Question 1

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees.The nurse knows that this finding indicates:

Accepted Answer

Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart.They reflect filling pressures and volume changes.Normal jugular venous pulsation is 2 cm or less above the sternal angle.Elevated pressure is a level of pulsation of more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

Question 2

The component of the conduction system referred to as the pacemaker of the heart is the:

Accepted Answer

Specialized cells in the SA node near the superior vena cava initiate an electrical impulse.Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart.

Question 3

A 45-year-old man is in the clinic for a routine physical examination.During the recording of his health history, the patient states that he has been having difficulty sleeping."I'll be sleeping great, and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:

Accepted Answer

Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with heart failure.Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load.Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

Question 4

The nurse is preparing to auscultate for heart sounds.Which technique is correct?

Accepted Answer

Auscultation should be done by inching the stethoscope in a rough "Z" pattern, from the base of the heart across and down, then over to the apex. This allows for thorough auscultation of all four areas (aortic, pulmonic, tricuspid, and mitral) and helps the nurse identify any abnormal sounds or murmurs. Listening at the site where the apical pulse is felt strongest may not necessarily correspond to the best location for auscultation, and listening for all possible sounds at each area at the same time is not recommended as it may lead to confusion and inaccurate assessment.

Question 5

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and split S₂.Which of these findings is an expected hemodynamic change related to age?

Accepted Answer

With aging, an increase in systolic blood pressure occurs.No significant change in diastolic pressure and no change in the resting heart rate occur with aging.Cardiac output at rest does not change with aging.

Question 6

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Accepted Answer

To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 11.1 mmol/L or known diabetes mellitus, obesity, any length of hormone replacement therapy in postmenopausal women, cigarette smoking, and low activity level.

Question 7

Which of these statements describes the closure of the valves in a normal cardiac cycle?

Accepted Answer

Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization.As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately.In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

Question 8

The nurse is examining a patient who has possible cardiac enlargement.Which statement about percussion of the heart is true?

Accepted Answer

Numerous comparison studies have shown that the percussed cardiac border correlates only moderately with the true cardiac border.Percussion is of limited usefulness in the female breast tissue, in a person who is obese, or in a person with a muscular chest wall.Chest radiography and echocardiography are significantly more accurate in detecting heart enlargement.

Question 9

When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?

Accepted Answer

About two-thirds of the freshly oxygenated blood from the placenta is shunted through an opening in the atrial septum, the foramen ovale, into the left side of the heart, where it is pumped out through the aorta.The foramen ovale closes within the first hour after birth because the pressure in the right side of the heart is now lower than in the left side.

Question 10

The mother of a 3-month-old infant states that her baby has not been gaining weight.With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again.What other information would the nurse need?

Accepted Answer

To screen for heart disease in an infant, the focus should be on feeding.Fatigue during feeding should be noted.An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short time hungry again.

Question 11

The direction of blood flow through the heart is best described by which of these?

Accepted Answer

Returning blood from the body empties into the right atrium, flows into the right ventricle, and then goes to the lungs through the pulmonary artery.The lungs oxygenate blood, and it is then returned to the left atrium through the pulmonary vein.Blood goes from there to the left ventricle and then to the aorta and out to other areas of the body.

Question 12

The nurse is reviewing the anatomy and physiological functioning of the heart.Which statement best describes what is meant by atrial kick?

Accepted Answer

Toward the end of diastole, the atria contract and push the last amount of blood (approximately 25% of stroke volume) into the ventricles.This active filling phase is called presystole, or atrial systole, or sometimes the atrial kick.

Question 13

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

Accepted Answer

If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit by using the bell of the stethoscope.The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis.Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults.Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain.

Question 14

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg.In reviewing her previous examination findings, the nurse notes that her blood pressure in her second month was 124/80 mm Hg.In evaluating this change, what does the nurse know to be true?

Accepted Answer

Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation.The blood pressure drops to its lowest point during the second trimester and then rises after that.

Question 15

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery.This finding would indicate:

Accepted Answer

A bruit is a blowing, swishing sound indicating blood flow turbulence; normally, none is present.

Question 16

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:

Accepted Answer

The second heart sound (S₂) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole.Although it is heard over all the precordium, the S₂ is loudest at the base of the heart.

Question 17

The electrical stimulus of the cardiac cycle follows which sequence?

Accepted Answer

Specialized cells in the SA node near the superior vena cava initiate an electrical impulse.The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum.There it is delayed slightly, allowing the atria the time to contract before the ventricles are stimulated.Then the impulse travels to the bundle of His, to the right and left bundle branches, and then through the ventricles.

Question 18

Before administering certain cardiovascular medications, the nurse needs to check the rate of the apical impulse at the:

Accepted Answer

The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the MCL.

Question 19

When assessing a patient's cardiovascular system, the nurse notes a high pitched scratchy sound at the apex of the heart.The nurse recognizes this as rubbing between the two walls of the sac surrounding and protecting the heart, called the:

Accepted Answer

The pericardium is a tough, fibrous, double-walled sac that surrounds and protects the heart.It has two layers that contain a few millilitres of serous pericardial fluid.Inflammation of the precordium gives rise to a friction rub.The sound is high pitched and scratchy, like sandpaper being rubbed.

Question 20

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border.This finding most likely suggests:

Accepted Answer

Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line (MCL).A heave or lift is a sustained forceful thrusting of the ventricle during systole.It occurs with ventricular hypertrophy as a result of increased workload.A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

Quiz 20: Heart and Neck Vessels