Finals Reviewer Flashcards
The anterior chest area that overlies the heart and great vessels is called the
a. endocardium.
b. epicardium.
c. myocardium.
d. precordium.
d. precordium.
The bicuspid, or mitral, valve is located
a. between the left atrium and the left ventricle.
b. between the right atrium and the right ventricle.
c. at the beginning of the ascending aorta.
d. at the exit of each ventricle near the great vessels.
a. between the left atrium and the left ventricle.
The semilunar valves are located
a. between the left atrium and the left ventricle.
b. between the right atrium and the right ventricle.
c. at the exit of each ventricle at the beginning of the great vessels.
d. at the beginning of the ascending aorta.
c. at the exit of each ventricle at the beginning of the great vessels.
The sinoatrial node of the heart is located on the
a. anterior wall of the left atrium.
b. anterior wall of the right atrium.
c. upper intraventricular system.
d. posterior wall of the right atrium.
d. posterior wall of the right atrium.
The P-wave phase of an electrocardiogram (ECG) represents
a. conduction of the impulse throughout the ventricles.
b. conduction of the impulse throughout the atria.
c. ventricular repolarization.
d. ventricular polarization.
b. conduction of the impulse throughout the atria.
Assessment technique most often associated
with evaluation of the cardiovascular system
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
d. Auscultation
Event of the heart when contraction of the ventricles forces blood into major vessels
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
h. Systole
Palpable murmur described as feeling like the
throat of a purring cat
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
g. Thrill
Audible variation between closure of two valves
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
i. Splitting
Area of auscultation located at second ICS at left sternal border
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
a. Pulmonic
Localized area of tissue necrosis caused by prolonged anoxia
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
c. Infarct
Area of auscultation located at the apex and
assessing the left ventricle; fourth to fifth ICS
at left midclavicular line (MCL)
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
f. Mitral
Area of auscultation at second ICS and right sternal border
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
j. Aortic
Part of stethoscope used to auscultate normal heart sounds
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
b. Diaphragm
The portion of the stethoscope used to assess
for murmurs
a. Pulmonic
b. Diaphragm
c. Infarct
d. Auscultation
e. Bell
f. Mitral
g. Thrill
h. Systole
i. Splitting
j. Aortic
e. Bell
During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client’s
a. base of the heart.
b. pulmonic valve area.
c. apex of the heart.
d. second left interspace.
c. apex of the heart.
The S4 heart sound
a. can be heard during systole.
b. is often termed ventricular gallop.
c. is usually due to a heart murmur.
d. can be heard during diastole.
d. can be heard during diastole.
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible
a. congestive heart failure.
b. angina.
c. palpitations.
d. acute anxiety reaction.
b. angina.
An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is
a. high serum level of low-density lipoproteins.
b. low-carbohydrate diets.
c. high serum level of high-density lipoproteins.
d. diets that are high in antioxidant vitamins.
a. high serum level of low-density lipoproteins.
The nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. Which of the following should be included in the nurse’s teaching plan?
a. Hispanic clients have a higher incidence of CHD than black or white Americans.
b. The incidence of hypertension in the white population of the United States is greater than in the black population.
c. Women are more likely to have serious stenosis after a heart attack.
d. Lowering elevated cholesterol and BP decreases the risk of heart attack
d. Lowering elevated cholesterol and BP decreases the risk of heart attack
The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client’s
a. apical pulse.
b. breath sounds.
c. jugular veins.
d. carotid arteries.
a. apical pulse.
The nurse is planning to auscultate a female adult client’s carotid arteries. The nurse should plan to
a. ask the client to hold her breath.
b. palpate the arteries before auscultation.
c. place the diaphragm of the stethoscope over the artery.
d. ask the client to breathe normally.
a. ask the client to hold her breath.
While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is
a. a normal sound heard in adult clients.
b. a wheezing sound.
c. associated with occlusive arterial disease.
d. heard when the artery is almost totally occluded.
c. associated with occlusive arterial disease.
