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Patient Focused Assessment The Art and Science 1st Edition Mansen Test Bank

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Patient Focused Assessment The Art and Science 1st Edition Mansen Test Bank

ISBN-13: 978-0132239387

ISBN-10: 0132239388

 

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Patient Focused Assessment The Art and Science 1st Edition Mansen Test Bank

ISBN-13: 978-0132239387

ISBN-10: 0132239388

 

 

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Patient-Focused Assessment (Mansen)

Chapter 24   Heart

 

1) It is suspected that a patient has damage to the chordae tendineae. The nurse would assess for findings associated with which part of the heart?

  1. Myocardium
  2. Valves
  3. Coronary arteries
  4. Pericardium

Answer:  2

Explanation:

  1. The myocardium is the muscle of the heart. This is not the best answer to this question.
  2. The chordae tendineae attach to the papillary muscles, which help to control valve motion.
  3. Chordae tendineae are not part of the coronary arteries.
  4. Chordae tendineae are not part of the pericardium.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Structure and Function

Learning Outcome:  1 Identify the significant anatomic features and structures of the heart.

 

2) The nurse identifies that a patient’s PR interval has lengthened. How would the nurse interpret this finding?

  1. There is retrograde conduction from the AV node to the SA node.
  2. The ventricles have depolarized early.
  3. Something has delayed conduction of the SA node through the AV node.
  4. A pathologic early repolarization of the ventricles has occurred.

Answer:  3

Explanation:

  1. Retrograde conduction results in an inverted P wave.
  2. Ventricular depolarization is represented the QRS complex.
  3. The PR interval represents the length of time it takes for an impulse from the SA node to travel to the AV node. Prolongation of the PR interval means this conduction has slowed.
  4. Repolarization of the ventricles is represented the T wave.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  The Electrocardiogram

Learning Outcome:  2 Describe the mechanical an electrical events of the cardiac muscle that occur within the cardiac cycle.

 

3) A patient presents to the emergency department with report of chest pain. The nurse would be more concerned that this pain is of cardiac origin if which descriptors of the pain are used?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. “My chest wall is tender to touch.”
  2. “It started about an hour after I ate some lasagna.”
  3. “I feel a heavy pressure on my chest.”
  4. “The pain is so sharp and stabbing that it made me sweat.”
  5. “The pain is easing since the paramedic gave me some nitroglycerin under my tongue.”

Answer:  3, 4, 5

Explanation:

  1. Tenderness to touch is more likely a musculoskeletal issue.
  2. Pain after ingesting spicy food may be of gastrointestinal origin.
  3. The feeling of pressure on the chest is often related to cardiac dysfunction.
  4. Sharp, stabbing pain and associated diaphoresis increase concern that the pain is of cardiac origin.
  5. Pain that is relieved with nitroglycerin is likely cardiac in origin.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Differential Diagnosis: Chest Pain

Learning Outcome:  3 Describe a focused cardiac history based on the essential parameters associated with manifestations of cardiovascular conditions.

 

 

4) A patient says, “I am exhausted. I can only sleep an hour or two before I get so short of breath that I have to sit up.” The nurse should ask additional assessment questions about which most likely condition?

  1. Orthopnea
  2. Hypertension
  3. Paroxysmal nocturnal dyspnea
  4. Sleep apnea

Answer:  3

Explanation:

  1. Orthopnea generally refers to being unable to breathe when lying down, which occurs almost immediately. This is not the best answer to this question.
  2. The nurse would ask questions about and assess for hypertension, but the situation described this patient does not reflect hypertension.
  3. Paroxysmal nocturnal dyspnea is characterized as an episode of shortness of breath or dyspnea that awakens an individual from sleep, often occurring about 1-2 hours after falling asleep and relieved assuming an upright position.
  4. Sleep apnea does not typically totally awaken the patient. In sleep apnea, the patient snores or gasps and returns to sleep, only to snore or gasp again when the airway becomes obstructed.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Paroxysmal Nocturnal Dyspnea

Learning Outcome:  3 Describe a focused cardiac history based on the essential parameters associated with manifestations of cardiovascular conditions.

5) The mother of a newborn says, “My bais not feeding nearly as well as when we first got home.” The nurse would be concerned about a cardiac etiology if the infant tires when feeding and takes longer than ________ minutes to finish a bottle.

Answer:  30

Explanation:  Feeding difficulties are often the initial finding of cardiovascular disorders that are noticed and reported parents. A newborn that takes longer than 30 minutes to finish a bottle should be assessed for cardiovascular problems.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Developmental Applications: Infants and Children

Learning Outcome:  3 Describe a focused cardiac history based on the essential parameters associated with manifestations of cardiovascular conditions.

