Deck 28: A Person-Centred Approach to Assessing the Cardiovascular and Lymphatic Systems

Question 1

Bradycardia occurs when the nurse assesses an apical heart rate of how many beats per minute in an adult?

A)Less than 60.
B)60-90.
C)90.
D)Greater than 100.

Answer 1

Less than 60.

Question 2

Pericardiocentesis would be utilised in which of the following situations?

A)Suspected damage to a heart valve.
B)Severe bradycardia.
C)Pericarditis.
D)Cardiac tamponade.

Answer 2

Cardiac tamponade.

Question 3

Place the following statements regarding cardiac catheterisation in the correct order:
1) inject contrast.
2) heart activity is filmed.
3) thread catheter to heart chamber.
4) catheter insertion in the leg.
5) peripheral IV insertion.

Answer 3

5,4,3,1,2

Question 4

When listening to heart sounds, the nurse expects to hear S1 and S2. The presence of an additional sound immediately following S2 is called ________, which can result from ________.

A)S3, a stenotic mitral valve.
B)S4, increased resistance to ventricular filling.
C)S4, inflammation of the pericardial sac.
D)S3, myocardial failure.

Question 5

The person is being evaluated for left atrium thrombus due to a dysrhythmia (altered heart rhythm). Which of the following common cardiac tests will be ordered to assess for thrombus?

A)Blood pool imaging.
B)Cardiac catheterisation.
C)Thallium scan.
D)Transoesophageal echocardiography (TEE).

Question 6

Tachycardia occurs when the nurse assesses an apical heart rate of how many beats per minute in an adult?

A)Less than 60.
B)60-90.
C)90.
D)Greater than 100.

Question 7

How many beats per minute does the nurse expect to hear listening to adult heart sounds when a normal sinus rhythm is present?

A)30-60.
B)60-100.
C)100-130.
D)130-160.

Question 8

The person is having a treadmill test. Which of the following is an important teaching point?

A)Smoking is permitted up until the time of the test.
B)Comfortable clothing and shoes should be worn for the test.
C)The person is nil by mouth for 6-8 hours before the test.
D)A hospital gown and slippers should be worn for the test.

Question 9

At which location will S1 be heard the loudest?

A)Right sternal border at the second intercostal space.
B)Left sternal border at the fifth intercostal space.
C)Left midclavicular line at the fifth intercostal space.
D)Right midclavicular line at the third intercostal space.

Question 10

An older adult is being evaluated for age-related cardiac changes. Common age-related changes include which of the following? (Select all that apply.)

A)Decreased cardiac output.
B)Increased cardiac output.
C)Decreased stroke volume.
D)Decreased blood pressure.

Question 11

The person is admitted to the hospital for evaluation and diagnosis of cardiovascular pathology. The person is scheduled for an ejection fraction study. What correct facts will guide teaching of the person? (Select all that apply.)

A)An ejection fraction (EF)study will measure the percentage of total blood in the ventricle ejected from the heart with each beat.
B)Stroke volume times heart rate equals cardiac output.
C)The normal ejection fraction is 70-90%.
D)An ejection fraction (EF)provides information about how effectively the heart is pumping.

Question 12

In the person with hypovolaemic shock, the nurse realises that the heart sounds will change in which of the following ways?

A)Diminished S2 and accentuated S1.
B)Diminished S1 and S2.
C)Accentuated S2 and diminished S1.
D)Accentuated S1 or S2.

Question 13

The person's ECG shows the following characteristics: PR interval .08, QRS .08 and isoelectric ST segment. What do these characteristics indicate?

A)Faster than normal conduction from the SA node to the ventricles, slower than normal conduction through the ventricles and normal ST segment.
B)Normal conduction from the SA node to the ventricles, normal conduction through the ventricles and abnormal ST segment.
C)Faster than normal conduction from the SA node to the ventricles, normal conduction through the ventricles and normal ST segment.
D)Normal conduction from the SA node to the ventricles, faster conduction through the ventricles and abnormal ST segment.

Question 14

The S1 heart sound corresponds to which of the following physiological events?

A)The onset of cardiac diastole.
B)Ejection of blood from the atria.
C)Closure of the aortic and pulmonary valves.
D)Closure of the AV valves.

Question 15

The nurse is caring for a person admitted with an atrial gallop. The nurse realises that which of the following cardiac conditions could result in this assessment finding? (Select all that apply.)

A)Cardiomyopathy.
B)Mitral valve prolapse.
C)Aortic stenosis.
D)Tricuspid regurgitation.

Question 16

A common laboratory test related to heart assessment is fasting lipids. Which of the following statements is true regarding this test?

A)Cholesterol levels should be less than 200 mg/dL.
B)HDL is not part of this test.
C)LDL is measured and should be over 130 mg/dL.
D)A normal triglyceride level is 200-300 mg/dL.

Question 17

The nurse is interviewing the person. Which functional health pattern is related to asking the person if they have had tests to check the function of their heart?

A)Activity-exercise.
B)Cognitive-perceptual.
C)Health-perception-health-management.
D)Nutritional-metabolic.

Question 18

At which location will S2 be heard the loudest?

A)Right sternal border at the second intercostal space.
B)Left sternal border at the fifth intercostal space.
C)Left midclavicular line at the fifth intercostal space.
D)Right midclavicular line at the third intercostal space.

Question 19

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

A)S1 then S2.
B)S2 then S1.
C)S2 then S3.
D)S3 then S4.

Question 20

What is an important nutritional-metabolic interview question to ask persons who are being evaluated for heart conditions?

A)'What heart medications are you taking?'
B)'Have you experienced chest pain in the last week?'
C)'Have you had a recent weight gain or loss?'
D)'Is there any change in your usual bowel elimination?'