Question 1

During an assessment of a healthy adult,where would the nurse expect to palpate the apical impulse?

Accepted Answer

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 
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 D

Question 2

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

Accepted Answer

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. 
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. C

Question 3

When listening to heart sounds,the nurse knows that which of the following statements concerning S1 is true?

Accepted Answer

A) S1 is louder than S2 at the base. 
B) S1 indicates the beginning of diastole. 
C) S1 coincides with the carotid artery pulse. 
D) S1 is caused by closure of the semilunar valves. 
A) S1 is louder than S2 at the base. 
B) S1 indicates the beginning of diastole. 
C) S1 coincides with the carotid artery pulse. 
D) S1 is caused by closure of the semilunar valves. C

Question 4

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

Accepted Answer

A) While listening with the bell of the stethoscope,have the patient take a deep breath and hold it. 
B) While auscultating one side with the bell of the stethoscope,palpate the carotid artery on the other side to check pulsations. 
C) Lightly apply the bell of the stethoscope over the carotid artery;have the patient take a breath,exhale,and hold it briefly while the nurse listens. 
D) Firmly place the bell of the stethoscope over the carotid artery,have the patient take a breath,exhale,and hold it briefly while the nurse listens. 
A) While listening with the bell of the stethoscope,have the patient take a deep breath and hold it. 
B) While auscultating one side with the bell of the stethoscope,palpate the carotid artery on the other side to check pulsations. 
C) Lightly apply the bell of the stethoscope over the carotid artery;have the patient take a breath,exhale,and hold it briefly while the nurse listens. 
D) Firmly place the bell of the stethoscope over the carotid artery,have the patient take a breath,exhale,and hold it briefly while the nurse listens.

Question 5

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction.Heart sounds are normal when she is supine,but with the patient sitting and leaning forward,the nurse hears a high-pitched,scratchy sound at the apex with the diaphragm.It disappears on inspiration.The nurse suspects:

Accepted Answer

A) increased cardiac output. 
B) another myocardial infarction. 
C) inflammation of the precordium. 
D) ventricular hypertrophy resulting from muscle damage. 
A) increased cardiac output. 
B) another myocardial infarction. 
C) inflammation of the precordium. 
D) ventricular hypertrophy resulting from muscle damage.

Question 6

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

Accepted Answer

A) systemic hypertension. 
B) pulmonic hypertension. 
C) pressure overload,as in aortic stenosis. 
D) volume overload,as in mitral regurgitation. 
A) systemic hypertension. 
B) pulmonic hypertension. 
C) pressure overload,as in aortic stenosis. 
D) volume overload,as in mitral regurgitation.

Question 7

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

Accepted Answer

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) palpate both arteries simultaneously to compare amplitude. 
D) instruct patient to take slow deep breaths during auscultation. 
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) palpate both arteries simultaneously to compare amplitude. 
D) instruct patient to take slow deep breaths during auscultation.

Question 8

A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's 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:

Accepted Answer

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?" 
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?"

Question 9

The nurse knows that normal splitting of the second heart sound is associated with:

Accepted Answer

A) expiration. 
B) inspiration. 
C) exercise state. 
D) low resting heart rate. 
A) expiration. 
B) inspiration. 
C) exercise state. 
D) low resting heart rate.

Question 10

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

Accepted Answer

A) Have patient turn to the left side and listen with the bell. 
B) Ask patient to hold his breath while the nurse listens again. 
C) No further assessment is needed because the nurse knows it is an S3. 
D) Watch patient's respirations while listening for effect on the sound. 
A) Have patient turn to the left side and listen with the bell. 
B) Ask patient to hold his breath while the nurse listens again. 
C) No further assessment is needed because the nurse knows it is an S3. 
D) Watch patient's respirations while listening for effect on the sound.

Question 11

During the precordial assessment on an 8-month pregnant patient,the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line.This would indicate:

Accepted Answer

A) right ventricular hypertrophy. 
B) increased volume and size of the heart as a result of pregnancy. 
C) displacement of the heart from elevation of the diaphragm. 
D) increased blood flow through the internal mammary artery. 
A) right ventricular hypertrophy. 
B) increased volume and size of the heart as a result of pregnancy. 
C) displacement of the heart from elevation of the diaphragm. 
D) increased blood flow through the internal mammary artery.

Question 12

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse.The apical pulse was 118 beats per minute;the radial pulse was 105 beats per minute.Calculate the pulse deficit.
Pulse deficit equals: _________

Accepted Answer

The pulse

Question 13

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg.In reviewing her previous exam,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?