 

 

6) The nurse should provide which instruction to the patient when performing the Schamroth’s test?

  1. Take a deep breath and hold it.
  2. Place your first fingers together back to back.
  3. Roll over onto your left side.
  4. Raise your arms above your head.

Answer:  2

Explanation:

  1. Schamroth’s test is not associated with ability to take a deep breath.
  2. The Schamroth’s test is for clubbing of the fingers. Normal finding when fingers are placed back to back is the presence of a small, diamond-shaped area where fingers do not touch at the base of the nail. This area disappears when clubbing is present.
  3. The patient does not need to be in this position for the Schamroth’s test.
  4. The Schamroth’s test does not require the patient to raise the arms above the head.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Inspection Level III

Learning Outcome:  4 Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

7) A patient’s QRS segment is four small boxes long. The nurse would document that this segment is ________ seconds in length.

Answer:  0.16

Explanation:  Each small box is 0.4 seconds in length, so four boxes is equal to 0.16 seconds.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  ECG analysis

Learning Outcome:  4 Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

8) Which nursing action would result in an inaccurate measurement of capillary refill time?

  1. Exert pressure directly on the nail.
  2. Hold the patient’s hand below heart level.
  3. Hold pressure until the area being assessed blanches.
  4. Exert pressure on the finger pad.

Answer:  2

Explanation:

  1. One method of measuring capillary refill time relies on direct pressure exerted on the nail.
  2. The patient’s hand should be positioned above heart level.
  3. The nurse should hold pressure until the area being assessed blanches as the time is counted from release of pressure until the area has returned to color.
  4. The nurse may elect to use the finger pad for this test.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Capillary Refill Time

Learning Outcome:  4 Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

9) The nurse has auscultated a heart sound that may be an S3 or a split S2. Which finding would the nurse assess as indicating this sound is most likely a split S2?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. It is heard best as the base of the heart.
  2. The pitch of the sound does not change.
  3. There is no change in the sound with ventilation.
  4. The sound disappears with coughing.
  5. The sound is heard best at the mitral area.

Answer:  1, 2

Explanation:

  1. A split S2 is heard best at the pulmonic site, which is at the base of the heart.
  2. Both components of an S2 are at the same pitch.
  3. S2 is heard best at the end of inspiration, while an S3 is not affected ventilations.
  4. A sound that disappears when the patient coughs is most likely respiratory in nature. This finding will not help differentiate an S3 from a split S2.
  5. An S3 is heard best at the mitral area.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Table 24-9 Criteria for Differentiating S3 from split S2

Learning Outcome:  5 Compare and contrast valvular and nonvalvular heart sounds and murmurs based on their unique characteristics.

 

10) The nurse auscultates a systolic murmur that is moderately loud and relatively easy to hear. A thrill can be palpated over the murmur. Which grade would the nurse assign to this murmur?

  1. Grade I
  2. Grade II
  3. Grade III
  4. Grade IV

Answer:  4

Explanation:

  1. Grade I murmurs are barely audible.
  2. Grade II murmurs are faint.
  3. Grade III murmurs are moderately loud, but do not have a thrill.
  4. Grade IV murmurs are easy to hear and have an associated thrill.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Auscultation Levels III/IV

Learning Outcome:  5 Compare and contrast valvular and nonvalvular heart sounds and murmurs based on their unique characteristics.

 

11) A patient is admitted with rheumatic heart disease. The nurse would review the patient’s medical history for which finding?

  1. Patient started smoking as a teenager.
  2. Patient just recovered from strep throat.
  3. Patient just had eye surgery.
  4. Patient complains of recent onset of knee pain.

Answer:  2

Explanation:

  1. Smoking is not associated with rheumatic heart disease.
  2. A strep infection often precedes the development of rheumatic heart disease.
  3. Eye surgery is not a risk factor for rheumatic heart disease.
  4. Rheumatic heart disease is not the same as rheumatoid arthritis.

Cognitive Level:  Applying

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  Rheumatic Heart Disease

Learning Outcome:  6 Identify the relationship between lifestyle behaviors and cardiovascular diseases and appropriate prevention behaviors.

 

 

12) A patient who reported chest pain has elevation of C-reactive protein (CRP). What does this finding indicate to the nurse?

  1. The patient has atherosclerosis.
  2. The patient will also have elevation of homocysteine levels.
  3. Inflammation is present somewhere in the patient’s body.
  4. Patient’s myocardium has been damaged.

