Question 1

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

Accepted Answer

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. C

Question 2

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

Accepted Answer

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 C

Question 3

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)  Elevated pressure related to heart failure D

Question 4

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?

Accepted Answer

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.

Question 5

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse.The apical pulse is 118 beats per minute, and the radial pulse is 105 beats per minute.What is the pulse deficit?

Accepted Answer

The answer of The nurse is assessing a patient's pulses...

Question 6

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:

Accepted Answer

A)  Heart failure
B)  Aortic stenosis
C)  Pulmonary edema
D)  Mitral regurgitation

Question 7

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

Accepted Answer

A)  Vena cava š right atrium š right ventricle š lungs š pulmonary artery š left atrium š left ventricle
B)  Right atrium š right ventricle š pulmonary artery š lungs š pulmonary vein š left atrium š left ventricle
C)  Aorta š right atrium š right ventricle š lungs š pulmonary vein š left atrium š left ventricle š vena cava
D)  Right atrium š right ventricle š pulmonary vein š lungs š pulmonary artery š left atrium š left ventricle

Question 8

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

Accepted Answer

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

Question 9

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:

Accepted Answer

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

Question 10

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:

Accepted Answer

A)  A normal heart
B)  Systolic murmur
C)  Enlargement of the left ventricle
D)  Enlargement of the right ventricle

Question 11

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

Accepted Answer

A)  Expiration
B)  Inspiration
C)  Exercise state
D)  Low resting heart rate

Question 12

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:

Accepted Answer

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?"

Question 13

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

Accepted Answer

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

Question 14

During the precordial assessment on a patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the MCL.This finding 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

Question 15

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?

Accepted Answer

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.

Question 16

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?

Accepted Answer

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.

Question 17

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

Accepted Answer

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

Question 18

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:

Accepted Answer

A)  Systemic hypertension
B)  Pulmonic hypertension
C)  Pressure overload, as in aortic stenosis
D)  Volume overload, as in heart failure

Question 19

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

Accepted Answer

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.

Question 20

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:

Accepted Answer

A)  Valvular disorder
B)  Blood flow turbulence
C)  Fluid volume overload
D)  Ventricular hypertrophy

Exam 20: Heart and Neck Vessels