Chapter 35: Assessment of the Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who has had a recent myocardial infarction
involving the left ventricle. Which assessment finding is expected?
a Faint S1 and S2 sounds
.
b Decreased cardiac output
.
c Increased blood pressure
.
d Absent peripheral pulses
.
ANS: B
The myocardium is the layer responsible for the contractile force of the
heart. Damage to this layer can result in decreased cardiac output. This
most likely would result in decreased blood pressure and strength of pe-
ripheral pulses. Absent peripheral pulses would be caused by an arterial
occlusion. S1 and S2 most likely would not be affected.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is caring for a client with coronary artery disease. What assess-
ment finding does the nurse expect if the client’s mean arterial blood pres-
sure decreases below 60 mm Hg?
a Increased cardiac output
.
b Hypertension
.
c Chest pain
.
d Decreased heart rate
.
ANS: C
Coronary artery blood flow occurs primarily during diastole. Mean arterial
pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coro-
nary arteries, and MAP of 60 to 70 mm Hg is necessary for adequate perfu-
sion to major body organs. If MAP decreases to below 60 mm Hg, the client
, with cardiac disease may have chest pain. Cardiac output most likely
would decrease, and blood pressure also would decrease. Heart rate may
increase as the body initiates compensatory mechanisms.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is assessing a client following a myocardial infarction. The client
is hypotensive. What additional assessment finding does the nurse expect?
a Heart rate of 120 beats/min
.
b Cool, clammy skin
.
c Oxygen saturation of 90%
.
d Respiratory rate of 8 breaths/min
.
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch
sense a pressure decrease in the vessels. The parasympathetic system re-
sponds by lessening the inhibitory effect on the sino-atrial (SA) node. This
results in an increase in heart rate. This tachycardia is an early response
and is seen even when blood pressure is not critically low.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse administers a beta blocker to a client after a myocardial infarc-
tion. What assessment finding does the nurse expect?
a Blood pressure increase of 10%
.
b Increasing respiratory rate
.
c Increased cardiac output
.
d Pulse decrease from 100 t`o 80 beats/min
.
ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart
, rate (HR). The beta blocker will decrease HR and blood pressure, increas-
ing ventricular filling time. It usually does not have effects on beta2-adren-
ergic receptor sites. Cardiac output will drop because of decreased heart
rate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Par-
enteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process:
Nursing Process (Assessment)
5. The nurse is assessing clients at a community health center. Which client
does the nurse determine is at high risk for cardiovascular disease?
a Older adult man with a history of asthma
.
b Asian-American man with colorectal cancer
.
c American Indian woman with diabetes mellitus
.
d Postmenopausal woman on hormone therapy
.
ANS: C
The incidence of coronary artery disease and hypertension is higher in
American Indians than in whites or Asian Americans. Diabetes mellitus in-
creases the risk for hypertension and coronary artery disease in people of
any race or ethnicity.
DIF: Cognitive Level: Knowledge/Remembering REF: pp. 692-693
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screen-
ing)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is obtaining a client’s health history. Which illness alerts the
nurse to the possibility of abnormal heart valves?
a Tuberculosis
.
b Recurrent viral pneumonia
.
c Rheumatic fever
.
d Asthma
.
ANS: C
Rheumatic fever is an inflammatory disease that typically is caused by in-
fection with group A beta-hemolytic streptococci that can affect the endo-
, cardium.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 694
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screen-
ing)
MSC: Integrated Process: Nursing Process (Assessment)
7. A nurse is performing an admission assessment on an older adult client
with multiple chronic diseases. The nurse assesses the heart rate to be 48
beats/min. What does the nurse do first?
a Document the finding in the chart.
.
b Evaluate for a pulse deficit.
.
c Assess the client’s medications.
.
d Administer 1 mg of atropine.
.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person
ages, resulting in bradycardia. The nurse should check the medication rec-
onciliation for medications that might cause such a drop in heart rate, then
should inform the health care provider. Documentation is important, but it
is not the priority action. The heart rate is not low enough for atropine to
be needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—
Potential for Alterations in Body Systems) MSC: Integrated Process:
Nursing Process (Analysis)
8. The nurse is assessing clients at a clinic. Which activity takes priority?
a Teaching smoking cessation to a middle-aged woman who
. smokes
b Planning an exercise regimen with a woman with a sedentary
. lifestyle
c Teaching an older man who is moderately obese to keep a food
. diary
d Assessing a man with familial coronary artery disease for specific
. risk factors
ANS: A
All of these risk factors contribute to the development of cardiovascular
disease, but cigarette smoking is a major risk factor for both coronary
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who has had a recent myocardial infarction
involving the left ventricle. Which assessment finding is expected?
a Faint S1 and S2 sounds
.
b Decreased cardiac output
.
c Increased blood pressure
.
d Absent peripheral pulses
.