The nurse assesses a hospitalized adult client and observes that the client’s jugular veins are fully extended. The nurse contacts the client’s physician because the client’s signs are indicative of
a. pulmonary emphysema.
b. diastolic murmurs.
c. patent ductus arteriosus.
d. increased central venous pressure.
d. increased central venous pressure.
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for
a. cardiac murmur.
b. left-sided heart failure.
c. constrictive pericarditis.
d. congestive heart failure.
a. cardiac murmur.
The nurse is auscultating the heart sounds of an adult client. To auscultate Erb’s point, the nurse should place the stethoscope at the
a. second intercostal space at the right sternal border.
b. third to fifth intercostal space at the left sternal border.
c. apex of the heart near the midclavicular line (MCL).
d. fourth or fifth intercostal space at the left lower sternal border.
b. third to fifth intercostal space at the left sternal border.
While auscultating an adult client’s heart rate and rhythm, the nurse detects a irregular pattern. The nurse should
a. assess the client for signs and symptoms of pulmonary disease.
b. document this as a normal finding.
c. schedule the client for an ECG.
d. refer the client to a physician.
d. refer the client to a physician.
The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should
a. be referred to a cardiologist for further evaluation.
b. be examined again in 6 months.
c. restrict exercise and strenuous activities.
d. recognize that this finding is normal in adolescents.
d. recognize that this finding is normal in adolescents.
While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of
a. pulmonary hypertension.
b. aortic stenosis.
c. mitral valve stenosis.
d. pulmonary hypotension.
c. mitral valve stenosis.
The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of
a. obstructive lung disease.
b. left-sided heart failure.
c. premature ventricular contractions.
d. aortic stenosis.
a. obstructive lung disease.
The major artery that supplies blood to the arm is the
a. radial artery
b. ulcer artery
c. posterior artery
d. brachial artery
d. brachial artery
The popliteal artery can be palpated at the
a. knee
b. great toe
c. ankle
d. inguinal ligament
a. knee
The posterior tibial pulse can be palpated at the
a. great toe
b. knee
c. top of the foot
d. ankle
d. ankle
Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body’s blood volume that is contained in the veins is nearly
a. 50%
b. 60%
c. 70%
d. 80%
c. 70%
The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the
a. degree of arterial occlusion that exists
b. pulse of a client with poor elasticity
c. competence of the saphenous vein valves
d. severity of thrombophlebitis
c. competence of the saphenous vein valves
Used to detect a weak peripheral pulse to monitor blood pressure in infants or children and to measure blood pressure in a lower extremity; it magnifies pulse sounds from the heart and blood vessels
Doppler ultrasound probe
Swelling caused by excessive fluid
Edema
Diffuse enlargement of terminal phalanges
Clubbing
A vasospastic disorder, primarily affects the hands, characterized by color change from pallor, to cyanosis to rubor; attacks precipitated by cold or emotional upset and relieved by warmth
Raynaud disease
The time it takes for color to return to the nail beds after they have been blanched by pressure; a good measure of peripheral perfusion and cardiac output
Capillary refill time
Determines the patency of the radial and ulnar arteries
Allen test
Swollen, distended, and knotted veins; occur most commonly in the legs
Varicose veins
Inflammation of a vein associated with thrombus formation
Thrombophlebitis
Usually occurs on tips of toes, metatarsal heads, and lateral malleoli; ulcers have pale ischemic base, well defined edges and no bleeding
Arterial ulcer
Usually occur on medial malleoli; ulcers have bleeding uneven edges
Venous ulcer
Rigid peripheral blood vessels; occurs more commonly in older adults
Arteriosclerosis
Deficient supply of oxygenated arterial blood to a tissue, caused by obstruction of a blood vessel
Ischemia
While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client’s legs. The nurse suspects that the client may be experiencing
a. venous stasis
b. varicose veins
c. thrombophlebitis
d. arterial insufficiency
d. arterial insufficiency
During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client’s ankles. The nurse suspects that the client may be experiencing
a. venous insufficiency
b. arterial occlusive disease
c. venous ulcers
d. ankle edema
a. venous insufficiency
