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
, 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
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
, 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
