Heart and Peripheral Vascular System

1. A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse’s appropriate response? The 128 represents the pressure in your blood vessels when:
a. “The ventricles relax and the aortic and pulmonic valves open.”
b. “The ventricles contract and the mitral and tricuspid valves close.”
c. “The ventricles contract and the mitral and tricuspid valves open.”
d. “The ventricles relax and the aortic and pulmonic valves close.”
ANS: B

Feedback
A The aortic and pulmonic valves open during systole, but ventricles fill during diastole.
B During systole the ventricles contract, creating a pressure that closes the atrioventricular (AV) valves (mitral and tricuspid).
C During systole the ventricles contract, creating a pressure that closes the AV valves (mitral and tricuspid).
D The ventricles are relaxed and the aortic and pulmonic valves close during diastole, rather than systole.
DIF: Cognitive Level: Understand REF: 225
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

2. A nurse determines that a patient has a heart rate of 42 beats per minute. What might be a cause of this heart rate?
a. Sinoatrial (SA) node failure
b. Atrial bradycardia
c. A well-conditioned heart muscle
d. Left ventricular hypertrophy
ANS: A

Feedback
A If the SA node is ineffective, the atrioventricular node may initiate contraction, but at a rate of 40 to 60 beats/min.
B The heart rate reflects the ventricular rate rather than the atrial rate.
C Although well-conditioned athletes may have slower heart rates, this rate is too slow for even an athlete.
D Left ventricular hypertrophy alters the strength of contraction rather than the heart rate.
DIF: Cognitive Level: Apply REF: 226
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

3. While taking a history, a nurse learns that a patient had rheumatic heart disease as a child. Based on this information, what abnormal data might this nurse expect to find during an examination?
a. An extra beat just before the S2 heart sound heard during auscultation
b. A raspy machine-like or blowing sound heard during auscultation
c. A prominent thrust of the heart against the chest wall felt on palpation
d. A visible indentation of pericardial tissue noted during inspection
ANS: B

Feedback
A An extra beat just before the S1 heart sound heard during auscultation is a description of the S4 heart sound that occurs when there is hypertrophy of the ventricle.
B A raspy machine-like or blowing sound heard during auscultation is a description of a murmur that can develop after rheumatic heart disease.
C A prominent thrust of the heart against the chest wall felt on palpation is a description of a heave, which may occur from left ventricular hypertrophy due to increased workload.
D A visible indentation of pericardial tissue noted during inspection is a description of a retraction that begins in the intercostal spaces and occurs with increased respiratory effort.
DIF: Cognitive Level: Analyze REF: 229| 259
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

4. A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient’s chest pain?
a. Stable angina
b. Esophageal reflux disease
c. Mitral valve prolapse
d. Costochondritis
ANS: D

Feedback
A Physical exertion, emotional stress, and cold worsen the chest pain associated with stable angina.
B A spicy or acidic meal, alcohol, or lying supine may worsen the chest pain associated with esophageal reflux.
C Only occasional position changes worsen the chest pain associated with mitral valve prolapse.
D Coughing, deep breathing, laughing, and sneezing worsen the chest pain associated with costochondritis.
DIF: Cognitive Level: Apply REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

5. The patient describes her chest pain as “squeezing, crushing, and 12 on a scale of 10.” This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms?
a. Tachycardia, tachypnea, and hypertension
b. Dyspnea, diaphoresis, and palpitations
c. Hyperventilation, fatigue, anorexia, and emotional strain
d. Fever, dyspnea, orthopnea, and friction rub
ANS: B

Feedback
A Tachycardia, tachypnea, and hypertension are symptoms associated with cocaine-induced chest pain.
B Dyspnea, diaphoresis, and palpitations are symptoms associated with unstable angina.
C Hyperventilation, fatigue, anorexia, and emotional strain are symptoms associated with panic disorder.
D Fever, dyspnea, orthopnea, and friction rub are symptoms associated with pericarditis.
DIF: Cognitive Level: Analyze REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

6. When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound?
a. A systolic murmur
b. An S3 heart sound
c. A friction rub
d. An S4 heart sound
ANS: C

Feedback
A Most systolic murmurs are caused by obstruction of the outflow of the semilunar valves or by incompetent AV valves.
B An S3 heart sound occurs when there is heart failure.
C Two classic findings of pericarditis are pericardial friction rub and chest pain.
D An S4 heart sound occurs when there is hypertrophy of the ventricle.
DIF: Cognitive Level: Apply REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

