Cardio and Peripheral Vascular assessment

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the ___________ artery.

a. Ulnar

b. Radial

c. Brachial

d. Deep palmar

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the ___________ artery.

a. Ulnar

b. Radial

c. Brachial

d. Deep palmar

ANS: C

The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into

the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial

arteries form two arches known as the superficial and deep palmar arches.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

a. Behind the knee

b. Over the lateral malleolus

c. In the groove behind the medial malleolus

d. Lateral to the extensor tendon of the great toe

ANS: D

The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.

Which vein(s) is (are) responsible for most of the venous return in the arm?

a. Deep

b. Ulnar

c. Subclavian

d. Superficial

ANS: D

The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiological change associated with the aging process?

a. Hormonal changes causing vasodilation and a resulting drop in blood pressure

b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency

c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: C

Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

a. Claudication

b. Sore muscles

c. Muscle cramps

d. Venous insufficiency

ANS: A

Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes.

During assessment of a patient with emphysema, the nurse examines the patient’s fingers from the side to detect:

a. Pitting edema

b. Early clubbing

c. Symmetry of the fingers

d. Insufficient capillary refill

ANS: B

The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing. Clubbing occurs with emphysema, chronic bronchitis, and chronic, cyanotic heart diseases.

The nurse is assessing a 64-year-old patient whose vital signs are normal, with a capillary refill time of 5 seconds. What should the nurse do next?

a. Ask the patient about a history of frostbite

b. Suspect that the patient has venous insufficiency

c. Consider this a delayed capillary refill time, and investigate further

d. Consider this a normal capillary refill time that requires no further assessment

ANS: C

Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia

When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+.

What should the nurse do next?

a. Document the finding

b. Auscultate the site for a bruit

c. Check for calf pain

d. Check capillary refill in the toes

ANS: B

If a pulse is weak or diminished at the femoral site, then the nurse should auscultate for a bruit. The presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient’s skin is warm, and capillary refill time is less than 2 seconds.

The nurse should:

a. Check for the presence of claudication

b. Refer the individual for further evaluation

c. Consider this finding as normal and proceed with the peripheral vascular evaluation

d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm

ANS: C

Palpating the ulnar pulses is not usually necessary. The ulnar pulses are not often palpable in the normal person. The other responses are not correct.

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) ___________ pulse.

a. Normal

b. Absent

c. Bounding

d. Weak, thready

ANS: C

A full, bounding pulse occurs with hyperkinetic states (e.g., exercise, anxiety, fever), anemia, and hyperthyroidism. An absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease

The nurse is attempting to assess the femoral pulses in an obese patient and should:

a. Ask the patient to assume a prone position

b. Ask the patient to bend his or her knees to the side in a froglike position

c. Firmly press against the bone with the patient in a semi-Fowler’s position

d. Listen with a stethoscope for pulsations as palpating the pulse in an obese person is extremely difficult

ANS: B

To help expose the femoral area, particularly in obese people, the nurse should ask the person

to bend his or her knees to the side in a froglike position

When auscultating a patient’s femoral arteries with the bell, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:

a. Are often associated with venous disease

b. Occur in the presence of lymphadenopathy

c. In the femoral arteries are caused by hypermetabolic states

d. Occur with turbulent blood flow, indicating partial occlusion

ANS: D

A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct

How should the nurse document mild, slight pitting edema in both of the ankles of a pregnant patient?

a. Bilateral pedal 1+ edema

b. Unilateral pedal 3+edema

c. Edema 4+ to upper extremities

d. Bilateral brawny edema

ANS: A

If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

During an adult patient assessment, the nurse has elevated the patient’s legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:

a. Significant elevational pallor

b. Venous filling within 15 seconds

c. No change in the coloration of the skin

d. Colour returning to the feet within 20 seconds of assuming a sitting position

ANS: B

In this test, it normally takes 10 seconds or less for colour to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor and delayed venous filling occur with arterial insufficiency

During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel “heavy in the calf” and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins that are apparent in her lower legs. Which condition is reflected by these findings?

a. Deep-vein thrombophlebitis

b. Varicose veins

c. Lymphedema

d. Raynaud’s phenomenon

ANS: B

Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment.