Answer:  3

Explanation:

  1. The nurse cannot determine that atherosclerosis is present from this finding.
  2. The patient may or may not have both of these elevations.
  3. Elevation of CRP indicates presence of inflammation.
  4. CRP is not specific to myocardial tissue.

Cognitive Level:  Analyzing

Client Need:  Health Promotion and Maintenance

Nursing/Int Conc:  Nursing Process: Assessment

Reference:  C-Reactive protein/Homocysteine and Cardiac Disease

Learning Outcome:  6 Identify the relationship between lifestyle behaviors and cardiovascular diseases and appropriate prevention behaviors.

13) A patient’s primary care provider has determined that the patient’s left ventricle is functioning adequately. Identify the left ventricle drawing an arrow to it.

 

 

Standard Text: Select the correct area on the image.

 

 

 

 

 

 

 

 

 

Correct Answer:

 

Rationale: The ventricles are the two lower chambers of the heart.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24:1: Identify the significant anatomic features and structures of the heart.

 

 

14) The patient’s stroke volume is 72 ml/beat. The patient’s heart rate is 82 beats per minute.

What is the patient’s cardiac output? ____________

Standard Text:

Correct Answer: 5904 mL per minute.

Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied heart rate for 1 minute.

72 ml/ beat x 82 beats/ minute= 5904 mL/ minute

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24:1: Identify the significant anatomic features and structures of the heart.

 

 

15) The provider who works on a cardiac unit is teaching the student provider about heart sounds. The student provider asks how the S1 heart sound is produced. Which of the following is the provider’s best response?

  1. “It results from the closure of the semilunar valves.”
  2. “It is heard when the aortic valve closes just slightly faster than the pulmonic valve.”
  3. “It results from the closure of the atrioventricular valves.”
  4. “It is caused atrial contraction and ejection of blood into the ventricles in late diastole.”

Correct Answer: 3

Rationale 1: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves.

Rationale 2: A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close.

Rationale 3: The S1 heart sound results from closure of the atrioventricular (AV) valves.

Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused atrial contraction and ejection of blood into the ventricles in late diastole.

Global Rationale: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close. The S1 heart sound results from closure of the atrioventricular (AV) valves. The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused atrial contraction and ejection of blood into the ventricles in late diastole.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Describe the mechanical and electrical events of the cardiac muscle that occur within the cardiac cycle.

 

16) During the focused interview, the patient makes the following statements. Which statement indicates that the patient has an increased risk of developing cardiovascular disease?

  1. “I was diagnosed with hypothyroidism about 5 years ago.”
  2. “My doctor always tells me when I come in that my blood pressure is low.”
  3. “I know my grandmother had diabetes, but every time it has been checked my glucose level has been normal.”
  4. “My total cholesterol has always been around 170.”

Correct Answer: 1

Rationale 1: Hypothyroidism may increase the patient’s risk for developing cardiovascular disease.

Rationale 2: Hypertension, not hypotension, is associated with the development of cardiovascular disease.

Rationale 3: Normal serum glucose levels indicate that the patient does not currently have diabetes, so this patient’s risk is not necessarily increased.

Rationale 4: The patient’s total cholesterol level is within normal limits. High cholesterol levels would increase the patient’s risk for cardiovascular disease.

Global Rationale: Hypothyroidism may increase the patient’s risk for developing cardiovascular disease. Hypertension, not hypotension, is associated with the development of cardiovascular disease. Normal serum glucose levels indicate that the patient does not currently have diabetes and so this patient’s risk is not necessarily increased. The patient’s total cholesterol level is within normal limits. High cholesterol levels would increase the patient’s risk for developing cardiovascular disease.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.3: Describe a focused cardiac history based on the essential parameters associated with manifestations of cardiovascular conditions.

 

 

17) The provider is preparing to assess a patient’s cardiovascular system. Which positions will the provider need to place the patient in during the assessment?

Standard Text: Select all that apply.

  1. Dorsal recumbent
  2. Leaning forward
  3. Right lateral position
  4. Left lateral position
  5. Sitting upright

Correct Answer: 1,2,4,5

Rationale 1: The patient will be asked to remain in a supine or dorsal recumbent position for part of the examination. The provider may be able to auscultate murmurs better while the patient is in this position.

Rationale 2: The patient will be asked to lean forward during auscultation of the heart. The provider should listen to the patient’s heart while the patient is leaning forward.

Rationale 3: This is not a common position to place the patient in for this type of examination.

