Test bank for Nursing Health Assessment 3rd Edition by Patricia M.Dillon Link full download: https://getbooksolutions.com/download/test-bank-for-nursinghealth-assessment-3rd-edition-by-dillon/ Chapter 06: Assessing the Cardiovascular System Multiple ChoiceIdentify the choice that best completes the statement or answers the question The S1 heart sound is made during which part of the cardiac cycle? 1) Systolic 2) Diastolic 3) Early diastolic 4) Midsystolic The nurse auscultates a widely split S2 heart sound Which is this assessment finding indicative of? 1) Atrial fibrillation 2) Left bundle branch block (LBBB) 3) Right bundle branch block (RBBB) 4) Ventricular fibrillation The nurse auscultates an S3 gallop rhythm in an adult Which disorder is this indicative of? 1) Atrial fibrillation 2) Heart failure 3) Ventricular tachycardia 4) Atrial septal defect Turbulent blood flow within the heart is heard as a murmur Which is the cause of the murmur? 1) Increased blood volume 2) Constricted blood vessels 3) Flow from a normal vessel to a dilated one 4) All of the above Ethnic variations have an impact on severity of coronary artery disease (CAD) Which individual is more likely to suffer from CAD? 1) Japanese American male 2) Puerto Rican female 3) African American female 4) White female The nurse auscultates an S2 sound during a cardiovascular system assessment Which conclusion by the nurse is most appropriate? 1) Normal finding 2) Mitral valve stenosis 3) Pericarditis 4) Hypertension Which location does the nurse use to assess S1? 1) Base left 2) Base right 3) Apex 4) Left lower sternal border The nurse notes an opening snap when auscultating a patient’s heart sounds Which does this finding indicate? 1) Atrial fibrillation 2) Pulmonary hypertension 3) Emphysema 4) Mitral stenosis The S3 rhythm often accompanies which heart problem? 1) Heart failure 2) Mitral stenosis 3) Pulmonary hypertension 4) Myocardial infarction (MI) 10 Which heart problem is responsible for an early systolic murmur? 1) Pericarditis 2) Turbulent venous flow 3) Ventricular septal defect (VSD) 4) Myocardial infarction (MI) 11 Which is often the cause of an additional heart sound heard during pregnancy? 1) A mammary soufflé 2) Friction rub 3) Venous hum 4) S4 gallop 12 Which of the following factors may affect a patient’s risk for heart disease? 1) Age 2) Gender 3) Ethnicity 4) All of the above 13 To measure jugular venous pressure, the patient should be placed in which position? 1) Supine 2) High Fowler’s 3) Semi-Fowler’s 4) Prone 14 Which action by the nurse will allow bruits to be heard most accurately? 1) Using a fetoscope 2) Using the diaphragm of the stethoscope 3) Using the bell of the stethoscope 4) Using the unassisted ear 15 An older adult patient is admitted to the critical care unit with uncontrolled hypertension The patient’s point of maximal impulse (PMI) is enlarged and displaced laterally Which is the normal size of the left ventricular impulse (LVI)? 1) 4 cm 16 The nurse notes an elevated jugular venous pressure (JVP) Which disease process can cause this assessment finding? 1) Hypovolemia 2) Constrictive pericarditis 3) Right ventricular hypertrophy 4) Abnormal venous wave forms 17 The nurse is assessing a patient’s heart sounds Which pitch is expected for the S2 sound? 1) Vibrating 2) Grating 3) Low 4) High ANS ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding]Concept: Assessment, Perfusion Difficulty: Easy Feedback1 S1 occurs during systole S1 does not occur during diastole S1 does not occur during early diastole.4 S1 does not occur during midsystole PTS: CON: Assessment | Perfusion ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference:Heading: 202Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Comprehension [Understanding]Concept: PerfusionDifficulty: Moderate Feedback1 A split R2 does not indicate atrial fibrillation.2 A split R2 does not indicate LBBB.3 A split R2 often indicates RBBB.4 A split R2 does not indicate ventricular fibrillation PTS: CON: Perfusion ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 192Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Evaluation [Evaluating]Concept: PerfusionDifficulty: Moderate Feedback1 The S3 gallop rhythm is not indicative of atrial fibrillation The S3 gallop rhythm is a sign of congestive heart failure (CHF) It relates to hemodynamic filling of a failing, noncompliant ventricle.3 The S3 gallop rhythm is not indicative of ventricular tachycardia The S3 gallop rhythm is not indicative of atrial septal defect PTS: CON: Perfusion ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 203Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Comprehension [Understanding]Concept: PerfusionDifficulty: Moderate Feedback1 Murmurs can be caused by increased blood volume Murmurs can be caused by constricted blood vessels Murmurs can be caused by flow from a constricted blood vessel to a dilated blood vessel Murmurs are defined as a series of audible, prolonged sounds resulting from turbulence created within the vascular system Causes of turbulent flow include increased flow through normal blood vessels creating frictional, audible sounds; flow through constricted blood vessels (as in aortic stenosis); flow into a dilated blood vessel from one of normal size; or a combination of these PTS: CON: Perfusion ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 173Integrated Processes: Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering]Concept: DiversityDifficulty: Easy Feedback1 Japanese and Puerto Ricans have a lower incidence of hypertension and high cholesterol; middle-aged white males have the highest incidence of CAD.2 Japanese and Puerto Ricans have a lower incidence of hypertension and high cholesterol; middle-aged white males have the