Clinical Guidelines in Primary Care 4th Edition Latest Update 2025 Questions Fully Solved
The nurse is aware that the muscle layer of the heart, which is responsible for the heart's contraction, is
the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium. - Answers d. myocardium.
The myocardium is the specialized muscle layer that allows the heart to contract.
The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His. - Answers c. sinoatrial (SA) node.
The SA node is the master pacemaker of the heart.
The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women
because acute chest pain is not present. Women are frequently misdiagnosed as having:
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications. - Answers b. indigestion.
Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women
having an MI.
The nurse identifies the "LUBB" sound of the "LUBB/DUBB" of the cardiac cycle as the sound of the:
a. AV valves closing.
,b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles. - Answers a. AV valves closing.
The LUBB is the first sound of a low pitch heard when the AV valves close.
A patient is admitted from the emergency department. The emergency department physician notes the
patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV.
This indicates the patient's condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure. - Answers b. severe heart failure.
Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or
symptoms of cardiac inefficiency may develop at rest.
The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does
have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is
aware that using the American College of Cardiology and the American Heart Association (ACC/AHA)
staging, this patient would be a:
a. stage A.
b. stage B.
c. stage C.
d. stage D. - Answers a. stage A.
The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary
conditions associated with the development of the disease.
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry
recognizes the need for added instruction when the patient says:
a. "I can ambulate in the hallway with this gadget on."
, b. "I always take off the telemetry device when I shower."
c. "My EKG is being watched by one of the nurses in CCU on the home unit."
d. "I am able to sleep just fine with this device on." - Answers b. "I always take off the telemetry device
when I shower."
Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location.
The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor
to shower.
The nurse assesses pitting edema that can be depressed approximately inch and refills in 15 seconds.
The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema. - Answers b. +2 edema.
A +2 edema can be documented if the skin can be depressed inch and respond within 15 seconds.
What do dark or "cold" spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion - Answers d. Tissue that has inadequate perfusion
Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or "cold spots"
indicate tissues that have inadequate perfusion.
The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication
of:
a. normal heart action.
b. mild heart failure.
The nurse is aware that the muscle layer of the heart, which is responsible for the heart's contraction, is
the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium. - Answers d. myocardium.
The myocardium is the specialized muscle layer that allows the heart to contract.
The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His. - Answers c. sinoatrial (SA) node.
The SA node is the master pacemaker of the heart.
The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women
because acute chest pain is not present. Women are frequently misdiagnosed as having:
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications. - Answers b. indigestion.
Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women
having an MI.
The nurse identifies the "LUBB" sound of the "LUBB/DUBB" of the cardiac cycle as the sound of the:
a. AV valves closing.
,b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles. - Answers a. AV valves closing.
The LUBB is the first sound of a low pitch heard when the AV valves close.
A patient is admitted from the emergency department. The emergency department physician notes the
patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV.
This indicates the patient's condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure. - Answers b. severe heart failure.
Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or
symptoms of cardiac inefficiency may develop at rest.
The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does
have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is
aware that using the American College of Cardiology and the American Heart Association (ACC/AHA)
staging, this patient would be a:
a. stage A.
b. stage B.
c. stage C.
d. stage D. - Answers a. stage A.
The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary
conditions associated with the development of the disease.
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry
recognizes the need for added instruction when the patient says:
a. "I can ambulate in the hallway with this gadget on."
, b. "I always take off the telemetry device when I shower."
c. "My EKG is being watched by one of the nurses in CCU on the home unit."
d. "I am able to sleep just fine with this device on." - Answers b. "I always take off the telemetry device
when I shower."
Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location.
The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor
to shower.
The nurse assesses pitting edema that can be depressed approximately inch and refills in 15 seconds.
The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema. - Answers b. +2 edema.
A +2 edema can be documented if the skin can be depressed inch and respond within 15 seconds.
What do dark or "cold" spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion - Answers d. Tissue that has inadequate perfusion
Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or "cold spots"
indicate tissues that have inadequate perfusion.
The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication
of:
a. normal heart action.
b. mild heart failure.