7. Which patient’s statement helps a nurse distinguish between chest pain originating from pericarditis rather than from angina?
a. “No, I have not done anything to strain chest muscles.”
b. “If I take a deep breath, the pain gets much worse.”
c. “This pain feels like there’s an elephant sitting on my chest.”
d. “Whenever this pain happens, it goes right away if I lie down.”
ANS: B

Feedback
A Chest pain from muscle strain may be aggravated by movement of arms.
B The chest pain from pericarditis is aggravated by deep breathing, coughing, or lying supine.
C “This pain feels like there’s an elephant sitting on my chest” is associated with a myocardial infarction.
D Chest pain relieved by rest occurs with angina.
DIF: Cognitive Level: Analyze REF: 230-231
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

8. While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination?
a. Flat jugular neck veins
b. Red, shiny skin on the legs
c. Weak, thready peripheral pulses
d. Edema of the feet and ankles
ANS: D

Feedback
A Flat jugular veins indicate a fluid deficit, which is not associated with dyspnea.
B Red, shiny skin on the legs is associated with peripheral arterial disease and is not associated with dyspnea.
C Weak, thready peripheral pulses indicate fluid deficit, which is not associated with dyspnea.
D This patient may have heart failure. Edema of the feet occurs with right ventricular heart failure. Dyspnea occurs with left ventricular heart failure.
DIF: Cognitive Level: Analyze REF: 230| 232-233
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

9. A nurse is assessing a patient’s peripheral circulation. Which finding indicates venous insufficiency of this patient’s legs?
a. Paresthesias and weak, thin peripheral pulses
b. Leg pain that can be relieved by walking
c. Edema that is worse at the end of the day
d. Leg pain that increases when the legs are lowered
ANS: C

Feedback
A Paresthesias and weak, thin peripheral pulses are characteristics of arterial insufficiencies rather than venous.
B Pain caused by arterial insufficiency gets worse by walking, because walking requires additional arterial blood.
C Dependent edema is an indication of venous insufficiency.
D Arterial pain is relieved by lowering the leg and aggravated by elevating the legs.
DIF: Cognitive Level: Apply REF: 233| 255
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

10. A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient?
a. 1+ edema of the feet and ankles bilaterally
b. The circumference of the right leg is larger than the left leg
c. Patchy petechiae and purpura of the lower extremities
d. Cool feet with capillary refill of toes greater than 3 seconds
ANS: D

Feedback
A Edema of 1+ of the feet and ankles bilaterally is an indication of a venous problem rather than an arterial problem.
B When one leg is larger in circumference than the other, it could be due to lymphedema or a deep vein thrombosis.
C Petechiae and purpura of the lower extremities indicate a bleeding problem, such as low platelets, rather than an arterial problem.
D The pain while walking that is relieved by rest is called intermittent claudication and is an indication of arterial insufficiency. Cool feet and prolonged capillary refill also occur due to arterial insufficiency.
DIF: Cognitive Level: Analyze REF: 233| 241
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

11. How does a nurse accurately palpate carotid pulses?
a. Two fingers of each hand are placed firmly over the right and left temples at the same time.
b. One finger is placed gently in the space between the biceps and triceps muscles.
c. Two fingers are placed at the thumb side of the forearm at the wrist.
d. One finger is placed along the right and then the left medial sternocleidomastoid muscle.
ANS: D

Feedback
A Two fingers of each hand placed firmly over the right and left temples at the same time is the correct procedure for palpating the temporal pulse.
B One finger placed gently in the space between the biceps and triceps muscles is the correct procedure for palpating the brachial pulse.
C Two fingers placed at the thumb side of the forearm at the wrist is the correct procedure for palpating the radial pulse.
D One finger placed along the right and then the left medial sternocleidomastoid muscle is the correct procedure for palpating the carotid pulses, checking each side separately.
DIF: Cognitive Level: Understand REF: 234-235
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

12. To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm?
a. “Rhythm 100 beats/min”
b. “Irregular rhythm”
c. “Rhythm noted at +2”
d. “Bounding rhythm”
ANS: B

Feedback
A This notation refers to the rate rather than the rhythm.
B The rhythm should be an equal pattern or spacing between beats. Irregular rhythms without any pattern should be noted.
C This notation refers to the amplitude rather than the rhythm.
D This notation refers to the contour rather than the rhythm.
DIF: Cognitive Level: Apply REF: 236
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

13. A nurse expects which finding during a cardiovascular assessment of a healthy adult?
a. Visible, consistent pulsations of the jugular vein
b. Pink nail beds with a 90-degree angle at the base
c. Capillary refill of the toes greater than 5 seconds
d. Bruits heard on auscultation of the carotid arteries
ANS: A