Accepted Answer

A) This is the result of peripheral vasodilatation and is an expected change. 
B) Because of increased cardiac output,the blood pressure should be higher this time. 
C) This is not an expected finding because it would mean a decreased cardiac output. 
D) This would mean a decrease in circulating blood volume,which is dangerous for the fetus. 
A) This is the result of peripheral vasodilatation and is an expected change. 
B) Because of increased cardiac output,the blood pressure should be higher this time. 
C) This is not an expected finding because it would mean a decreased cardiac output. 
D) This would mean a decrease in circulating blood volume,which is dangerous for the fetus.

Question 14

The vital signs of a 70-year-old patient with a history of hypertension are BP 180/100 and HR 90.The nurse hears an extra heart sound at the apex immediately before S1.The sound is heard only with the bell while patient is in left lateral position.With these findings and the patient's history,the nurse knows that this extra heart sound is most likely:

Accepted Answer

A) split S1. 
B) atrial gallop. 
C) diastolic murmur. 
D) summation sound. 
A) split S1. 
B) atrial gallop. 
C) diastolic murmur. 
D) summation sound.

Question 15

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

Accepted Answer

A) atrioventricular (AV)node. 
B) sinoatrial (S
A) node. 
C) bundle of His. 
D) bundle branches. 
A) atrioventricular (AV)node. 
B) sinoatrial (S
A) node. 
C) bundle of His. 
D) bundle branches.

Question 16

The electrical stimulus of the cardiac cycle follows which sequence?

Accepted Answer

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 
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

Question 17

In percussing the left cardiac border,the nurse would expect to hear dullness at the:

Accepted Answer

A) third left intercostal space midclavicular line and fifth left intercostal space left sternal border. 
B) fourth left intercostal space medial to midclavicular line and second left intercostal space midclavicular line. 
C) fifth left intercostal space midclavicular line and second left intercostal space sternal border. 
D) fifth left intercostal space sternal border and second right intercostal space midclavicular line. 
A) third left intercostal space midclavicular line and fifth left intercostal space left sternal border. 
B) fourth left intercostal space medial to midclavicular line and second left intercostal space midclavicular line. 
C) fifth left intercostal space midclavicular line and second left intercostal space sternal border. 
D) fifth left intercostal space sternal border and second right intercostal space midclavicular line.

Question 18

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:

Accepted Answer

A) decreased fluid volume. 
B) increased cardiac output. 
C) narrowing of jugular veins. 
D) increased pressure in the right side of his heart. 
A) decreased fluid volume. 
B) increased cardiac output. 
C) narrowing of jugular veins. 
D) increased pressure in the right side of his heart.

Question 19

The sac that surrounds and protects the heart is called the:

Accepted Answer

A) pericardium. 
B) myocardium. 
C) endocardium. 
D) pleural space. 
A) pericardium. 
B) myocardium. 
C) endocardium. 
D) pleural space.

Question 20

Which of the following would the nurse expect to find during a cardiac assessment on a 4-year-old child?

Accepted Answer

A) S3 when sitting up 
B) Persistent tachycardia above 150 
C) Murmur at second left intercostal space when supine 
D) Palpable apical impulse in fifth left intercostal space lateral to midclavicular line 
A) S3 when sitting up 
B) Persistent tachycardia above 150 
C) Murmur at second left intercostal space when supine 
D) Palpable apical impulse in fifth left intercostal space lateral to midclavicular line

Exam 19: Heart and Neck Vessels

During an assessment of a healthy adult,where would the nurse expect to palpate the apical impulse?

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

When listening to heart sounds,the nurse knows that which of the following statements concerning S1 is true?

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

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

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

A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's 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:

The nurse knows that normal splitting of the second heart sound is associated with:

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

During the precordial assessment on an 8-month pregnant patient,the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line.This would indicate:

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse.The apical pulse was 118 beats per minute;the radial pulse was 105 beats per minute.Calculate the pulse deficit. Pulse deficit equals: _________

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg.In reviewing her previous exam,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?

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

The electrical stimulus of the cardiac cycle follows which sequence?

In percussing the left cardiac border,the nurse would expect to hear dullness at the:

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:

The sac that surrounds and protects the heart is called the:

Which of the following would the nurse expect to find during a cardiac assessment on a 4-year-old child?

Critical Thinking in Health Assessment

Developmental Tasks and Health Promotion Across the Life Cycle

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status Assessment

Domestic Violence Assessment

Assessment Techniques and the Clinical Setting

General Survey, measurement, vital Signs

Pain Assessment: the Fifth Vital Sign

Nutritional Assessment

Skin, hair, and Nails

Head, face, and Neck, including Regional Lymphatics

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus,rectum,and Prostate

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Reassessment of the Hospitalized Adult

The Pregnant Female

Functional Assessment of the Older Adult

Filters

When listening to heart sounds,the nurse knows that which of the following statements concerning S₁ is true?

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