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?

a. “It is easily palpable; pounds under the fingertips.”

b. “It has greater than normal force, and then it suddenly collapses.”

c. “It is hard to palpate, fades in and out, and is easily obliterated by pressure.”

d. “The rhythm is regular, but the force varies with alternating beats of large and small amplitudes.”

ANS: C

A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

During an assessment, a patient tells the nurse that her fingers often change colour when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, and then red with a burning, throbbing pain. The nurse suspects that she is experiencing:

a. Lymphedema

b. Raynaud’s phenomenon

c. Deep vein thrombosis

d. Chronic arterial insufficiency

ANS: B

The condition with episodes of abrupt, progressive tricolour changes of the fingers in response to cold, vibration, or stress is known as Raynaud’s phenomenon.

The nurse is reviewing an assessment of a patient’s peripheral pulses and notes previous documentation of radial pulses to be “2+.” The nurse recognizes that this reading indicates what type of pulse?

a. Bounding

b. Normal

c. Weak

d. Absent

ANS: B

When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse

During an assessment, the nurse is unable to palpate pulses in the patient’s left lower leg.

What should the nurse do next?

a. Document that the pulses are nonpalpable

b. Reassess the pulses in 1 hour

c. Ask the patient turn to the side and then palpate for the pulses again

d. Use the Doppler device to assess the pulses

ANS: D

The nurse should be prepared to assess pulses in the lower extremities by using the Doppler device if they cannot be detected by palpation.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

a. Auscultate over the area with a fetoscope.

b. Use a goniometer to measure the pulsations.

c. Use a Doppler device to check for pulsations over the area.

d. Check for the presence of pulsations with a stethoscope.

ANS: C

Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.

While auscultating heart sounds, the nurse hears a murmur. Which of these modes should be used to assess this murmur?

a. Electrocardiography

b. Bell of the stethoscope

c. Diaphragm of the stethoscope

d. Palpation with the nurse’s palm of the hand

ANS: B

The bell of the stethoscope is best for soft, low-pitched sounds, such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds, such as breath, bowel, and normal heart sounds

During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The nurse should:

a. Document the findings in the patient’s record.

b. Wait 10 minutes, and auscultate the sound again.

c. Ask the patient how he or she is feeling.

d. Ask another nurse to double check the finding.

ANS: D

If an abnormal finding is not familiar, then the nurse may ask another examiner to double-check the finding. The other responses do not help identify the unfamiliar sound.

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:

a. Pericardium

b. Myocardium

c. Endocardium

d. Pleural space

ANS: A

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

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

a. Vena cava > right atrium > right ventricle > lungs > pulmonary artery > left atrium > left ventricle

b. Right atrium > right ventricle > pulmonary artery > lungs > pulmonary vein > left atrium > left ventricle

c. Aorta > right atrium > right ventricle > lungs > pulmonary vein > left atrium > left ventricle > vena cava

d. Right atrium > right ventricle > pulmonary vein > lungs > pulmonary artery > left atrium > left ventricle

ANS: B

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.

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

a. The atria contract during systole and attempt to push against closed valves.

b. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.

d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: D

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.

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

a. Mitral and tricuspid

b. Tricuspid and aortic

c. Aortic and pulmonic

d. Mitral and pulmonic

ANS: C

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

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

a. The aortic valve closes slightly before the tricuspid valve.

b. The pulmonic valve closes slightly before the aortic valve.

c. The tricuspid valve closes slightly later than the mitral valve.

d. Both the tricuspid and pulmonic valves close at the same time.

ANS: C

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).

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

a. Atrioventricular (AV) node

b. Sinoatrial (SA) node

c. Bundle of His

d. Bundle branches

ANS: B

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.

The electrical stimulus of the cardiac cycle follows which sequence?

a. AV node > SA node > bundle of His

b. Bundle of His > AV node > SA node

c. SA node > AV node > bundle of His > bundle branches

d. AV node > SA node > bundle of His > bundle branches

ANS: C

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.

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:

a. Decreased fluid volume

b. Increased cardiac output

c. Narrowing of jugular veins

d. Elevated pressure related to heart failure

ANS: D

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.

