Deck 29: Nursing Assessment of the Patient With Cardiovascular Disorders

Question 1

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

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

Answer 1

S1, then S2

Question 2

The nurse is assessing a patient's 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?

A) Have the patient turn the head to the right.
B) Have the patient hold the breath while the nurse is listening.
C) Press the stethoscope tighter against the patient's skin.
D) Have the patient lean on the overbed table.

Answer 2

Have the patient lean on the overbed table.

Question 3

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

A) Severe valve stenosis
B) Cardiomyopathy
C) Stenosis of the carotid arteries
D) Aortic aneurysm

Answer 3

Severe valve stenosis

Question 4

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

A) Ventricular volume overload
B) Ventricular hypertrophy from hypertension
C) Atrial fibrillation
D) A stenotic aortic valve

Question 5

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?

A) "Some stress is healthy for the heart. If constant chest pain develops, you need to have it investigated."
B) "Stress is an everyday occurrence and should be managed by resting frequently."
C) "Type A personalities tend to seek out higher-stress jobs. Maybe you should seek different employment."
D) "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."

Question 6

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

A) Rheumatic fever and strep throat infections
B) Rubella and chickenpox
C) Asthma and bronchitis
D) Otitis media and respiratory syncytial virus RSV)

Question 7

The S1 heart sound corresponds to which physiological event?

A) Closure of the AV valves
B) Closure of the semilunar valves
C) Ejection of blood from the atria
D) The onset of relaxation

Question 8

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?

A) Aortic stenosis
B) Mitral stenosis
C) Aortic regurgitation
D) Mitral regurgitation

Question 9

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

A) The patient complains of intermittent chest pain during mild exercise.
B) The patient has a history of urinary retention.
C) The patient complains of fatigue and dyspnea after walking up several flights of stairs.
D) The patient's father has a history of smoking.

Question 10

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

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

Question 11

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

A) 2^nd intercostal space left of the sternum
B) 5^th intercostal space midclavicular line
C) 3^rd intercostal space right of the sternum
D) 4^th intercostal space left midaxillary line

Question 12

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

A) Skin tenting poor turgor) and heart rate 102
B) Pallor and peripheral edema
C) Bounding peripheral pulses and pulse oximeter reading 90%
D) Prolonged capillary refill and diminished peripheral pulses

Question 13

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

A) "Your mitral and tricuspid valves are not closing at exactly the same time."
B) "You probably have some calcification in the pulmonary valve that slows its closure."
C) "Your aortic valve is closing more slowly than it should."
D) "Your atrioventricular valves are not closing at exactly the same time."

Question 14

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.

A) "How often do you get up to go to the bathroom at night?"
B) "Are you still waking up at night because you are short of breath?"
C) "How long after you go to bed do you start having trouble breathing?"
D) "Do you still have to sleep on three pillows at night?"
E) "Are you still having palpitations at night?"

Question 15

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?

A) Heart failure
B) Extension of the MI
C) Renal failure
D) Liver failure

Question 16

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 nurse's priority will be to assess for which other finding?

A) Absence of bowel sounds
B) Lung sounds for crackles
C) Diminished pulses
D) Sluggish pupil response

Question 17

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

A) Medications
B) Airway and oxygen status
C) Activity tolerance
D) Chest pain

Question 18

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.

A) "We don't give sulfa drugs for cardiac problems, so that won't be an issue."
B) "If it just makes you sick to your stomach, it isn't really an allergy."
C) "What happens when you take sulfa drugs?"
D) "When did you first find out about this allergy?"
E) "If we need to give you a sulfa drug, we will be sure to give you an antihistamine with it."

Question 19

A patient is being evaluated for intermittent chest pain. The nurse's 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.

Question 20

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

A) Conduct a physical exam and discuss the findings.
B) Review the patient's previous medical record and determine risks from that information.
C) Discuss the patient's perceived area of health risks.
D) Conduct a health history and physical exam to determine the areas of risk and use these findings to educate the patient.

Question 21

A patient has mild pitting edema over the lower legs. A ¼-inch indentation remains in the tissue after the nurse depresses it with a finger. The nurse would document this finding as + _______ pitting edema.

Question 22

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

A) Turn the patient to the left side and reassess in 10 minutes.
B) Place the patient in a supine position and raise the head of the bed to 30 degrees for reassessment.
C) Notify the patient's primary physician immediately.
D) Ask the patient to cough and assess for the disappearance of the JVD.

Question 23

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

A) Ask the patient to bear down as if moving the bowels.
B) Compress the right upper abdomen for 30 seconds.
C) Use a reflex hammer to tap on the xiphoid process.
D) Roll the patient to the right side and percuss over the left abdomen.

Question 24

A woman diagnosed with coronary artery disease says, "I would have come to the doctor sooner, but I didn't think women get heart disease." Which information should the nurse provide?

A) Women are more likely than men to die suddenly from cardiac disease.
B) Men die more often from cardiac disease, but it is beginning to affect women as well.
C) There is very little gender difference in deaths from cardiac disease.
D) There have been no good studies examining gender and cardiac death rates.

Question 25

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

A) Request an X-ray of the patient's hands.
B) Ask the patient if an injury occurred to the hands.
C) Review the patient's history for pulmonary disorders.
D) Ask if the patient has diabetes.

Question 26

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

A) The patient should avoid stress and exposure to communicable diseases.
B) The patient and the nurse should work together to identify other risk factors and establish a plan for health living.
C) The nurse should prepare the patient for the eventuality of an early death.
D) The nurse should encourage the patient not to have biological children.

Question 27

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.

A) "How many packs of cigarettes do you smoke a day?"
B) "How many years have you been smoking?"
C) "Have you ever tried to quit smoking?"
D) "How much money do you spend on cigarettes each month?"
E) "How do you feel about smoking?"

Question 28

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

Question 29

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?

A) The last physician must have been a psychiatrist.
B) The patient thrives in a high-stress environment.
C) The patient probably avoids social contact and focuses on negative emotions.
D) This patient has been treated for depression.

Question 30

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.

A) A murmur that is audible with the stethoscope barely touching the chest wall
B) A very soft, barely audible murmur
C) A loud murmur
D) A softly palpable thrill
E) No appreciable vibration