Feedback
A Visible, consistent pulsations of the jugular vein is an expected finding.
B Pink nail beds with a 90-degree angle at the base is not a normal finding; the angle at the base should be 160 degrees.
C Capillary refill of the toes greater than 5 seconds is not a normal finding. Capillary refills should be 2 seconds or less.
D Bruits heard on auscultation of the carotid arteries is not a normal finding. Bruits indicate occlusion of a blood vessel.
DIF: Cognitive Level: Apply REF: 235| 237
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

14. Which pulse may be a challenge for a nurse to palpate?
a. Temporal
b. Femoral
c. Popliteal
d. Dorsalis pedis
ANS: C

Feedback
A The temporal pulse is palpated over the temporal bone on each side of the head.
B For the femoral pulse, palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac.
C For the popliteal pulse, palpate the popliteal artery behind the knee in the popliteal fossa to assess perfusion. This pulse may be difficult to find.
D For the dorsalis pedis pulse, palpate on the inner aspect of the ankle below and slightly behind the medial malleolus (ankle bone).
DIF: Cognitive Level: Understand REF: 241-242
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

15. When assessing a patient with aortic valve stenosis, the nurse listens for which sound to detect a thrill?
a. Sustained thrust of the heart against the chest wall during systole
b. Visible sinking of the tissues between and around the ribs
c. Fine, palpable vibration felt over the precordium
d. Bounding pulse noted bilaterally
ANS: C

Feedback
A A sustained thrust of the heart against the chest wall during systole is a description of a lift.
B A visible sinking of the tissues between and around the ribs is a description of a retraction.
C A thrill is a palpable vibration over the precordium or artery.
D A thrill feels like a palpable vibration rather than a bounding pulse.
DIF: Cognitive Level: Understand REF: 243| 248
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

16. A nurse is having difficulty auscultating a patient’s heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds?
a. Lie in a supine position.
b. Cough.
c. Hold his or her breath for a few seconds.
d. Sit up and lean forward.
ANS: C

Feedback
A Lying in a supine position will not reduce the noise of breathing.
B Coughing may clear some secretions, but when the lung sounds are so noisy that the heart sounds are difficult to hear, coughing is not sufficient to eliminate the noise from respirations.
C Holding the breath for a few seconds eliminates the noise of breathing long enough to hear several cardiac cycles of heart sounds. The holding of the breath can be repeated if needed to hear the heart sounds again.
D Sitting up and leaning forward brings the heart closer to the thoracic wall, but will not eliminate noise produced by the lungs.
DIF: Cognitive Level: Analyze REF: 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

17. While assessing edema on a male patient’s lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient’s leg. How does the nurse document this finding?
a. No edema
b. 1+ edema
c. 2+ edema
d. 3+ edema
ANS: B

Feedback
A No pit left after palpation indicates no edema.
B A barely perceptible pit is detected after palpation.
C A deeper pit that rebounds in a few seconds after palpation is 2+ edema.
D A deep pit that rebounds in 10 to 20 seconds after palpation is 3+ edema.
DIF: Cognitive Level: Apply REF: 238
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

18. Where does a nurse place a stethoscope to auscultate the mitral valve area? Choose the letter that corresponds to the correct stethoscope placement.

a. A
b. B
c. D
d. E
ANS: D

Feedback
A A is the location of the aortic valve area—second intercostal space, right sternal border.
B B is the location of the pulmonic valve area—fifty-second intercostal space, left sternal border.
C D is the location of the tricuspid valve area—fourth intercostal space, left sternal border.
D E is the location of the mitral valve area—the fifth intercostal space, midclavicular line.
DIF: Cognitive Level: Understand REF: 245-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

19. Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border?
a. Pulmonic
b. Tricuspid
c. Mitral
d. Aortic
ANS: B

Feedback
A Pulmonic valve sounds are best heard in the second intercostal space at the left of the sternal border.
B Tricuspid valve sounds are best heard in the fourth intercostal space at the left of the sternal border.
C Mitral valve sounds are best heard in the fifth intercostal space at the midclavicular line.
D Aortic valve sounds are best heard in the second intercostal space at the right of the sternal border.
DIF: Cognitive Level: Remember REF: 245-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

20. A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment?
a. S4 heart sound
b. Clubbing of fingers
c. Splitting of the S1 heart sound
d. Pericardial friction rub
ANS: A