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?

a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.

b. Because of increased cardiac output, the blood pressure should be higher at this time.

c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output.

d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: A

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

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?

a. Increase in resting heart rate

b. Increase in systolic blood pressure

c. Decrease in diastolic blood pressure

d. Increase in diastolic blood pressure

ANS: B

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.

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:

a. “When was your last electrocardiography done?”

b. “It’s probably because it’s been so hot at night.”

c. “Do you have any history of problems with your heart?”

d. “Have you had a recent sinus infection or upper respiratory infection?”

ANS: C

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.

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

a. Family history, hypertension, stress, and age

b. Personality type, high cholesterol, diabetes, and smoking

c. Smoking, hypertension, obesity, diabetes, and high cholesterol

d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

ANS: C

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

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?

a. Infant’s sleeping position

b. Sibling history of eating disorders

c. Amount of background noise when eating

d. Presence of dyspnea or diaphoresis when sucking

ANS: D

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

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

a. Palpate the artery in the upper one-third of the neck.

b. Listen with the bell of the stethoscope to assess for bruits.

c. Simultaneously palpate both arteries to compare amplitude.

d. Instruct the patient to take slow deep breaths during auscultation.

ANS: B

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

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:

a. Valvular disorder

b. Blood flow turbulence

c. Fluid volume overload

d. Ventricular hypertrophy

ANS: B

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

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:

a. A normal heart

b. Systolic murmur

c. Enlargement of the left ventricle

d. Enlargement of the right ventricle

ANS: D

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

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

a. Third left intercostal space at the MCL

b. Fourth left intercostal space at the sternal border

c. Fourth left intercostal space at the anterior axillary line

d. Fifth left intercostal space at the MCL

ANS: D

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

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

a. Percussion is a useful tool for outlining the heart’s borders.

b. Percussion is easier in patients who are obese.

c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border.

d. Only expert health care providers should attempt percussion of the heart.

ANS: C

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

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

a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas

b. Listening by inching the stethoscope in a rough “Z” pattern, from the base of the heart across and down, then over to the apex

c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest

d. Listening for all possible sounds at a time at each specified area

ANS: B

Auscultation of breath sounds should not be limited to only four locations. Sounds produced by the valves may be heard all over the precordium. The stethoscope should be inched in a rough “Z” pattern from the base of the heart, across and down, and then over to the apex; or, starting at the apex, it should be slowly worked up (see Figure 20-20). Listening selectively to one sound at a time is best

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse’s response?

a. Talk with the patient about his intake of caffeine.

b. Perform ECG after the examination.

c. No further response is needed because sinus arrhythmia can occur normally.

d. Refer the patient to a cardiologist for further testing.

ANS: C

The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person’s breathing, increasing at the peak of inspiration and slowing with expiration.

When listening to heart sounds, the nurse knows that S1:

a. Is louder than S2 at the base of the heart.

b. Indicates the beginning of diastole.

c. Coincides with the carotid artery pulse.

d. Is caused by the closure of the semilunar valves.

ANS: C

S1 coincides with the carotid artery pulse, is the start of systole, and is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. The nurse should gently feel the carotid artery pulse while auscultating at the apex; the sound heard as each pulse is felt is S1

During the cardiac auscultation, the nurse hears a sound immediately occurring after S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

a. Have the patient turn to the left side while the nurse listens with the bell of the

stethoscope.

b. Ask the patient to hold his or her breath while the nurse listens again.

c. No further assessment is needed because the nurse knows this sound is S3.

d. Watch the patient’s respirations while listening for the effect of breathing on the sound.

ANS: D

Split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. Split S2 is heard only in the pulmonic valve area, the second left interspace. When split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Rather, the nurse should concentrate on the split while watching the person’s chest rise up and down with breathing.

Which of these findings would the nurse expect to notice during a cardiac assessment of a 4-year-old child?

a. S3 when sitting up

b. Persistent tachycardia above 150 beats per minute

c. Murmur at the second left intercostal space when supine

d. Palpable apical impulse in the fifth left intercostal space lateral to MCL

ANS: C

Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?

a. S3 is indicative of heart disease in children.

b. These findings can all be normal in a child.

c. These findings are indicative of congenital problems.

d. The venous hum most likely indicates an aneurysm.