Rationale 4: The patient will be asked to lie on the left side during part of this examination. In obese patients, heart sounds are best heard at the apical area with the patient in the left lateral position.

Rationale 5: The provider will most likely begin this examination with the patient in this position. This is the position the provider should ask the patient to assume when beginning chest auscultation.

Global Rationale: The provider will most likely begin this examination with the patient sitting upright, especially when beginning chest auscultation. The patient will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The provider may be able to auscultate murmurs better with the patient in this position. The patient will be asked to lean forward during auscultation of the heart. The patient will be asked to lie on the left side during part of this examination. In obese patients, heart sounds are best heard at the apical area with the patient in the left lateral position. Right lateral position is not a common position to place the patient in during this type of examination.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

 

18) The provider is preparing to perform a cardiac assessment on a patient. Rank the following elements of the assessment in order of occurrence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Auscultation of the patient’s heart, apical pulse, and carotid arteries

Choice 2. Inspection of the patient’s head and neck, chest, abdomen, and extremities

Choice 3. Percussion of the patient’s chest

Choice 4. Palpation of the precordium and pulses

Correct Answer: 2,4,3,1

Rationale 1: The fourth of these steps is auscultation. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated.

Rationale 2: The first of these steps is inspection of the patient’s head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected.

Rationale 3: The third of these steps is percussion, which is conducted to determine the cardiac borders.

Rationale 4: The second of these steps is palpation. Palpation includes the precordium and carotid pulses.

Global Rationale: Physical assessment of the cardiovascular system follows an organized pattern. It begins with inspection of the patient’s head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected. Palpation includes the precordium and carotid pulses. Percussion of the chest is conducted to determine the cardiac borders. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

 

19) The provider is assessing a full-term African American newborn who is 18 hours old. The provider would document which of the following as a normal finding?

  1. Lethargy
  2. Heart rate 120–125
  3. Bulging of the precordium
  4. Pale conjunctiva

Correct Answer: 2

Rationale 1: The infant should be easily aroused and alert.

Rationale 2: The heart rate of a newborn initially may be as high as 100–180 beats per minute but should decrease over the next few hours to 120–140 beats per minute.

Rationale 3: Precordial bulging should always be evaluated and is never considered a normal finding.

Rationale 4: The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby’s race.

Global Rationale: The infant should be easily aroused and alert. The heart rate of a newborn initially may be as high as 100–180 beats per minute but should decrease over the next few hours to 120–140 beats per minute. Precordial bulging should always be evaluated and is never considered a normal finding. The skin should demonstrate perfusion with pink quality in the nail beds, mucous membranes, and conjunctiva regardless of the baby’s race.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

 

20) The provider notes a pregnant patient’s blood pressure has dropped from 122/70 taken in her second month of pregnancy to 118/64 in her fifth month. Which action the provider is most appropriate?

  1. Assess for signs of hemorrhage.
  2. Document the blood pressure as a normal finding.
  3. Consult the obstetrician.
  4. Tell the patient to come in the next day so the obstetrician can recheck her blood pressure.

Correct Answer: 2

Rationale 1: This small drop in blood pressure is expected, and the provider does not need to assess the patient for signs of hemorrhage.

Rationale 2: During the second trimester, the woman’s blood pressure drops to its lowest point. This is secondary to peripheral vasodilatation. It gradually rises again during the third trimester.

Rationale 3: The obstetrician does not need to be consulted because this is a normal finding.

Rationale 4: The patient does not need to return to have her blood pressure checked on the following day.

Global Rationale: This small drop in blood pressure is expected, and the provider does not need to assess the patient for signs of hemorrhage. During the second trimester, the woman’s blood pressure drops to its lowest point. This is secondary to the peripheral vasodilatation. It gradually rises again during the third trimester. The obstetrician does not need to be consulted because this is a normal finding. The patient does not need to return to have her blood pressure checked on the following day.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

 

21) A 39-year-old patient has been admitted to the hospital with complaints of increasing fatigue. The history is remarkable for rheumatic fever in childhood. The provider hears a diastolic murmur at the apex when the patient is in the left lateral position. The murmur is described as a rumble without radiation. This description is most consistent with:

  1. tricuspid regurgitation.
  2. mitral regurgitation.
  3. mitral stenosis.
  4. pulmonic stenosis.

Correct Answer: 3

Rationale 1: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, high-pitched, and may radiate.

Rationale 2: Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla.

Rationale 3: The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the patient is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused rheumatic fever or a cardiac infection.

Rationale 4: The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck.

