Chapter 20 - Q & A Flashcards
What is the sac that surrounds and protects the heart is called?
a. Myocardium
b. Pericardium
c. Endocardium
d. Pleural space
ANS: B
The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. The myocardium is the muscular wall of the heart. The endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves. The pleural space is the space between the visceral and parietal pleura of each lung. The sac that surrounds and protects the heart is the pericardium.
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 and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is then returned to the left atrium through the pulmonary vein. The blood goes from there to the left ventricle and then out to the body through the aorta.
The nurse is reviewing the anatomy and physiologic 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, which valve closures are heard best at the base of the heart?
a. Aortic and pulmonic
b. Mitral and pulmonic
c. Mitral and tricuspid
d. Tricuspid and aortic
ANS: A
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 pulmonic valve closes slightly before the aortic valve.
b. The aortic valve closes slightly before the tricuspid valve.
c. Both the tricuspid and pulmonic valves close at the same time.
d. The tricuspid valve closes slightly later than the mitral valve.
ANS: D
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).
What component of the conduction system is referred to as the pacemaker of the heart?
a. Bundle of His
b. Bundle branches
c. Sinoatrial (SA) node
d. Atrioventricular (AV) node
ANS: C
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. After the electrical impulse is initiated, it travels across the atria to the AV node where it is delayed slightly so the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.
Which sequence does the electrical stimulus of the cardiac cycle follow?
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: D
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, 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. What does this finding indicate?
a. Decreased fluid volume
b. Increased cardiac output
c. Narrowing of jugular veins
d. Elevated pressure r/t 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 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, 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 the split S2 heart sound. Which of these findings can be explained by the expected hemodynamic changes r/t 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 changed 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.” Which is the best response by the nurse?
a. “When was your last electrocardiogram?”
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. Although the symptom the patient is describing is likely r/t heart failure, asking when his last electrocardiogram was is not as important as finding out about a history of heart problems. These symptoms are not associated with a sinus or upper respiratory infection.
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 100 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women. Although heredity, or inherited DNA variation, and lifestyle factors each contribute independently to the development of coronary artery disease (CAD), a favorable lifestyle is
associated with a 46% lower risk for CAD events than is an unfavorable lifestyle.
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 want to have?
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. The infant’s sleeping position, sibling history of eating disorders, and amount of background noise with eating are not r/t the symptoms this infant is experiencing. These symptoms are characteristic of heart
disease.
What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
a. Palpate the artery in the upper one-third of the neck.
b. Simultaneously palpate both arteries to compare amplitude.
c. Listen with the bell of the stethoscope to assess for bruits.
d. Instruct the patient to take slow deep breaths during auscultation
ANS: C
If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. 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. The carotid pulse should be palpated medial to the sternomastoid muscle near the base of the neck (not the upper third).
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. What does this finding indicate?
a. Valvular disorder
b. Blood flow turbulence
c. Fluid volume overload
d. Ventricular hypertrophy
ANS: B
A blowing, swishing sound heard over the carotid artery is a bruit. This sound indicates blood flow turbulence; normally none is present. It does not indicate a valvular disorder (that would be heard when auscultating the heart not the carotid artery), fluid volume overload or ventricular hypertrophy.
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. What does this finding most likely indicate?
a. Systolic murmur
b. Diastolic murmur
c. Enlargement of the left ventricle
d. Enlargement of the right ventricle
ANS: D
This movement along the sternal border is an apical impulse. Normally the examiner may or may not see an apical impulse, but when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. 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, as in this patient; a left ventricular heave is seen at the apex.
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
a. Third left intercostal space at the midclavicular line
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 midclavicular line
ANS: D
The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular
line.
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
a. Percussion is easier in patients who are obese.
b. Percussion is a useful tool for outlining the heart’s borders.
c. Only expert health care providers should attempt percussion of the heart.
d. Studies show that percussed cardiac borders do not correlate well with the true cardiac border.
ANS: D
Numerous comparison studies have shown that the percussed cardiac border correlates only moderately with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargement.
The nurse is preparing to auscultate for heart sounds. Which technique is correct?
a. Listening for all possible sounds at a time at each specified area.
b. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.
c. Listening to the sounds only at the site where the apical pulse is felt to be the
strongest.
d. Listening by inching the stethoscope in a rough Z pattern, from the base of the
heart across and down, then over to the apex.
ANS: D
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, then over to the apex; or, starting at the apex, it should be slowly worked up. 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 should the nurse do?
a. Document this as a normal finding.
b. Talk with the patient about his intake of caffeine.
c. Perform an electrocardiogram after the examination.
d. Refer the patient to a cardiologist for further testing.
ANS: A
This is sinus dysrhythmia which occurs normally in young adults and children. With sinus dysrhythmia, the rhythm varies with the person’s breathing, increasing at the peak of inspiration and slowing with expiration. The nurse should document this as a normal finding. This is a normal finding so there is no need to question the patient about his caffeine intake, perform an electrocardiogram,
or refer to a cardiologist.
What is the best description of the S1 heart sound?
a. Indicates the beginning of diastole.
b. Coincides with the carotid artery pulse.
c. Louder than the S2 at the base of the heart.
d. Is caused by the closure of the semilunar valves.
ANS: B
The S1 coincides with the carotid artery pulse, is the start of systole, and is louder than the S2 at the apex of the heart; the S2 is louder than the S1 at the base. The nurse should gently feel the carotid artery pulse while auscultating at the apex of the heart; the
sound heard as each pulse is felt is the S1.
During cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. What should the nurse do to further assess this sound?
a. Ask the patient to hold his or her breath while the nurse listens again.
b. No further assessment is needed because the nurse knows this sound is an S3.
c. Watch the patient’s respirations while listening for the effect on the sound.
d. Have the patient turn to the left side while the nurse listens with the bell of the
stethoscope.
ANS: C
A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the 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 on 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 midclavicular
line
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 an 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. These findings can all be normal in a child.
b. An S3 is indicative of heart disease in children.
c. The venous hum most likely indicates an aneurysm.
d. These findings are indicative of congenital problems.
ANS: A
These are all commonly found in children. A physiologic S3, which occurs early in diastole just after S2, 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 pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.