ANS: B

Physiological S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathological significance. Heart murmurs, which are innocent (or functional) in origin, are very common through childhood

In assessing for S4 with a stethoscope, the nurse would listen with the:

a. Bell of the stethoscope at the base with the patient leaning forward

b. Bell of the stethoscope at the apex with the patient in the left lateral position

c. Diaphragm of the stethoscope in the aortic area with the patient sitting

d. Diaphragm of the stethoscope in the pulmonic area with the patient supine

ANS: B

S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is heard immediately before S1. S4 is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for this sound. S4 is heard best at the apex, with the person in the left lateral position.

A 30-year-old woman with a history of mitral valve problems states that she has been “very tired.” She has started waking up at night and feels like her “heart is pounding.” During the assessment, the nurse palpates a thrill and forceful pushing of the ventricle at the fifth left intercostal space MCL. In the same area, the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with:

a. Heart failure

b. Aortic stenosis

c. Pulmonary edema

d. Mitral regurgitation

ANS: D

These findings are consistent with mitral regurgitation. Subjective findings include fatigue, palpitation, and orthopnea, and objective findings are (1) a thrill in systole at the apex; (2) a lift (heave or forceful pushing of the ventricle) at the apex; (3) the apical impulse displaced down and to the left; (4) S1 is diminished, S2 is accentuated, and S3 at the apex is often present; and (5) a pansystolic murmur that is often loud, blowing, best heard at the apex, and radiating well to the left axilla

During a cardiac assessment of a 38-year-old patient in the hospital for “chest pain,” the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and S3 on auscultation. Which of these conditions best explains the cause of these findings?

a. Fluid overload

b. Atrial septal defect

c. MI

d. Heart failure

ANS: D

Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema, anxiety, confusion, jugular vein distention, and fatigue. S3 is associated with heart failure and is always abnormal after 35 years of age. S3 may be the earliest sign of heart failure.

The nurse knows that normal splitting of S2 is associated with:

a. Expiration

b. Inspiration

c. Exercise state

d. Low resting heart rate

ANS: B

Normal or physiological splitting of S2 is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.

During a cardiovascular assessment, the nurse knows that a thrill is:

a. A palpable vibration of rushing blood flow

b. Palpated in the right epigastric area

c. Associated with ventricular hypertrophy

d. A murmur auscultated at the third intercostal space

ANS: A

A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur

During a cardiovascular assessment, the nurse knows that S4 is:

a. Heard at the onset of atrial diastole

b. Usually a normal finding in the older adult

c. Heard at the end of ventricular diastole

d. Heard best over the second left intercostal space with the individual sitting upright

ANS: C

S4 is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. S4 occurs just before S1

During an assessment, the nurse notes that the patient’s apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:

a. Systemic hypertension

b. Pulmonic hypertension

c. Pressure overload, as in aortic stenosis

d. Volume overload, as in heart failure

ANS: D

With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy and dilation are present.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it.

b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations.

c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

ANS: C

The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient to take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope and, therefore, should be avoided.

The nurse is preparing for a class on risk factors for heart disease and identifies the population with the highest prevalence of heart disease as people of:

a. African descent

b. European descent

c. Indigenous descent

d. South Asian descent

ANS: A

The prevalence of heart disease and stroke is higher among adults of African descent than in any other ethnic group.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding?

a. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working.

b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained.

c. An impulse will be visible at the fourth or fifth intercostal space at or inside the MCL.

d. The jugular veins will not be detected during this manoeuvre.

ANS: B

When performing hepatojugular reflux by pushing on the right upper quadrant of the patient’s abdomen, just below the rib cage, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

a. Normal for this age

b. Lower than expected

c. Higher than expected, probably as a result of crying

d. Higher than expected, reflecting persistent tachycardia

ANS: A

The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for heart disease? (Select all that apply.)

a. Ethnicity

b. Increased low-density lipoproteins

c. Smoking

d. Gender

e. Hypertension

f. Diabetes

g. Family history

ANS: B, C, E, F

The major risk factors for heart disease and stroke are high blood pressure, smoking, high cholesterol levels, obesity, physical inactivity, and diabetes. Additionally, the use of hormone replacement therapy increases the risk for heart disease in postmenopausal women