Global Rationale: The murmur associated with tricuspid regurgitation is often described as systolic, blowing, high-pitched, and may radiate. Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla. The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the patient is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused rheumatic fever or a cardiac infection. The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.5: Compare and contrast valvular and nonvalvular heart sounds and murmurs based on their unique characteristics.

 

 

22) During a routine physical examination, a patient reports a close relative recently died from complications related to heart disease. The patient requests information about his own risk for the development of heart disease. The provider reviews the patient’s risk factors. Which risk factor associated with heart disease is modifiable?

  1. Father died from coronary artery disease.
  2. Patient is 5′4″ and weighs 282 pounds.
  3. Patient is 73 years old.
  4. Patient is a female.

Correct Answer: 2

Rationale 1: Modifiable risk factors are those over which the patient has some degree of control. Family history is a nonmodifiable risk factor.

Rationale 2: Modifiable risk factors are those over which the patient has some degree of control. Obesity is a modifiable risk factor.

Rationale 3: Modifiable risk factors are those over which the patient has some degree of control. Age is a nonmodifiable risk factor.

Rationale 4: Modifiable risk factors are those over which the patient has some degree of control. Gender is a nonmodifiable risk factor.

Global Rationale: Modifiable risk factors, such as obesity, are those over which the patient has some degree of control. Family history, age, and gender are nonmodifiable risk factors.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.6: Identify the relationship between lifestyle behaviors and cardiovascular diseases and appropriate prevention behaviors.

 

23) Based on the equation CO = HR × SV, what compensatory mechanism occurs first in terms of a patient’s ability to maintain cardiac output?

  1. Decrease in resistance
  2. Increase in heart rate
  3. Increase in contractility
  4. Decrease in contractility

Answer: 2

NCLEX domain:  Physiological Adaptation

Cognitive Level:  Application

Nursing Process:  Assessment

Integrated Process: Teaching and Learning

Question Type:  Multiple Choice

Rationale: In order to maintain cardiac output (CO), the initial compensatory mechanism is for a patient to increase his/her heart rate.  Increased heart rate will only provide a temporary response, as it will eventually lead to decreased ventricular filling time. More effective long-term measures to maintain cardiac output would be to decrease preload and resistance and increase contractility, which represents the components of stroke volume (SV).

 

24) The provider notes an apical heart rate between 40 and 60 beats per minute. The patient denies any athletic history and other than the decreased heart rate appears to be medically stable. The provider suspects that:

  1. Medication may be responsible for the appearance of bradycardia
  2. The patient needs to undergo a thallium stress test
  3. Ordering an EKG may provide etiologic evidence for the bradycardia
  4. The patient maybe clinically dehydrated

Answer: 3

NCLEX domain:  Physiological Adaptation

Cognitive Level:  Analysis

Nursing Process:  Assessment

Integrated Process: Teaching and Learning

Question Type:  Multiple Choice

Rationale:  A pattern of bradycardia without corresponding clinical symptoms requires further investigation and ordering an EKG would provide evidence.  The provider may suspect that the SA node has failed as the primary pacemaker of the heart and that either the AV node or the ventricles have taken over to maintain the patient’s heart rate.  These are known as intrinsic rates. While medications may account for a decrease in heart rate, there is no indication that the patient is on medication therapy the stated provided information.  Ordering a thallium stress test would not be an appropriate intervention, as the heart rate is too low.  If clinical dehydration were severe, this may cause an effect on cardiac rate and rhythm, but again, the information provided is that the patient appears to be medically stable.

 

 

25) Which factors, if incorporated into lifestyle changes, may help to decrease risk of cardiac disease?  Select all that apply:

  1. Avoiding second hand smoke
  2. Taking 325 mg of aspirin on a daily basis
  3. Including walking as part of a daily exercise regimen
  4. Reducing processed foods in the diet
  5. Decreasing consumption of alcohol
  6. Maintaining an appropriate BMI based on proportional body size

Answer: 1, 3, 4, 5, 6

NCLEX domain:  Health Promotion and Maintenance

Cognitive Level:  Application

Nursing Process: Planning

Integrated Processes:  Teaching and Learning

Question Type:  Multiple Select

Rationale:  Decreasing one’s risk of cardiac disease is initially met using methods of primary prevention.  These include but are not limited to: avoiding second hand smoke, taking low dose aspirin (81 mg) on a daily basis, increasing physical activity (aerobic exercise or any other physical type of activity), reducing sodium and fat in the diet, limiting consumption of alcohol, and maintaining an appropriate BMI ratio based on proportional body size.  A dose of 325 mg of aspirin on a daily basis is not considered to be a low dose therapy.

