make the sound any louder or easier to hear.

Rationale 4: Having the patient lean forward may help the nurse hear a pericardial rub more clearly, as the heart will be closer to the chest wall.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 17

Type: MCSA

The nurse is completing a physical assessment on a clinic patient who has been complaining of fatigue and intermittent chest pain over the last several weeks. Upon auscultation of the chest, the nurse hears an S1, S2, and S3. Because of these findings, the nurses priority will be to assess for which other finding?

1. Absence of bowel sounds

2. Lung sounds for crackles

3. Diminished pulses

4. Sluggish pupil response

Correct Answer: 2

Rationale 1: The absence of bowel sounds is not associated with the assessment described.

Rationale 2: S1 and S2 heart sounds are normal. An S3 indicates excess fluid, and the nurse would want to assess for crackles in the lungs. The nurse might also check for JVD, peripheral edema, ascites, and other signs of fluid overload.

Rationale 3: Diminished pulses would not be an expected finding in this scenario.

Rationale 4: Sluggish pupil response does not correlate with an S3 heart sound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 18

Type: MCMA

A review of the medical record reveals that a patient has been diagnosed with paroxysmal nocturnal dyspnea (PND). Which questions would the nurse ask to assess the status of this condition?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. How often do you get up to go to the bathroom at night?

2. Are you still waking up at night because you are short of breath?

3. How long after you go to bed do you start having trouble breathing?

4. Do you still have to sleep on three pillows at night?

5. Are you still having palpitations at night?

Correct Answer: 2,3

Rationale 1: PND is associated with fluid, but not with the need to urinate at night.

Rationale 2: PND is dyspnea that occurs an hour or so after retiring. It is caused by the redistribution of body fluids.

Rationale 3: PND generally occurs one to two hours after the patient goes to bed.

Rationale 4: Asking about the number of pillows would address orthopnea.

Rationale 5: Palpitations at night can be caused by many factors and are not specifically related to PND.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-3

Question 19

Type: MCMA

During admission assessment for evaluation of chest pain, the patient reports an allergy to sulfa drugs. Which nursing statements are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. We dont give sulfa drugs for cardiac problems, so that wont be an issue.

2. If it just makes you sick to your stomach, it isnt really an allergy.

3. What happens when you take sulfa drugs?

4. When did you first find out about this allergy?

5. If we need to give you a sulfa drug, we will be sure to give you an antihistamine with it.

Correct Answer: 3,4

Rationale 1: The nurse should not predict which medications will be needed and should not dismiss the seriousness of a drug allergy.

Rationale 2: The nurse should not assume that the patient is talking about just getting sick to your stomach. Additional information is needed.

Rationale 3: Part of the assessment of allergy is to determine what effects are noted when the drug is taken.

Rationale 4: Asking about the first incidence of allergic reaction may provide additional information about the drugs effects.

Rationale 5: The nurse should not worry the patient about the possibility of receiving a sulfa drug. It is very unlikely that a situation would arise in which an alternate drug could not be used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-3

Question 20

Type: FIB

A patient is being evaluated for intermittent chest pain. The nurses concern about a cardiac origin for this pain would be increased if the patient reports his mother had a myocardial infarction at the age of ______ years or younger.

Standard Text:

Correct Answer: 55

Rationale : The patients risk for cardiac dysfunction increases if a blood relative had CAD at or under age 55.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-3

Question 21

Type: MCMA

A patient being assessed for cardiovascular illness reports smoking cigarettes. Which nursing questions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. How many packs of cigarettes do you smoke a day?

2. How many years have you been smoking?

3. Have you ever tried to quit smoking?

4. How much money do you spend on cigarettes each month?

5. How do you feel about smoking?

Correct Answer: 2,3,5

Rationale 1: The number of packs smoked is an important component in calculating pack-years.

Rationale 2: The number of years a patient has been smoking is an important component in calculating pack-years.

Rationale 3: Efforts at smoking cessation are an important part of this patients history.

Rationale 4: This question may be asked as a strategy to encourage smoking cessation but is not a part of general assessment.

Rationale 5: The patients attitude toward smoking is an important assessment prior to a discussion of the risks it entails.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-3

Question 22

Type: MCSA

A patient being assessed for cardiac illness states, My previous doctor told me I had a type D personality. How would the nurse interpret this information?

1. The last physician must have been a psychiatrist.

2. The patient thrives in a high-stress environment.

3. The patient probably avoids social contact and focuses on negative emotions.

4. This patient has been treated for depression.

Correct Answer: 3

Rationale 1: Type D personality can be diagnosed by physicians in other specialties besides psychiatry.

Rationale 2: Type D personality types do not tolerate high-stress environments well.

Rationale 3: Type D personalities are distressed and tend to focus on negative emotions. They avoid social contact.

Rationale 4: Type D persons are distressed but may or may not have been treated professionally for depression.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-3

Question 23

Type: MCSA

The nurse assesses changes in the patients fingers. The fingertips look swollen, and the nails seem to angle downward. How should the nurse proceed?

1. Request an X-ray of the patients hands.

2. Ask the patient if an injury occurred to the hands.

3. Review the patients history for pulmonary disorders.

4. Ask if the patient has diabetes.

Correct Answer: 3

Rationale 1: There is no need for an X-ray of this finding.

