Chapter 54: Assessment of the Cardiac System Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 54: Assessment of the Cardiac System

MULTIPLE CHOICE

1. The nurse establishing teaching priorities for a community health program would rank cardiovascular disease as a cause of death as

a.

first.

b.

fifth.

c.

seventh.

d.

tenth.

ANS: A

Cardiovascular disease is the leading cause of illness and death in the United States, affecting more than one in five people.

DIF: Comprehension/Understanding REF: p. 1354 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Promotion Programs

2. The nurse would explain that angina pain usually differs from the pain of a myocardial infarction (MI) in that angina pain

a.

is accompanied by palpitations.

b.

is seldom relieved by rest.

c.

lasts less than 15 minutes.

d.

radiates to the arm, jaw, or throat.

ANS: C

The pain of angina is usually short-lived, lasting less than 15 minutes; does not radiate; can be relieved by rest, with or without vasodilators; and is not associated with palpitations. Stable angina is relieved with rest or nitrates. Both types of pain may radiate. Both types of pain may occur with palpitations, and in women, palpitations may occur instead of chest pain.

DIF: Comprehension/Understanding REF: p. 1359 OBJ: Intervention

MSC: Physiological Integrity-Pathophysiology

3. The nurse assessing an American Indian client would assess for other cardiovascular risk factors because the prevalence of heart disease in this group is

a.

no different from other ethnic groups and all should be assessed.

b.

the highest of all ethnic groups in America.

c.

the second highest of all ethnic groups in America.

d.

varies widely between different geographical locations.

ANS: C

The ethnic group with the highest prevalence of CVD is native Hawaiians, followed by American Indians, whites, and blacks .

DIF: Application/Applying REF: p. 1355 OBJ: Intervention

MSC: Physiological Integrity-Pathophysiology

4. A clients record contains a notation that the client is orthopneic. Which question by the nurse would obtain the most useful information?

a.

About how far can you walk before it occurs?

b.

Does anyone else in your family have this too?

c.

How many pillows do you need to sleep on?

d.

When did you first notice this problem?

ANS: C

Orthopnea is difficulty in breathing except when sitting erect or when standing. When the person lies down there is an increase in pulmonary venous and capillary pressure in the lungs, leading to cough and dyspnea. Orthopnea generally indicates a serious cardiac problem, and quantifying the distress helps the nurse gauge the degree the client is compromised. People with orthopnea try various things to be able to sleep including sleeping in recliners and increasing the number of pillows used.

DIF: Application/Applying REF: p. 1362 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

5. The nurse would explain to a client who reports being frequently short of breath that the most common form of dyspnea associated with cardiac disorders is

a.

exertional dyspnea.

b.

idiopathic dyspnea.

c.

orthopnea.

d.

paroxysmal nocturnal dyspnea.

ANS: A

The most frequently reported dyspnea in clients with cardiovascular disorders is that associated with exertion.

DIF: Comprehension/Understanding REF: p. 1362 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

6. The nurse performing an admission assessment of a 36-year-old client with cardiac valve disease would know the most relevant fact is that the client has

a.

a childhood history of rheumatic fever.

b.

a recent rash on the upper extremities.

c.

allergies to shellfish.

d.

been a smoker for the last 3 years.

ANS: A

A childhood history of rheumatic fever is associated with structural mitral valve disease.

DIF: Analysis/Analyzing REF: p. 1363 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

7. The finding during a routine assessment that would most strongly suggest to the nurse the presence of serious heart or lung disease is

a.

blanching of nail beds when compressed.

b.

broken vessels in the legs.

c.

duskiness of the buccal mucosa.

d.

pulse rate greater than 90 beats/min.

ANS: C

The nurse should observe the skin and mucous membranes for abnormalities such as central or peripheral cyanosis. The presence of a bluish tinge or duskiness is indicative of central cyanosis. Central cyanosis implies serious heart or lung disease because impaired physiologic functioning is leading to decreased arterial oxygen saturation. Peripheral cyanosis, seen in lips, ear lobes, and nail beds, suggests peripheral vasoconstriction.

