NSG 3160: CH. 20: HEART & NECK VESSELS
QUESTIONS WITH COMPLETE SOLUTIONS
A 25-year-old woman in her fifth month of pregnancy has a
blood pressure of 100/70 mm Hg. In reviewing her previous
examination, the nurse notes that her blood pressure in her
second month was 124/80 mm Hg. In evaluating this change,
what does the nurse know to be true?
a. This decline in blood pressure is the result of peripheral
vasodilatation and is an expected change.
b. Because of increased cardiac output, the blood pressure
should be higher at this time.
c. This change in blood pressure is not an expected finding
because it means a decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating
blood volume, which is dangerous for the fetus. Correct
Answers A
A 30-year-old woman with a history of mitral valve problems
states that she has been "very tired." She has started waking up
at night and feels like her "heart is pounding." During the
assessment, the nurse palpates a thrill and lift at the fifth left
intercostal space midclavicular line. In the same area, the nurse
also auscultates a blowing, swishing sound right after the S1.
What do these findings most likely indicate?
a. Heart failure
b. Aortic stenosis
c. Pulmonary edema
d. Mitral regurgitation Correct Answers D
,A 45-year-old man is in the clinic for a routine physical
examination. During the recording of his health history, the
patient states that he has been having difficulty sleeping. "I'll be
sleeping great, and then I wake up and feel like I can't get my
breath." Which is the best response by the nurse?
a. "When was your last electrocardiogram?"
b. "It's probably because it's been so hot at night."
c. "Do you have any history of problems with your heart?"
d. "Have you had a recent sinus infection or upper respiratory
infection?" Correct Answers C
A 70-year-old patient with a history of hypertension has a blood
pressure of 180/100 mm Hg and a heart rate of 90 beats per
minute. The nurse hears an extra heart sound at the apex
immediately before the S1. The sound is heard only with the bell
of the stethoscope while the patient is in the left lateral position.
Based on these findings and the patient's history, the nurse
should recognize this extra heart sound is most likely what?
a. Split S1
b. Atrial gallop
c. Diastolic murmur
d. Summation sound Correct Answers B
A patient has been admitted with chronic arterial symptoms.
During the assessment, the nurse would expect which findings?
(Select all that apply.)
a. Skin of the patient is pale and cool.
b. His ankles have two small, weeping ulcers.
c. He states that the pain gets worse when walking.
d. Patient works long hours sitting at a computer desk.
e. Patient has a history of diabetes and cigarette smoking.
, f. Patient states that the pain is worse at the end of the day.
Correct Answers A,C,E
A patient has been diagnosed with venous stasis. Which finding
would the nurse most likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg Correct
Answers D
A patient has hard, nonpitting edema of the left lower leg and
ankle. The right leg has no edema. When interpreting these
findings, what would the nurse recall?
a. Alterations in arterial function will cause edema.
b. Nonpitting, hard edema occurs with lymphatic obstruction.
c. Phlebitis of a superficial vein will cause bilateral edema.
d. Long-standing arterial obstruction will cause pitting edema.
Correct Answers B
A patient is experiencing pain in the left calf when they exercise
which disappears after resting for a few minutes. What problem
in the left leg does this indicate?
a. Venous obstruction
b. Partial blockage of an artery
c. Claudication due to venous abnormalities
d. Ischemia caused by the complete blockage of an artery
Correct Answers B
A patient is recovering from several hours of orthopedic surgery.
During an assessment of the patient's lower legs, the nurse will
QUESTIONS WITH COMPLETE SOLUTIONS
A 25-year-old woman in her fifth month of pregnancy has a
blood pressure of 100/70 mm Hg. In reviewing her previous
examination, the nurse notes that her blood pressure in her
second month was 124/80 mm Hg. In evaluating this change,
what does the nurse know to be true?
a. This decline in blood pressure is the result of peripheral
vasodilatation and is an expected change.
b. Because of increased cardiac output, the blood pressure
should be higher at this time.
c. This change in blood pressure is not an expected finding
because it means a decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating
blood volume, which is dangerous for the fetus. Correct
Answers A
A 30-year-old woman with a history of mitral valve problems
states that she has been "very tired." She has started waking up
at night and feels like her "heart is pounding." During the
assessment, the nurse palpates a thrill and lift at the fifth left
intercostal space midclavicular line. In the same area, the nurse
also auscultates a blowing, swishing sound right after the S1.
What do these findings most likely indicate?
a. Heart failure
b. Aortic stenosis
c. Pulmonary edema
d. Mitral regurgitation Correct Answers D
,A 45-year-old man is in the clinic for a routine physical
examination. During the recording of his health history, the
patient states that he has been having difficulty sleeping. "I'll be
sleeping great, and then I wake up and feel like I can't get my
breath." Which is the best response by the nurse?
a. "When was your last electrocardiogram?"
b. "It's probably because it's been so hot at night."
c. "Do you have any history of problems with your heart?"
d. "Have you had a recent sinus infection or upper respiratory
infection?" Correct Answers C
A 70-year-old patient with a history of hypertension has a blood
pressure of 180/100 mm Hg and a heart rate of 90 beats per
minute. The nurse hears an extra heart sound at the apex
immediately before the S1. The sound is heard only with the bell
of the stethoscope while the patient is in the left lateral position.
Based on these findings and the patient's history, the nurse
should recognize this extra heart sound is most likely what?
a. Split S1
b. Atrial gallop
c. Diastolic murmur
d. Summation sound Correct Answers B
A patient has been admitted with chronic arterial symptoms.
During the assessment, the nurse would expect which findings?
(Select all that apply.)
a. Skin of the patient is pale and cool.
b. His ankles have two small, weeping ulcers.
c. He states that the pain gets worse when walking.
d. Patient works long hours sitting at a computer desk.
e. Patient has a history of diabetes and cigarette smoking.
, f. Patient states that the pain is worse at the end of the day.
Correct Answers A,C,E
A patient has been diagnosed with venous stasis. Which finding
would the nurse most likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg Correct
Answers D
A patient has hard, nonpitting edema of the left lower leg and
ankle. The right leg has no edema. When interpreting these
findings, what would the nurse recall?
a. Alterations in arterial function will cause edema.
b. Nonpitting, hard edema occurs with lymphatic obstruction.
c. Phlebitis of a superficial vein will cause bilateral edema.
d. Long-standing arterial obstruction will cause pitting edema.
Correct Answers B
A patient is experiencing pain in the left calf when they exercise
which disappears after resting for a few minutes. What problem
in the left leg does this indicate?
a. Venous obstruction
b. Partial blockage of an artery
c. Claudication due to venous abnormalities
d. Ischemia caused by the complete blockage of an artery
Correct Answers B
A patient is recovering from several hours of orthopedic surgery.
During an assessment of the patient's lower legs, the nurse will
