Exam 3: end of chapter questions

Ch.17; #1

Which of the following statements describes the cardiovascular system most accurately?

A. It is a double pump circulating out to the lungs and body.

B. It has a heart with six chambers, great vessels, and valves

C. It includes concepts of precontractility, postcontractility, and load.

D. It functions with a conduction system that starts in the ventricles.

A. It is a double pump circulating out to the lungs and body.

Rationale: The heart is a double pump with four chambers, four valves, and a conduction system that has a pacemaker originating in the atrium (SA node). Concepts of preload, after load, and contractility are used when considering the effectiveness of the pumping.

Ch.17; #2

In a healthy patient, the myocardial cells in the ventricle depolarize and contract during _____.

A. prediastole

B. diastole

C. systole

D. postsystole

C. Systole

Rationale: The SA node depolarizes and the atria contract, which appears as the P wave on an ECG. After a brief pause at the AV junction, the impulse travels through the bundle of His, bundle branches, and Purkinje fibers. The muscle cells depolarize and contract, appearing as the QRS complex on the ECG. The end result is ventricular systole and ejection of blood to the lungs and body, producing the heartbeat.

Ch.17; #3

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is _____.

A. S1 greater than S2

B. S1 is equal to S2

C. S2 is greater than S1

D. No Si is heard

A. S1 greater than S2

Rationale: Closure of the mitral and tricuspid valves at the beginning of systole produces the S1. This closure prevents back flow of blood from the ventricles into the atria. S1 is loudest over these valves, located in the 5th left ICS at the sternal border (tricuspid) and the 5th left ICS at the MCL (mitral).

Ch.17; #4

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following?

A. The bilateral carotid pulse

B. The presence of bruits

C. The highest level of jugular venous pulsation

D. The strength of the jugular veins

C. The highest level of jugular venous pulsation

Rationale: The nurse looks for fluid volume overload in the patient with congestive heart failure (CHF). An elevated jugular venous pulsation reflects fluid volume overload in the right heart. The bilateral carotid pulse is never palpated, because doing so may obstruct the circulation to the brain and cause carotids for the presence of narrowing that may lead to stroke; the carotids, not the jugular veins, are also palpated for arterial pulse strength.

Ch.17; #5

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?

A. Auscultate heart sounds

B. Inspect the precordium

C. Percuss the left border

D. Obtain pulse and blood pressure

D. Obtain pulse and blood pressure

Rationale: Blood pressure serves as an indicator of hemodynamic stability in this acute situation. Evaluating the pulse and blood pressure indicates if the patent has an effective pulse. Although heart sounds will be auscultated, the highest priority is identifying the consequences of chest pain and cardiac ischemia. Abnormal heart sounds may or may not reflect ischemia.

Ch.17; #6

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when preforming patient teaching?

A. Teach the patient the most serious information

B. Give the patient brochures to review before the next visit

C. Discuss risk factors that the patient is interested in modifying

D. Describe consequences of risk factors to motivate the patient

C. Discuss risk factors that the patient is interested in modifying.

Rationale: Because multiple risk factors are apparent, the most effective strategy may be for the patient to identify those items that he or she would like to change. Presentation of many brochures is likely to overwhelm the patient; it is better to focus attention on one of two things that the patient is interested in modifying..

Ch.17; #7

Which of the following clusters of symptoms are common in women preceding an MI?

A. Chest pain, nausea, diaphoresis

B. Weight gain, edema, nocturia

C. Dizziness, palpitations, low pulse

D. Fatigue, difficulty sleeping, dyspnea

D. Fatigue, difficulty sleeping, dyspnea

Rationale: Men typically have chest pain, nausea, and diaphoresis. Weight gain, edema, and nocturne are typically symptoms of CHF. Dizziness, palpations, and low pulse are common with arrhythmias. Fatigue is a common presenting symptom in women.

Ch.17; #8

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following?

A. Grade III systolic murmur

B. Grade I systolic murmur

C. Grade V diastolic murmur

D. Grade II diastole murmur

A. Grade III systolic murmur

Rationale: A medium loud murmur is graded III or IV on a I to VI scale. Murmurs between S1 and S2 are systolic; those between S2 and S1 are diastolic.

Ch.17; #9

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heart best at the apex. Which of the following does the nurse report?

A. S3 gallop

B. S4 gallop

C. Systolic ejection click

D. Split S2

A. S3 gallop

Rationale: Because of the clinical situation, the nurse is concerned about the pump function with loss of muscle from the MI. The S3 gallop results from a forceful atrial contraction during presystole that ejects blood into a ventricle that cannot expand further. The S4 gallop immediately precedes S1, and the S3 gallop follows S2.

Ch.17; #10

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis?

A. Ineffective cardiac tissue perfusion

B. Decreased cardiac output

C. Impaired gas exchange

D. Excess fluid volume

D. Excess fluid volume

Rationale: Ineffective cardiac tissue perfusion describes the lack of blood being supplied to the myocardium and relates to cardiac ischemia and chest pain. Impaired gas exchange, a respiratory diagnosis, focuses on the exchange of oxygen and carbon dioxide at the alveolar level. Decreased cardiac output relates to CHF and reduced circulation. Dyspnea from fluid in the lungs and edema and weight gain from fluid accumulation in the body support the most accurate labeling of excess fluid volume.