DIF: Comprehension/Understanding REF: p. 1361 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

8. During the physical examination of a client, the nurse checks the client for neck vein distention. To perform this assessment properly, the client should be positioned

a.

first lying, then sitting, then standing.

b.

in a side-lying position with knees flexed.

c.

lying supine with head of bed elevated 15-30 degrees.

d.

sitting upright with neck flexed slightly forward.

ANS: C

The distensibility of the neck veins reflects the pressure and volume changes within the right atrium in most people. Evaluate neck vein distention by having the client lay supine with the head of bed elevated 15-30 degrees (for most people), turn the clients head slightly away from you, loosen or remove clothing that compresses the neck or upper thorax. Use oblique lighting and observe both sides of the neck. Measure the highest point of venous pulsation.

DIF: Application/Applying REF: pp. 1370-1371

OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

9. The nurse evaluating the head and neck of a client would assess the carotid arteries by

a.

asking the client to bear down and hold the breath while observing the arteries.

b.

auscultating the arteries with the diaphragm of the stethoscope.

c.

instructing the client to lie down and examining the arteries with oblique lighting.

d.

palpating the arteries simultaneously, comparing amplitudes, rates, and rhythms.

ANS: B

Carotid artery examination indicates the adequacy of stroke volume and the patency of the arteries. Using the fingertips, the nurse gently palpates the carotid arteries one side at a time. The nurse notes whether a bruit is present by listening to the carotid arteries with the diaphragm of the stethoscope.

DIF: Application/Applying REF: p. 1371 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

10. The nurse palpating the precordium of a 73-year-old client for the point of maximal intensity (PMI) would place the hands

a.

at Erbs point in an elderly client.

b.

at the level of the sternal manubrium.

c.

at the fifth intercostal space, medial to the midclavicular line.

d.

to the left of the angle of Louis.

ANS: C

Also called the point of maximal impulse, the PMI, or apical impulse, is usually seen at the apex. The PMI is associated with left ventricular contraction and should appear at the fifth intercostal space medial to the left midclavicular line.

DIF: Application/Applying REF: p. 1372 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

11. The nurse auscultating heart sounds would recognize that the normal closure of the mitral and tricuspid valves creates the

a.

apical pulse.

b.

atrial gallop.

c.

S1 heart sound.

d.

S2 heart sound.

ANS: C

The first heart sound (S1) is linked to closure of the mitral and tricuspid valves.

DIF: Knowledge/Remembering REF: p. 1372 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. The nurse is attempting to identify the timing of a murmur detected in a client. The additional activity necessary to make this assessment would be

a.

assessment of blood pressure.

b.

estimation of the clients fluid status.

c.

evaluation of peripheral pulses.

d.

identification of S1 and S2.

ANS: D

It is imperative to identify S1 and S2 heart sounds to determine the place and duration. The murmur is then described as occurring in early, mid, or late systole or diastole.

DIF: Application/Applying REF: p. 1374 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Techniques of Physical Assessment

13. In doing a breath sound assessment on a client who has left ventricular failure, the nurse would anticipates the finding of

a.

audible S3 and S4.

b.

crackles in the lung bases.

c.

inspiratory wheeze.

d.

pericardial friction rub.

ANS: B

Crackles frequently signal left ventricular failure and usually occur just after the onset of an S3 gallop. As pulmonary capillary pressure rises from the backward pressure of left ventricular failure, fluid shifts into the intra-alveolar spaces, and crackles can be auscultated.

DIF: Comprehension/Understanding REF: p. 1372 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

14. The nurse would explain to a client that the isoenzyme most useful in the diagnosis of myocardial infarction is

a.

CK-MB.

b.

CK-MM

c.

myoglobin.

d.

troponin

ANS: D

The enzymes most often used to detect MI are myoglobin, creatine kinase, and troponin. Myoglobin is released rapidly, but its short half-life makes it less useful in clients who present several hours after an infarction. CK-MB is specific for cardiac muscle. Troponin is as sensitive as CK-MB but is more specific and is more useful in excluding myocardial infarction when CK-MB is falsely elevated. CK-MM is a measure of skeletal muscle enzymes.

DIF: Comprehension/Understanding REF: p. 1382 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values

15. A client who had a myocardial infarction has an elevated blood glucose level and is getting insulin. The client asks why this is occurring because the client does not have diabetes. The best answer by the nurse is

a.