ANS: B
The myocardium is the layer responsible for the contractile force of the
heart. Damage to this layer can result in decreased cardiac output. This
most likely would result in decreased blood pressure and strength of pe-
ripheral pulses. Absent peripheral pulses would be caused by an arterial
occlusion. S1 and S2 most likely would not be affected.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is caring for a client with coronary artery disease. What assess-
ment finding does the nurse expect if the client’s mean arterial blood pres-
sure decreases below 60 mm Hg?
a Increased cardiac output
.
b Hypertension
.
c Chest pain
.
d Decreased heart rate
.
ANS: C
Coronary artery blood flow occurs primarily during diastole. Mean arterial
pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coro-
nary arteries, and MAP of 60 to 70 mm Hg is necessary for adequate perfu-
sion to major body organs. If MAP decreases to below 60 mm Hg, the client
, with cardiac disease may have chest pain. Cardiac output most likely
would decrease, and blood pressure also would decrease. Heart rate may
increase as the body initiates compensatory mechanisms.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is assessing a client following a myocardial infarction. The client
is hypotensive. What additional assessment finding does the nurse expect?
a Heart rate of 120 beats/min
.
b Cool, clammy skin
.
c Oxygen saturation of 90%
.
d Respiratory rate of 8 breaths/min
.
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch
sense a pressure decrease in the vessels. The parasympathetic system re-
sponds by lessening the inhibitory effect on the sino-atrial (SA) node. This
results in an increase in heart rate. This tachycardia is an early response
and is seen even when blood pressure is not critically low.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—
Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse administers a beta blocker to a client after a myocardial infarc-
tion. What assessment finding does the nurse expect?
a Blood pressure increase of 10%
.
b Increasing respiratory rate
.
c Increased cardiac output
.
d Pulse decrease from 100 t`o 80 beats/min
.
ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart
, rate (HR). The beta blocker will decrease HR and blood pressure, increas-
ing ventricular filling time. It usually does not have effects on beta2-adren-
ergic receptor sites. Cardiac output will drop because of decreased heart
rate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Par-
enteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process:
Nursing Process (Assessment)
5. The nurse is assessing clients at a community health center. Which client
does the nurse determine is at high risk for cardiovascular disease?
a Older adult man with a history of asthma
.
b Asian-American man with colorectal cancer
.
c American Indian woman with diabetes mellitus
.
d Postmenopausal woman on hormone therapy
.
ANS: C
The incidence of coronary artery disease and hypertension is higher in
American Indians than in whites or Asian Americans. Diabetes mellitus in-
creases the risk for hypertension and coronary artery disease in people of
any race or ethnicity.
DIF: Cognitive Level: Knowledge/Remembering REF: pp. 692-693
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screen-
ing)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is obtaining a client’s health history. Which illness alerts the
nurse to the possibility of abnormal heart valves?
a Tuberculosis
.
b Recurrent viral pneumonia
.
c Rheumatic fever
.
d Asthma
.
ANS: C
Rheumatic fever is an inflammatory disease that typically is caused by in-
fection with group A beta-hemolytic streptococci that can affect the endo-
, cardium.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 694
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screen-
ing)
MSC: Integrated Process: Nursing Process (Assessment)
7. A nurse is performing an admission assessment on an older adult client
with multiple chronic diseases. The nurse assesses the heart rate to be 48
beats/min. What does the nurse do first?
a Document the finding in the chart.
.
b Evaluate for a pulse deficit.
.
c Assess the client’s medications.
.
d Administer 1 mg of atropine.
.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person
ages, resulting in bradycardia. The nurse should check the medication rec-
onciliation for medications that might cause such a drop in heart rate, then
should inform the health care provider. Documentation is important, but it
is not the priority action. The heart rate is not low enough for atropine to
be needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—
Potential for Alterations in Body Systems) MSC: Integrated Process:
Nursing Process (Analysis)
8. The nurse is assessing clients at a clinic. Which activity takes priority?
a Teaching smoking cessation to a middle-aged woman who
. smokes
b Planning an exercise regimen with a woman with a sedentary
. lifestyle
c Teaching an older man who is moderately obese to keep a food
. diary
d Assessing a man with familial coronary artery disease for specific
. risk factors
ANS: A
All of these risk factors contribute to the development of cardiovascular
disease, but cigarette smoking is a major risk factor for both coronary