The nurse is assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs “seem cold all the time and sometimes feel tingly” The nurse suspects that the client may be experiencing
a. varicose veins
b. intermittent claudication
c. edema
d. thrombophlebitis
b. intermittent claudication
The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by
a. eating a high-protein diet
b. resting frequently
c. drinking large quantities of milk
d. getting regular exercise
d. getting regular exercise
The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should
a. apply K-Y jelly to the client’s skin
b. place the client in a supine position with the head flat
c. place the tip of the probe in a 30-degree angle to the artery
d. apply gel used for ECG to the client’s skin
a. apply K-Y jelly to the client’s skin
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse
should assess the client for
a. lymphedema
b. Raynaud’s disease
c. poor peripheral pulses
d. bruits over the radial artery
a. lymphedema
After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client’s
a. femoral pulse
b. popliteal pulse
c. brachial pulse
d. tibial pulse
c. brachial pulse
The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. The nurse should instruct the client to
a. assume a supine position
b. rest his arm on the examination table
c. flex his elbow about 90 degrees
d. make a fist with his left hand
c. flex his elbow about 90 degrees
While inspecting the skin color of a male client’s legs, the nurse observes that the client’s legs are slightly cyanotic while he is sitting on the edge of the examination table. The nurse should refer the client to a physician for possible
a. arterial insufficiency
b. congestive heart failure
c. Raynaud’s disease
d. venous insufficiency
d. venous insufficiency
While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with
a. localized infection
b. systemic infection
c. arterial insufficiency
d. malignancy
d. malignancy
The abdominal contents are enclosed externally by the abdominal wall musculature – three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external
a. rectal abdominis
b. transverse abdominis
c. abdominal oblique
d. umbilical oblique
c. abdominal oblique
The sigmoid colon is located in this area of the abdomen: the
a. left upper quadrant
b. left lower quadrant
c. right upper quadrant
d. right lower quadrant
b. left lower quadrant
The pancreas of an adult client is located
a. below the diaphragm and extending below the right costal margin
b. posterior to the left midaxillary line and posterior to the stomach
c. high and deep under the diaphragm and can be palpated
d. deep in the upper abdomen and is not normally palpable
d. deep in the upper abdomen and is not normally palpable
The primary function of the gallbladder is to
a. store and excrete bile
b. aid in the digestion of protein
c. produce alkaline mucus
d. produce hormones
a. store and excrete bile
The colon originates in this abdominal area: the
a. right lower quadrant
b. right upper quadrant
c. left lower quadrant
d. left upper quadrant
a. right lower quadrant
Inspiratory arrest or causes client to hold breath
Murphy sign
Right upper quadrant (RUQ) pain or tenderness
Cholecystitis
Bacterium Helicobacter pylori
Peptic ulcer disease
Shifting dullness and fluid wave tests
Ascites
Can identify a mass or enlarged organ in an ascitic abdomen
Ballottement test
Absent or high-pitched bowel sounds
Paralytic ileus
Assessed by raising right leg from hip
Positive psoas sign
Release of pressure quickly after deep palpation
Rebound tenderness
Protrusion of the bowel through the abdominal wall
Hernia
Increased peristaltic waves
Intestinal obstruction
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client’s
a. right upper quadrant
b. right lower quadrant
c. left upper quadrant
d. left lower quadrant
a. right upper quadrant
To palpate for tenderness of an adult client’s appendix, the nurse should begin the abdominal assessment at the client’s
a. left upper quadrant
b. left lower quadrant
c. right upper quadrant
d. right lower quadrant
d. right lower quadrant
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment at the client at the
a. left lower quadrant
b. left upper quadrant
c. right upper quadrant
d. right lower quadrant
b. left upper quadrant
The nurse plans to assess an adult client’s kidneys for tenderness. The nurse should assess the area at the
a. right upper quadrant
b. left upper quadrant
c. external oblique angle
d. costovertebral angle
d. costovertebral angle