highest incidence of CAD.3 African Americans have an earlier onset and greater severity of CAD than other groups; African American women have a greater incidence of CAD than white women.4 African American women have a greater incidence of CAD than white women PTS: CON: Diversity ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive level: Analysis [Analyzing]Concept: Perfusion Difficulty: Moderate Feedback1 S2 is a normal finding when auscultating the chest during a cardiovascular assessment S2 does not indicate mitral valve stenosis.3 S2 does not indicate pericarditis S2 does not indicate hypertension PTS: CON: Perfusion ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Application [Applying]Concept: Assessment Difficulty: Moderate Feedback1 S1 is not auscultated at the left base S1 is not auscultated at the right base The nurse auscultates S1 at the apex S1 is not auscultated at the left lower sternal border PTS: CON: Assessment ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Evaluation [Evaluating]Concept: Perfusion, Assessment Difficulty: Moderate Feedback1 An opening snap is not a heart sound that is indicative of atrial fibrillation An opening snap is not a heart sound that is indicative of pulmonary hypertension An opening snap is not a heart sound that is indicative of emphysema An opening snap is a heart sound that occurs for patients diagnosed with mitral stenosis PTS: CON: Perfusion | Assessment ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Evaluation [Evaluating]Concept: Perfusion, Assessment Difficulty: Moderate Feedback1 An S3 in an adult is a sign of a failing heart The S3 rhythm often accompanies heart failure.2 An S3 in an adult is not indicative of mitral stenosis An S3 in an adult is not indicative of pulmonary hypertension An S3 in an adult is not indicative of an MI PTS: CON: Perfusion | Assessment 10 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 192Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Analysis [Analyzing]Concept: Perfusion Difficulty: Moderate Feedback1 An early systolic murmur is not caused by pericarditis An early systolic murmur is not caused by turbulent venous flow An early systolic murmur can be caused by VSD An early systolic murmur is not caused by an MI PTS: CON: Perfusion 11 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 172Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering]Concept: Pregnancy, Perfusion Difficulty: Easy Feedback1 A mammary soufflé is a murmur that develops from increased blood flow through the mammary artery, occurring late in pregnancy or during lactation.2 A friction rub is an abnormal finding A venous hum is an abnormal finding An S4 gallop is an abnormal finding PTS: CON: Pregnancy | Perfusion 12 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 173Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering]Concept: Assessment, Perfusion Difficulty: Easy Feedback1 The risk for cardiovascular disease increases with age.2 Men have a greater incidence of cardiovascular disease than women Women have a higher mortality rate within year post-MI than men.3 Certain cardiovascular diseases are more prevalent in specific races or ethnic backgrounds.4 The risk for cardiovascular disease increases with age Men have a greater incidence of cardiovascular disease than women Women have a higher mortality rate within year post-MI than men Certain cardiovascular diseases are more prevalent in specific races or ethnic backgrounds PTS: CON: Assessment | Perfusion 13 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 184Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Application [Applying]Concept: Assessment, Perfusion Difficulty: Moderate Feedback1 The patient is not placed in a supine position to measure jugular venous pressure The patient is not placed in a high Fowler’s position to measure jugular venous pressure To measure jugular venous pressure, elevate the patient’s head to 30 to 45 degrees.4 The patient is not placed in a prone position to measure jugular venous pressure PTS: CON: Assessment | Perfusion 14 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 190Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Application [Applying]Concept: Assessment Difficulty: Moderate Feedback1 The fetoscope is best for detecting fetal heart sounds.2 The diaphragm is best for detecting high-pitch sounds.3 Bruits are low-pitch sounds heard best with the bell portion of the stethoscope.4 A stethoscope must be used to assess a bruit PTS: CON: Assessment 15 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 187Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Analyzing [Analysis]Concept: Perfusion, Assessment Difficulty: Difficult Feedback1 The normal side of the PMI (also referred to as the LVI) is to cm The LVI (PMI) is normally no greater than cm at the apex A PMI > cm may indicate ventricular hypertrophy.4 A PMI > cm may indicate ventricular hypertrophy PTS: CON: Perfusion | Assessment 16 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 184Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive level: Comprehension [Understanding]Concept: Perfusion, Assessment Difficulty: Easy Feedback1 Hypovolemia causes a low JVP Constrictive pericarditis can cause an elevated JVP Right ventricular hypertrophy causes giant A waves Abnormal venous wave forms cause a low JVP PTS: CON: Perfusion | Assessment 17 ANS: Chapter number and title: 6, Assessing the Cardiovascular System Chapter learning objective: N/A Chapter page reference: 202Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive level: Knowledge [Remembering]Concept: Assessment, Perfusion Difficulty: Easy Feedback1 The pitch of the S2 sound is not vibrating The pitch of the S2 sound is not grating The pitch of the S2 sound is not low