C HAPTER 12: C ARDIOVASCULAR C LINICAL
A SSESSMENT
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What sounds are created by the turbulence of blood flow through a vessel
caused by constriction of the blood pressure cuff?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: A
Korotkoff sounds are the sounds created b y turbulence of blood flow
within a vessel caused by constriction of the blood pressure cuff.
Abnormal heart sounds are known as the third heart sound (S3) and the
fourth heart sound (S4); they are referred to as gallops when
auscultated during an episode of tachycardia. Murmurs are produced by
turbulent blood flow through the chambers of the heart, from forward
flow through narrowed or irregular valve openings, or backward
regurgitate flow through an incompetent valve.
PTS: 1 DIF: Cognitive Level: Unders tanding REF: p.
191 OBJ: Nursing Process Step: Assessment TOP:
, Cardiovascular Clinical Assessment MSC: NC LEX: Physiologic
Integrit y
2. Abnormal heart sounds are labeled S3 and S4 and are referred to as what
when auscultated during a tachycardic episode?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: D
Abnormal heart sounds are known as the third heart sound (S3) and the
fourth heart sound (S4); they are referred to as gallops when
auscultated during an episode of tachycardia. Murmurs are produced by
turbulent flood flow through the chambers of the heart, from forward
flow through narrowed or irregular valve openings, or backward
regurgitate flow through an incompetent valve. Korotkoff sounds are
the sounds created by turbulence of blood f low within a vessel caused
by constriction of the blood pressure cuff. Pulse pressure describes the
difference between systolic and diastolic values. A normal pulse
pressure is 40 mm Hg.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
194 OBJ: Nursi ng Process Step: Assessment TOP:
Cardiovascular Clinical Assessment MSC: NC LEX: Physiologic
Integrit y
3. A heart murmur is described as blowing, grating, or harsh. This
description would fall under which criteria?
, a. Intensit y
b. Qualit y
c. Timing
d. Pitch
ANS: B
Qualit y is whether the murmur is blowing, grating, or harsh. Intensit y
is the loudness graded on a scale of 1 through 6; the higher the number,
the louder is the murmur. Timing is the place in the cardiac cycle
(s ystole/diastole). Pitch is whether the tone is high or low.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
195 OBJ: Nursing Process Step: Assessment TOP:
Cardiovascular MSC: NC LEX: Physiologic Integrit y
4. The nurse assesses the dorsalis pedis and posterior tibial pulses as weak
and thready. What should the nurse document for the pulse volume?
a. 0
b. 1+
c. 2+
d. 3+
ANS: B
Pulse volumes are 0, not palpable; 1+, faintl y palpable (weak and
thready); 2+, palpable (normal pulse); and 3+, bounding (hyperdynamic
pulse).
A SSESSMENT
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What sounds are created by the turbulence of blood flow through a vessel
caused by constriction of the blood pressure cuff?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: A
Korotkoff sounds are the sounds created b y turbulence of blood flow
within a vessel caused by constriction of the blood pressure cuff.
Abnormal heart sounds are known as the third heart sound (S3) and the
fourth heart sound (S4); they are referred to as gallops when
auscultated during an episode of tachycardia. Murmurs are produced by
turbulent blood flow through the chambers of the heart, from forward
flow through narrowed or irregular valve openings, or backward
regurgitate flow through an incompetent valve.
PTS: 1 DIF: Cognitive Level: Unders tanding REF: p.
191 OBJ: Nursing Process Step: Assessment TOP:
, Cardiovascular Clinical Assessment MSC: NC LEX: Physiologic
Integrit y
2. Abnormal heart sounds are labeled S3 and S4 and are referred to as what
when auscultated during a tachycardic episode?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: D
Abnormal heart sounds are known as the third heart sound (S3) and the
fourth heart sound (S4); they are referred to as gallops when
auscultated during an episode of tachycardia. Murmurs are produced by
turbulent flood flow through the chambers of the heart, from forward
flow through narrowed or irregular valve openings, or backward
regurgitate flow through an incompetent valve. Korotkoff sounds are
the sounds created by turbulence of blood f low within a vessel caused
by constriction of the blood pressure cuff. Pulse pressure describes the
difference between systolic and diastolic values. A normal pulse
pressure is 40 mm Hg.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
194 OBJ: Nursi ng Process Step: Assessment TOP:
Cardiovascular Clinical Assessment MSC: NC LEX: Physiologic
Integrit y
3. A heart murmur is described as blowing, grating, or harsh. This
description would fall under which criteria?
, a. Intensit y
b. Qualit y
c. Timing
d. Pitch
ANS: B
Qualit y is whether the murmur is blowing, grating, or harsh. Intensit y
is the loudness graded on a scale of 1 through 6; the higher the number,
the louder is the murmur. Timing is the place in the cardiac cycle
(s ystole/diastole). Pitch is whether the tone is high or low.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
195 OBJ: Nursing Process Step: Assessment TOP:
Cardiovascular MSC: NC LEX: Physiologic Integrit y
4. The nurse assesses the dorsalis pedis and posterior tibial pulses as weak
and thready. What should the nurse document for the pulse volume?
a. 0
b. 1+
c. 2+
d. 3+
ANS: B
Pulse volumes are 0, not palpable; 1+, faintl y palpable (weak and
thready); 2+, palpable (normal pulse); and 3+, bounding (hyperdynamic
pulse).
