Chapter 31: Assessment of Cardiovascular System Lewis: Medical-Surgical Nursing, 10th Edition

MULTIPLE CHOICE 1. A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring. ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit. DIF: Cognitive Level: Apply (application) REF: 668 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse? a. A right bundle-branch block. c. The QRS duration is 0.13 seconds. b. The PR interval is 0.21 seconds. d. The heart rate (HR) is 41 beats/min. ANS: D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches. DIF: Cognitive Level: Analyze (analysis) REF: 662 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to a. ask about risk factors for atherosclerosis. b. determine family history of heart disease. c. assess for symptoms of left ventricular hypertrophy. d. auscultate carotid arteries for the presence of a bruit. ANS: C This study source was downloaded by from CourseH on :47:17 GMT -05:00 ASSESSMENT OF CARDIOVASCULAR SYSTEM The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease. DIF: Cognitive Level: Analyze (analysis) REF: 667 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. diaphragm of the stethoscope with the patient lying flat. b. bell of the stethoscope with the patient in the left lateral position. c. diaphragm of the stethoscope with the patient in a supine position. d. bell of the stethoscope with the patient sitting and leaning forward. ANS: B Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2. DIF: Cognitive Level: Apply (application) REF: 668 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review? a. Troponin c. Low-density lipoprotein (LDL) b. Homocysteine (Hcy) d. B-type natriuretic peptide (BNP) ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL). DIF: Cognitive Level: Apply (application) REF: 670 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart. ANS: D This study source was downloaded by from CourseH on :47:17 GMT -05:00 Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary. DIF: Cognitive Level: Apply (application) REF: 667 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. it will be important not to move at all during the procedure. b. monitored anesthesia care will be provided during the procedure. c. a flushed feeling may be noticed when the contrast dye is injected. d. arterial pressure monitoring will be required for 24 hours after the test