 

26) The patient presents with complaints of new onset chest pain.  The pain location of the pain is substernal and the patient reports slight difficulty in swallowing.  Which questions should the provider ask in order to confirm a differential diagnosis?   Select all that apply:

  1. “When did this chest pain start?”
  2. “Is the pain constant or intermittent?”
  3. “When was the last time you had blood work?”
  4. “Does anything help to relieve the pain?”
  5. “When was the last time you had something to eat?”
  6. “Have you taken anything to relieve the pain?”

Answer: 1, 2, 4, 5, 6

NCLEX domain:  Reduction of Risk Potential

Cognitive Level:  Application

Nursing Process: Assessment

Integrated Processes:  Communication/Documentation

Question Type:  Multiple Select

Rationale:  A patient presenting with chest pain requires a further investigation to determine the etiology so as to provide appropriate clinical intervention.  Asking the patient about the onset, duration, and intensity, incidence of alleviating factors, whether or not the patient has eaten, and if the patient has taken anything to relieve the symptoms would help to confirm a differential diagnosis.  With regard to the last time the patient had blood work, this would not be considered to be an important diagnostic factor, as the incident is occurring now and blood work could easily be obtained to indicate the patient’s current clinical status.

 

27) The provider is using palpation technique during a physical examination of a patient.  Which information could be obtained using this method with regard to the cardiac system?

  1. Outline of the heart
  2. Determination of S1 heart sound
  3. Assessment of radial pulses
  4. Blood pressure

Answer:  3

NCLEX domain:  Health Promotion and Maintenance

Cognitive Level:  Application

Nursing Process:  Assessment

Integrated Processes:  Communication/Documentation

Question Type:  Multiple Choice

Rationale:  Palpation techniques for physical examination of the heart include assessment of peripheral pulses, presence of heaves, lifts or thrills, location of point of maximal impulse (PMI) and determination of aortic pulsation.  The outline of the heart (estimation of heart size) is performed using percussion.  Auscultation is used to determine blood pressure and heart sounds.

 

28) The provider has performed a Schamroth test on a patient.  Which finding would indicate an abnormal result?

  1. Capillary refill of 4 seconds
  2. 180-degree angle between the nail bed and cuticle
  3. Appearance of diamond shaped window between nail beds
  4. Presence of extra heart sound

Answer:  2

NCLEX domain:  Health and Promotion Maintenance

Cognitive Level:  Application

Nursing Process:  Assessment

Integrated Process:  Communication/Documentation

Question Type:  Multiple Choice

Rationale:  The Schamroth test is done to determine if clubbing is present in an individual. The presence of clubbing is considered to be an abnormal finding which can be associated with a variety of cardiac and non-cardiac etiologies such as endocarditis, cyanotic congenital heart disease, pulmonary disorders, gastrointestinal disorders, and malignancies.  The technique used to determine the presence of clubbing is to place the distal phalanges of corresponding fingers in direct opposition and note a small diamond shaped window between nail beds.  If this finding is found, then there is no clubbing.  If however, the window is not formed, this is due to an increased convexity of the nail bed and the angle between the nail bed and with an increased cuticle. A normal finding would be to see an angle of less than 165 degrees.  Capillary refill indicates tissue perfusion and even though this finding represents decreased perfusion, it is not representative of a Schamroth test. Similarly, the detection of an extra heart sounds maybe abnormal in certain conditions but again is not related to a Schamroth test.

 

 

29) The provider is going to measure JVP in a patient to determine a baseline measurement.  Arrange in order the steps that the provider would take in order to make this determination.

  1. Apply lighting using a penlight.
  2. Place the patient is a supine position.
  3. Position the patient at a 45-degree angle.
  4. Look across the patient’s chest.
  5. Stand on the right side of the patient’s bed.
  6. Locate the angle of Louis on the patient.

Answer:  2, 3, 6, 5, 4, 1

NCLEX domain:  Health Promotion Maintenance

Cognitive Level:  Application

Nursing Process: Planning

Integrated Process:  Teaching and Learning

Question Type:  Ordered Sequence

Rationale:  The patient must be placed in the correct position, supine at a 45-degree angle, so as to allow for visualization of the external jugular veins and location of the angle of Louis.  The provider should assume a position to view the patient’s neck from the right side and look across the patient’s chest.  Tangential lighting on the neck with a penlight may be beneficial.

 

 

 

 

 

 

 

30) The provider is reviewing laboratory data for a male patient. Which finding would cause the most concern relative to the cardiac system?