I am not sure, but I will ask the doctor and let you know.

b.

It is an expected side effect of the medications we gave you.

c.

The stress of your heart attack makes blood sugar rise.

d.

You probably are a diabetic and werent diagnosed until now.

ANS: C

The stress of the illness and damage to the myocardium often raise blood glucose level. If the nurse does not know the answer to a question, option a is a good choice. If you do not know, find out and tell the client.

DIF: Application/Applying REF: p. 1383 OBJ: Assessment

MSC: Physiological Integrity-Pathophysiology

16. The nurse would explain to a client that an electrical representation of the cardiac cycle shows that a normal PR interval is between 0.12 second and

a.

0.15 second.

b.

0.16 second.

c.

0.18 second.

d.

0.20 second.

ANS: D

The normal PR interval is between 0.12 and 0.20 second, averaging 0.16 second.

DIF: Comprehension/Understanding REF: pp. 1376-1377

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

17. A nurse understands that the basic premise of an ECG is that it shows

a.

altered electrical activity from pathologic changes.

b.

damage to the valves inside the heart.

c.

the status of the clients coronary arteries.

d.

the approximate time since a myocardial infarction occurred.

ANS: A

The ECG provides multidirectional examination of electrical events in the heart. Myocardial infarction causes tissue damage/death, which alters the electrical activity in predictable patterns. This altered electrical activity shows up on the ECG as abnormalities that help diagnose the occurrence and location of an infarction.

DIF: Comprehension/Understanding REF: p. 1377 OBJ: Intervention

MSC: Physiological Integrity

18. In evaluating a clients ECG tracing, the nurse notes three small squares between the upstroke and downstroke of the QRS wave. The nurse would record the QRS interval as

a.

0.04 second.

b.

0.06 second.

c.

0.08 second.

d.

0.12 second.

ANS: D

Each small square on ECG tracing paper is 0.04 second, making the QRS interval in this client 0.12 second.

DIF: Application/Applying REF: pp. 1376-1377

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

19. The nurse would explain to a client that the benefit of a Holter monitor over an ECG is that the Holter monitor

a.

does not require a lengthy hospital stay.

b.

is a continuous recording, often for 24 hours.

c.

is less expensive than the traditional ECG.

d.

provides a two-dimensional view of the coronary arteries.

ANS: B

The Holter monitor is a recording of a continuous ECG tracing. It is usually placed for 24 hours on an outpatient basis. Neither it nor an ECG require hospitalization. It is not less expensive nor does it provide a view of the coronary arteries.

DIF: Comprehension/Understanding REF: p. 1377 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

20. The nurse would explain to a client that an exercise ECG is useful as one means of detecting

a.

cardiac dysrhythmias.

b.

coronary artery disease.

c.

heart failure.

d.

valvular disorders.

ANS: B

An exercise ECG, referred to as a stress test, is helpful as an adjunctive diagnostic study for coronary artery disease, although it can produce false-positive findings in some clients, especially women.

DIF: Comprehension/Understanding REF: pp. 1377-1378

OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

21. In developing a standard teaching plan for the outpatient unit where stress testing is performed, the nurse would include information that the

a.

test may cause chest pain and may need to be stopped.

b.

test should not be interrupted for any reason.

c.

client should attempt to exercise before arriving for the test.

d.

clients balance must be good for performance of this test.

ANS: A

The nurse should include a warning that this test may trigger chest pain and dyspnea. The test will be terminated early if the client shows (1) signs of cardiac intolerance, (2) ECG changes, (3) wall motion abnormalities or reversible perfusion defects seen on a concurrent echocardiogram.

DIF: Comprehension/Understanding REF: p. 1378 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

22. To best facilitate a clients understanding of an electrophysiologic study, the nurse would explain that this study will

a.

enable the physician to reproduce dysrhythmias and evaluate antidysrhythmic drugs.

b.

evaluate the relationship of the atrium to the ventricles during contractions.

c.

increase the understanding of the strength of the muscles in the ventricles.

d.

interrupt blood flow to coronary arteries and assess the hearts electrical system.