The client visits the clinic because she experienced bright hematemesis yesterday. the nurse should refer the client to a physician because this symptom is indicative of
a. stomach ulcers
b. pancreatic cancer
c. decreased gastric motility
d. abdominal tumors
a. stomach ulcers
The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. the nurse should further assess the client for
a. peptic ulcer
b. bulimia
c. appetite changes
d. pancreatic disorders
c. appetite changes
A client visits the clinic visits there clinic for a routine examination. the client tells the nurse that she has become constipated because she is taking iron tablets prescribed for anemia. the nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the client has understood the instructions when she says
a. “I can decrease the constipation if I eat foods high in fiber and drink water”
b. “I should cut down on the number of iron tablets I am taking each day”
c. “constipation should decrease if I take the iron tablets with milk”
d. “I should discontinue the iron tablets and eat foods that are high in iron”
a. “I can decrease the constipation if I eat foods high in fiber and drink water”
The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look at the colostomy bag or the area. A priority nursing diagnosis for this client is
a. denial related to temporary colostomy
b. fear related to potential outcome of surgery
c. disturbed body image related to temporary colostomy
d. altered role functioning related to frequent colostomy bag changes
c. disturbed body image related to temporary colostomy
The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first
a. palpate the incision site
b. auscultate for bowel sounds
c. percuss for tympany
d. inspect the abdominal area
d. inspect the abdominal area
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should
a. ask the client to empty his bladder
b. place the client in a side-laying position
c. ask the client to hold his breath for a few seconds
d. tell the client to raise his arms above his head
a. ask the client to empty his bladder
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible
a. liver disease
b. abdominal distention
c. Cushing syndrome
d. internal bleeding
d. internal bleeding
While assessing an adult client’s abdomen, the nurse observes that the client’s umbilicus is deviated tot he left. The nurse should refer the client to a physician for possible
a. gallbladder disease
b. cachexia
c. kidney trauma
d. masses
d. masses
While assessing an adult client’s abdomen, the nurse observes that the client’s umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible
a. umbilical hernia
b. ascites
c. intra-abdominal bleeding
d. pancreatitis
a. umbilical hernia
The nurse assess an adult male client’s abdomen and observes diminished abdominal respirations. The nurse determines that the client should be further assessed for
a. liver disease
b. umbilical hernia
c. intestinal obstruction
d. peritoneal irritation
d. peritoneal irritation
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible
a. aortic aneurysm
b. paralytic ileus
c. gastroenteritis
d. fluid and electrolyte imbalance
b. paralytic ileus
While assessing the abdominal sounds of an adult client, the nurse hears high pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible
a. intestinal obstruction
b. gastroenteritis
c. inflamed appendix
d. cirrhosis of the liver
a. intestinal obstruction
During a physical examination of an adult client, the nurse is preparing to auscultate the client’s abdomen. The nurse should
a. palpate the abdomen
b. listen in each quadrant for 15 seconds
c. use the diaphragm of the stethoscope
d. begin auscultation in the left upper quadrant
c. use the diaphragm of the stethoscope
To palpate the spleen of an adult client, the nurse should
a. ask the client to exhale deeply
b. place the right hand below the left costal margin
c. point the fingers of the left hand downward
d. ask the client to remain in a supine position
b. place the right hand below the left costal margin
The nurse is planning to assess a client’s abdomen for rebound tenderness. The nurse should
a. perform this abdominal assessment first
b. ask the client to assume a side-lying position
c. palpate lightly while slowly releasing pressure
d. palpate deeply while quickly releasing pressure
d. palpate deeply while quickly releasing pressure
To assess an adult client for possible appendicitis and a positive posts sign, the nurse should
a. rotate the client’s knee internally
b. palpate at the lower right quadrant
c. raise the client’s right leg from the hip
d. support the client’s right knee and ankle
c. raise the client’s right leg from the hip