  1. Troponin 1 value of 0.2 ng/mL
  2. AST 25 U/L
  3. CK –I value of 5%
  4. LDH 1 value of 80%

Answer: 4

NCLEX domain:  Reduction of Risk Potential

Cognitive Level:  Analysis

Nursing Process:  Assessment

Integrated Process:  Communication/Documentation

Question Type:  Multiple Choice

Rationale:  All of the reported diagnostics reflect cardiac data inclusive of enzymes and markers that may be attributable to cardiac events.  The troponin 1 value is within normal range.  A value of greater than 1.5 ng/mL is consistent with MI.  The AST value noted is within normal range for a male patient.  Although the CK-1 value is slightly increased above normal range (0 to 1%), this specific isoenzyme is associated with brain tissue.  The LDH-1 isoenzyme is correlated with erythrocytes and heart tissue and is extremely elevated.  Normal range is 17 to 27%.

 

 

31) The provider examines an adult female patient and notes a prolonged CRT of greater than 3 seconds.  Based on this observation, what potential etiologies might account for this clinical presentation?  Select all that apply:

  1. Hypervolemia
  2. Dehydration
  3. Cardiac disease
  4. Vasodilation of tissues
  5. Increased muscle contractility

Answer: 2, 3

NCLEX domain:  Physiological Adaptation

Cognitive Level:  Analysis

Nursing Process:  Assessment

Integrated Process:  Teaching and Learning

Question Type:  Multiple Select

Rationale:  CRT provides information relative to the adequacy of capillary circulation and tissue perfusion.  Thus, a prolonged CRT time would indicate decreased blood volume as a result of poor perfusion or dehydration.  If the CRT is prolonged, this may also be due to congestive heart failure and/or the presence of peripheral vascular disease.  Prolonged CRT is not associated with hypervolemia, vasodilation of tissues or increased muscle contractility.

 

 

32) The instructor is working with a group of nursing students regarding physical assessment techniques relative to detection of pulses.  Which student nurse action, if observed, would require immediate attention the instructor?

  1. Student reports a pulse deficit of 10 based on a radial pulse of 62 and an apical pulse of 72.
  2. Student documents a radial pulse as 72 and irregular after palpating for 15 seconds.
  3. Student obtains a Doppler to assess peripheral pulses in a patient after attempting to obtain pulse measurement manually on a patient who has vascular disease.
  4. The student documents bilateral pulses as being strong and equal, +2.

Answer: 2

NCLEX domain:  Safe Effective Care Environment

Cognitive Level:  Analysis

Nursing Process: Evaluation

Integrated Process:  Communication/Documentation

Question Type:  Multiple Choice

Rationale:  If an irregular pulse is observed, then the prudent provider would palpate the pulse for a full minute in order to make the determination of an irregular rhythm.  As the nursing student only used 15 seconds to note the pulse rate and quality, this is not consistent with evidence-based clinical practice guidelines.  All of the other observed actions are within the standard of care and do not require any intervention.

 

33) The provider is aware that cardiovascular changes associated with pregnancy are usually the result of:

  1. reduced cardiac output.
  2. increased blood volume.
  3. reduced venous return.
  4. impaired red blood cell production.

Correct Answer: 2

Rationale 1: Reduced cardiac output is not the cause of the cardiovascular changes that occur during pregnancy.

Rationale 2: The cardiovascular changes associated with pregnancy are usually the result of increase blood volume.

Rationale 3: Reduced venous return is not the case of the cardiovascular changes that occur during pregnancy.

Rationale 4: Impaired red blood cell production is not the cause of the cardiovascular changes that occur during pregnancy.

Global Rationale: The cardiovascular changes associated with pregnancy are usually the result of increase blood volume. Reduced cardiac output, reduced venous return, and impaired red blood cell production are not the cause of the cardiovascular changes that occur during pregnancy.

Type: MCSA

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe a focused cardiac history based on the essential parameters associated with manifestations of cardiovascular conditions.

 

34) When palpating the patient’s chest, the provider includes the palpation of the PMI (point of maximal impulse). In an otherwise healthy adult, this is located at the:

  1. fifth ICS MCL.
  2. second ICS RSB.
  3. third ICS LSB.
  4. fourth ICS LSB.

Correct Answer: 1

Rationale 1: The point of maximal impulse (PMI) is located at the fifth ICS MCL.

Rationale 2: The point of maximal impulse (PMI) is not located as the second ICS RSB.

Rationale 3: The point of maximal impulse (PMI) is not located as the third ICS LSB.