ANS: A

The purpose of the electrophysiologic study is to reproduce any dysrhythmia so that its origin may be isolated. Antidysrhythmic drugs may be administered during the study to evaluate their effect.

DIF: Comprehension/Understanding REF: p. 1381 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

23. The critical piece of information related to the clients myocardium that is obtained through a PET scan is

a.

electrical activity of the heart.

b.

myocardial viability.

c.

patency of coronary arteries.

d.

status of valves.

ANS: B

A PET scan demonstrates cellular metabolism via tracing glucose uptake and use. A client with decreased perfusion but normal glucose uptake has viable, but hibernating, myocardium. This information is used to choose candidates for revascularization.

DIF: Knowledge/Remembering REF: p. 1379 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

24. A nurse explains the purpose of echocardiography to a client as

a.

a picture of both the structures in the heart and their motion.

b.

an image of the heart and great vessels from a posterior view.

c.

hemodynamic pressure monitoring and analysis of oxygenation.

d.

the use of extra contrast dye to visualize pulmonary arteries.

ANS: A

The echocardiogram essentially provides a continuous picture of the beating heart. Option b refers to a transesophageal echocardiogram, option c to a right heart catheterization, and option d to a CT scan using the pulmonary embolus protocol.

DIF: Comprehension/Understanding REF: p. 1379 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests

25. A client has an elevated level of C-reactive protein. The nurse explains the significance of this finding as

a.

an indication of an inflammatory process like atherosclerosis.

b.

not related to future cardiac events such as myocardial infarction.

c.

suggestive of a recent pulmonary embolus.

d.

worrisome because it signals possible myocardial irritability.

ANS: A

Atherosclerosis is in part a chronic, low-grade inflammatory process. Elevation of the C-reactive protein occurs in inflammation and has been linked to future cardiovascular risks.

DIF: Comprehension/Understanding REF: p. 1383 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values

26. The nurse planning a secondary prevention program for risk reduction would focus on clients who

a.

already have a diagnosis of cardiovascular disease.

b.

do not yet have cardiovascular disease and wish to prevent it.

c.

have two or more family members with cardiovascular disease.

d.

want information about cardiovascular disease.

ANS: A

Risk factor modification in clients who do not yet have cardiovascular disease is primary prevention. Risk factor modification in clients who do have cardiovascular disease is considered secondary prevention.

DIF: Application/Applying REF: p. 1363 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Promotion Programs

27. The nurse providing education at a community forum on obesity and heart disease informs the group that obese is described as a body mass index greater than

a.

15 kg/m2.

b.

20 kg/m2.

c.

25 kg/m2.

d.

30 kg/m2.

ANS: D

For adults, an overweight body mass index (BMI) is 25-29.9 kg/m2. Obesity is defined as a BMI of greater than 30 kg/m2.

DIF: Comprehension/Understanding REF: p. 1365 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Promotion Programs

28. A client is taking the herbal supplements bilberry and evening primrose. The nurse would specifically question the client about manifestations of

a.

angina.

b.

dyspnea.

c.

hypertension.

d.

palpitations.

ANS: A

Bilberry and evening primrose are among several anti-anginal herbal supplements.

DIF: Application/Applying REF: p. 1365 OBJ: Assessment

MSC: Physiological Integrity Basic Care and Comfort-Complementary and Alternative Therapies

MULTIPLE RESPONSE

1. Important information the nurse should collect when a client complains of chest pain includes (Select all that apply)

a.

aggravating and relieving factors.

b.

associated manifestations.

c.

characteristics.

d.

duration.

e.

location.

ANS: A, B, C, D, E

All components are important to assess when the client complains of chest pain.

DIF: Application/Applying REF: pp. 1355-1360

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Alteration in Body Systems

2. Women with heart disease often present with which symptom? (Select all that apply.)

a.

Chest pain

b.

Dyspnea

c.

Fatigue

d.

Nausea

e.

Palpitations

ANS: B, C, D, E

Women can experience chest pain, but most often present with complaints of dyspnea, nausea and vomiting, fatigue, neck or jaw pain, back pain, dizziness, or palpitations. This is a contributing factor to womens higher death rate from heart disease.

DIF: Knowledge/Remembering REF: pp. 1355-1359

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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