Rationale 2: This assessment does not represent an injury pattern.

Rationale 3: This assessment describes clubbing which indicates chronic oxygen deficiency.

Rationale 4: Diabetes would not cause this change to the fingertips.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-1

Question 24

Type: FIB

A patient has mild pitting edema over the lower legs. A -inch indentation remains in the tissue after the nurse depresses it with a finger. The nurse would document this finding as + _______ pitting edema.

Standard Text:

Correct Answer: 1

Rationale : +1 edema is mild edema in which finger pressure leaves a -inch indentation. +2 edema is moderate, a – to -inch indentation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 25

Type: FIB

The nurse assesses full and bounding pulses in a patient being assessed for cardiac risk factors. The nurse would document this finding as +_____ pulses.

Standard Text:

Correct Answer: 3

Rationale : Full and bounding pulses should be documented as +3 pulses.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 26

Type: MCSA

The nurse notes jugular venous distention (JVD) when the patient is lying flat in bed. Which nursing action is indicated?

1. Turn the patient to the left side and reassess in 10 minutes.

2. Place the patient in a supine position and raise the head of the bed to 30 degrees for reassessment.

3. Notify the patients primary physician immediately.

4. Ask the patient to cough and assess for the disappearance of the JVD.

Correct Answer: 2

Rationale 1: Changing the patients position to one side will not result in appreciable changes in the JVD.

Rationale 2: The nurse should reassess with the head of the bed elevated to at least 30 degrees.

Rationale 3: There is no reason to notify the physician for a finding that could be normal.

Rationale 4: The muscles of the neck may move during coughing, but the JVD will not disappear.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 27

Type: MCSA

The nurse, assessing a patient for cardiac failure, has elected to test for abdominojugular reflux. Which action is indicated?

1. Ask the patient to bear down as if moving the bowels.

2. Compress the right upper abdomen for 30 seconds.

3. Use a reflex hammer to tap on the xiphoid process.

4. Roll the patient to the right side and percuss over the left abdomen.

Correct Answer: 2

Rationale 1: Bearing down is not associated with the abdominojugular reflux.

Rationale 2: Compression of the right upper abdomen will cause the blood volume in the abdomen to be displaced back to the right atrium. This influx of blood will be reflected in the jugular veins if the heart if failing.

Rationale 3: Eliciting the abdominojugular reflux does not require the use of a reflex hammer.

Rationale 4: This action does not test for the abdominojugular reflux.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 28

Type: MCMA

A review of the medical record reveals that a patient has a grade IV/VI cardiac murmur. The nurse would expect which findings upon assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A murmur that is audible with the stethoscope barely touching the chest wall

2. A very soft, barely audible murmur

3. A loud murmur

4. A softly palpable thrill

5. No appreciable vibration

Correct Answer: 3,4

Rationale 1: A murmur that can be heard with the stethoscope barely touching the chest wall is grade V/VI.

Rationale 2: A very soft, barely audible murmur is grade I/VI.

Rationale 3: Grade IV/VI murmurs are loud.

Rationale 4: Grade IV/VI murmurs present a softly palpable thrill.

Rationale 5: Loud murmurs with no vibration or thrill are grade III/VI.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29-4

Question 29

Type: MCSA

A woman diagnosed with coronary artery disease says, I would have come to the doctor sooner, but I didnt think women get heart disease. Which information should the nurse provide?

1. Women are more likely than men to die suddenly from cardiac disease.

2. Men die more often from cardiac disease, but it is beginning to affect women as well.

3. There is very little gender difference in deaths from cardiac disease.

4. There have been no good studies examining gender and cardiac death rates.

Correct Answer: 1

Rationale 1: Mortality rates, particularly from sudden death, are currently higher in women that in men.

Rationale 2: Women are affected by cardiac disease and are more likely to die from sudden cardiac death.

Rationale 3: Women are more likely than men to die, especially suddenly, from cardiac disease.

Rationale 4: Good studies are available, and they indicate women are more likely to suffer sudden cardiac death than are men.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-2

Question 30

Type: MCSA

A review of family history reveals that a significant number of a patients ancestors died very early from cardiac diseases. What is the best use of this information for the patient and the nurse?

1. The patient should avoid stress and exposure to communicable diseases.

2. The patient and the nurse should work together to identify other risk factors and establish a plan for health living.

3. The nurse should prepare the patient for the eventuality of an early death.

4. The nurse should encourage the patient not to have biological children.

Correct Answer: 2

Rationale 1: It will not be possible for the patient to avoid stress. Management of stress is a more realistic goal. It will be impossible to avoid all communicable diseases, but maintaining a healthy lifestyle will help the body manage any diseases contracted.

Rationale 2: The patient cannot change genetic risk factors but can modify many other risk factors once they are identified. The nurse should assist the patient in developing a healthy lifestyle.

Rationale 3: There is no guarantee of an early death for this patient.

Rationale 4: Even though this patients family history is significant, the nurse should not try to convince the patient not to have children. The nurse should provide information about risk and support the patients personal decisions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29-2

 

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