Rationale 4: The point of maximal impulse (PMI) is not located as the fourth ICS LSB.

Global Rationale: The point of maximal impulse (PMI) is located at the fifth ICS MCL. The other answer options do not reflect the correct location to palpate the PMI.

Type: MCSA

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

35) The provider is examining a patient’s chest using the bell of the stethoscope. The sounds likely to be heard with the bell include:

  1. S1.
  2. murmurs.
  3. S2.
  4. thrills.

Correct Answer: 2

Rationale 1: The bell of the stethoscope is not used to auscultate S1 sounds when assessing the patient’s chest.

Rationale 2: The bell of the stethoscope is used when auscultating the patient’s chest to assess for murmurs.

Rationale 3: The bell of the stethoscope is not used to auscultate S2 sounds when assessing the patient’s chest.

Rationale 4: The bell of the stethoscope is not used to auscultate thrills when assessing the patient’s chest.

Global Rationale: The bell of the stethoscope is used when auscultating the patient’s chest to assess for murmurs. The bell of the stethoscope is not used to auscultate S1 sounds, S2 sounds, or thrills when assessing the patient’s chest.

Type: MCSA

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Explain the relationship between the anatomy and physiology of the cardiovascular system and the cardiac examination using the four physical assessment techniques.

 

36) An infant has a patent ductus arteriosus. Consistent with this anomaly, what may the provider expect to detect on assessment?

  1. Thrill
  2. Heave
  3. Murmur
  4. Bruit

Correct Answer: 3

Rationale 1: A thrill is not expected assessment finding for an infant patient diagnosed with a patent ductus arteriosus.

Rationale 2: A heave is not an expected assessment finding for an infant patient diagnosed with a patent ductus arteriosus.

Rationale 3: When providing care to an infant patient diagnosed with a patent ductus arteriosus, the provider would expect to auscultate a murmur upon assessment.

Rationale 4: A bruit is not an expected assessment finding for an infant patient diagnosed with a patent ductus arteriosus.

Global Rationale: When providing care to an infant patient diagnosed with a patent ductus arteriosus, the provider would expect to auscultate a murmur upon assessment. The provider would not expect to ausculate a thrill, a heave, or a bruit.

Type: MCSA

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.5: Compare and contrast valvular and nonvalvular heart sounds and murmurs based on their unique characteristics.

 

37) The provider is assessing a patient for modifiable risk factors for cardiac disease. Which is the best question for the provider to include in the interview?

  1. “Did your father have heart disease?”
  2. “Do you smoke cigarettes?”
  3. “Have you ever tried to lose weight?”
  4. “How old are you?”

Correct Answer: 2

Rationale 1: A father with heart disease is a non-modifiable risk factor.

Rationale 2: A modifiable risk factor for cardiovascular disease is cigarette smoking.

Rationale 3: While weight is a modifiable risk factor for cardiovascular disease, there is no evidence that the patient is overweight.

Rationale 4: Age is a non-modifiable risk factor.

Global Rationale: A modifiable risk factor for cardiovascular disease is cigarette smoking. A father with heart failure and age are non-modifiable risk factors. While weight is a modifiable risk factor for cardiovascular disease, there is no evidence that the patient is overweight.

Type: MCSA

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.6: Identify the relationship between lifestyle behaviors and cardiovascular diseases and appropriate prevention behaviors.

 

38) The provider is interviewing a patient during the first visit after a recent myocardial infarction. What should the provider ask the patient to assess behaviors that may reduce risk for a second heart attack?

  1. “Are you planning to return to work?”
  2. “What kind of food do you like?”
  3. “Do you exercise regularly?”
  4. “Have you had any further chest pain?”

Correct Answer: 3

Rationale 1: There is no evidence that the patient’s work would increase the risk for a second heart attack.

Rationale 2: Asking the patient what foods they like is not an appropriate question to assess behaviors that may reduce the risk of a second heart attack.

Rationale 3: Regular exercise has been shown to decrease the risk of a second heart attack.

Rationale 4: While it is important to assess the patient for chest pain, this does not assess the patient’s risk for a second heart attack.

Global Rationale: Regular exercise has been shown to decrease the risk of a second heart attack. There is no evidence that the patient’s work would increase the risk for a second heart attack. Asking the patient what foods they like is not an appropriate question to assess behaviors that may reduce the risk of a second heart attack. While it is important to assess the patient for chest pain, this does not assess the patient’s risk for a second heart attack.

Type: MCSA

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.6: Identify the relationship between lifestyle behaviors and cardiovascular diseases and appropriate prevention behaviors.

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