Deck 13: Cardiovascular Clinical Assessment

Question 1

A nurse palpates the descending aorta and feels a strong,bounding pulse.The nurse reports the findings to the physician because the results suggest

A) decreased cardiac output.
B) increased cardiac output.
C) an aneurysm.
D) aortic insufficiency.

Answer 1

an aneurysm.

Question 2

Abnormal heart sounds are labeled S? and S? and are referred to as __________ when auscultated during a tachycardic episode.

A) Korotkoff sounds
B) pulse pressure
C) murmurs
D) gallops

Answer 2

gallops

Question 3

A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs.The patient is admitted with a diagnosis of "rule out myocardial infarction." The history portion of the assessment should be guided by

A) medical history.
B) history of prior surgeries.
C) presenting symptoms.
D) a review of systems.

Answer 3

presenting symptoms.

Question 4

The abdominojugular reflux test determines the presence of

A) right ventricular failure.
B) hypoxemia.
C) liver failure.
D) pitting edema.

Question 5

A heart murmur is described as blowing,grating,or harsh.This description would fall under which criteria?

A) Intensity
B) Quality
C) Timing
D) Pitch

Question 6

The presence of a carotid or femoral bruit may be evidence of

A) left-sided heart failure.
B) blood flow through a partially occluded vessel.
C) the early onset of pulmonary embolism.
D) myocardial rupture.

Question 7

A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs.The patient is admitted with a diagnosis of "rule out myocardial infarction." When inspecting the patient,the nurse notes that the patient needs to sit in a high Fowler position to breathe.This may indicate

A) pericarditis.
B) anxiety.
C) heart failure.
D) angina.

Question 8

When checking the patient's back,the nurse pushes her thumb into the patient's sacrum.An indentation remains.The nurse charts that the patient has

A) sacral compromise.
B) delayed skin turgor.
C) pitting edema.
D) dehydration.

Question 9

Evaluation of arterial circulation to an extremity is accomplished by assessing which of the following?

A) Homans sign
B) Skin turgor
C) Peripheral edema
D) Capillary refill

Question 10

_____ are created by the turbulence of blood flow through a vessel caused by constriction of the blood pressure cuff.

A) Korotkoff sounds
B) Pulse pressures
C) Murmurs
D) Gallops

Question 11

An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis.Physical assessment findings reveal tachycardia with an S? and a 3/6 systolic murmur.Which of the following descriptions best describes the murmur heard with mitral stenosis?

A) High-pitched systolic sound
B) Medium-pitched systolic sound
C) High-pitched diastolic sound
D) Low-pitched diastolic sound

Question 12

A patient's blood pressure is 90/72 mm Hg.What is the patient's pulse pressure?

A) 40 mm Hg
B) 25 mm Hg
C) 18 mm Hg
D) 12 mm Hg

Question 13

A nurse from the ICU receives a report from the ED nurse on a patient that includes a diagnosis of syncope unknown etiology.Orthostatic VS lying: 110/80 mm/Hg; sitting: 100/74 mm/Hg; standing: 92/40 mm/Hg.Based on this information,the nurse should monitor the patient's

A) breathing.
B) dietary intake.
C) peripheral pulses.
D) activity.

Question 14

Which of the following conditions is usually associated with clubbing?

A) Central cyanosis
B) Peripheral cyanosis
C) Carbon monoxide poisoning
D) Acute hypoxemia

Question 15

An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis.Physical assessment findings reveal tachycardia with an S? and a 3/6 systolic murmur.The grading of a murmur as a 3/6 refers to which of the following characteristics of murmurs?

A) Intensity
B) Quality
C) Timing
D) Pitch

Question 16

A sudden increase in left atrial pressure,acute pulmonary edema,and low cardiac output,caused by the ventricle contracting during systole,are all characteristics of

A) acute mitral regurgitation.
B) aortic insufficiency.
C) chronic mitral regurgitation.
D) pericardial friction rub.

Question 17

The nurse assesses the dorsalis pedis and posterior tibial pulses as weak and thready.Indicate the correct documentation for the pulse volume that the nurse would use.

A) 0
B) 1+
C) 2+
D) 3+

Question 18

The purpose of the Allen test is to

A) assess adequate blood flow through the ulnar artery.
B) occlude the brachial artery and evaluate hypoxemia to the hand.
C) test the patency of an internal graft.
D) determine the size of needle to be used for puncture.

Question 19

An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis.Physical assessment findings reveal tachycardia with an S? and a 3/6 systolic murmur.The nurse knows that the presence of an S? heart sound is

A) normal for a person this age.
B) a ventricular gallop.
C) a systolic sound.
D) heard best with the diaphragm of the stethoscope.

Question 20

An assessment finding of pulsus alternans may indicate evidence of

A) left-sided heart failure.
B) jugular venous distention.
C) pulmonary embolism.
D) myocardial ischemia.

Question 21

Which of the following describe(s)S?,the first heart sound?

A) It is associated with closure of the mitral and tricuspid valves.
B) It is a high-pitched sound.
C) It can be heard most clearly with the diaphragm of the stethoscope.
D) The best listening point is in the aortic area.
E) The "split" sound can best be detected in the tricuspid area.

Question 22

During a history examination,a patient tells the nurse,"The cardiologist says I have a leaking valve." The nurse documents that the patient has a history of

A) acute mitral regurgitation.
B) aortic insufficiency.
C) chronic mitral regurgitation.
D) pericardial friction rub.

Question 23

A patient was admitted on the night shift with a diagnosis of acute myocardial infarction.Upon auscultation,the nurse hears a harsh,holosystolic murmur along the left sternal border.The nurse notifies the physician immediately because the symptoms indicate the patient has developed

A) papillary muscle rupture.
B) tricuspid stenosis.
C) ventricular septal rupture.
D) pericardial friction rub.

Question 24

Heart murmurs are characterized by which of the following criteria?

A) Intensity
B) Location
C) Quality
D) Pitch
E) Pathologic cause

Question 25

A patient was admitted to the ICU 3 days ago with a diagnosis of myocardial infarction.The patient is complaining of increased chest pain when coughing,swallowing,and changing positions.The nurse hears a systolic scratching sound upon auscultation of the apical pulse.The nurse notifies the physician.Based on the symptoms,the physician suspects a(n)

A) acute mitral regurgitation.
B) aortic insufficiency.
C) chronic mitral regurgitation.
D) pericardial friction rub.