Feedback
A An S4 heart sound signifies a noncompliant or “stiff’’ ventricle. Coronary artery disease is a major cause of a stiff ventricle.
B Clubbing of fingers occurs due to chronic hypoxia rather than a stiff ventricle.
C Splitting of the S1 heart sound indicates a valve problem rather than ventricular hypertrophy. When the mitral and tricuspid valves do not close at the same time, S1 sounds as if it were split into two sounds instead of one.
D Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.
DIF: Cognitive Level: Apply REF: 225-226| 248
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

21. What does the S2 heart sound represent?
a. The beginning of systole.
b. The closure of the aortic and pulmonic valves.
c. The closure of the tricuspid and mitral values
d. A split heard sound on exhalation
ANS: B

Feedback
A The beginning of systole is the S1 heart sound.
B The second heart sound is made by the closing of these valves, which indicates the beginning of diastole.
C The tricupid and mitral valves create the S1 heart sound.
D A split sound on exhalation is not a correct statement.
DIF: Cognitive Level: Remember REF: 226| 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

22. How is the first heart sound (S1) created?
a. Pulmonic and tricuspid valves close.
b. Mitral and aortic valves close.
c. Aortic and pulmonic valves close.
d. Mitral and tricuspid valves close.
ANS: D

Feedback
A The pulmonic and tricuspid valves are the valves of the right side of the heart, and they do not close simultaneously in the cardiac cycle.
B The mitral and aortic valves are the valves of the left side of the heart, and they do not close simultaneously in the cardiac cycle.
C The aortic and pulmonic valves are the semilunar valves that create the second heart sound.
D The first heart sound (S1) is made by the closing of the mitral (M1) and tricuspid (T1) valves.
DIF: Cognitive Level: Remember REF: 226| 244
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

23. A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve?
a. Second intercostal space, right sternal border
b. Second intercostal space, left sternal border
c. Fourth intercostal space, left sternal border
d. Fifth intercostal space, left midclavicular line
ANS: A

Feedback
A Second intercostal space, right sternal border is the location for listening to the aortic valve.
B Second intercostal space, left sternal border is the location for listening to the pulmonic valve.
C Fourth intercostal space, left sternal border is the location for listening to the tricuspid valve.
D Fifth intercostal space, left midclavicular line is the location for listening to the mitral valve.
DIF: Cognitive Level: Apply REF: 244-246
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

24. A nurse who is auscultating a patient’s heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding?
a. An opening snap
b. A diastolic murmur
c. A systolic murmur
d. A pericardial friction rub
ANS: C

Feedback
A An opening snap is caused by the opening of the mitral or tricuspid valve and is an abnormal sound heard in diastole when either valve is thickened, stenotic, or deformed. The sounds are high pitched and occur early in diastole.
B A diastolic murmur is heard after the S2 heart sound at the beginning of diastole.
C The blowing sound is a murmur. The nurse determines whether it is a systolic or a diastolic murmur based on where it is heard during the cardiac cycle. S1 indicates the beginning of systole; the sound is made by the closing of the mitral and tricuspid valves, which is followed by ventricular contraction or systole.
D Pericardial friction rubs have a rubbing sound that is usually present in both diastole and systole, and is best heard over the apical area.
DIF: Cognitive Level: Apply REF: 248-249
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

25. A nurse determines that a patient’s jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find?
a. Weight loss
b. Tented skin turgor
c. Peripheral edema
d. Capillary refill greater than 5 seconds
ANS: C

Feedback
A Weight loss occurs with loss of fluid rather than fluid overload.
B Tented skin turgor occurs with fluid loss rather than fluid overload.
C The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A pressure of 3.5 inches indicates fluid volume excess, which causes peripheral edema due to excessive fluid in blood vessels.
D Capillary refill greater than 5 seconds occurs with arterial insufficiency rather than fluid overload.
DIF: Cognitive Level: Analyze REF: 252-253| 260-261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

26. How does a nurse assess the competence of venous valves in patients who have varicose veins?
a. Notes how quickly veins fill after lifting one leg above the level of the heart
b. Assesses for Homan sign in both lower extremities while the patient is supine
c. Assesses capillary refill on the toes of both feet while the patient is sitting in the chair
d. Measures the circumference of both calves and compares the results
ANS: A

Feedback
A Noting how quickly veins fill after lifting one leg above the level of the heart is the procedure to test for incompetent veins.
B Homan sign is an unreliable test for deep vein thrombosis.
C Assessing capillary refill assesses perfusion (blood flow from arteries) rather than competence of venous valves.
D Measuring the circumference of both calves and comparing the results is used to assess deep vein thrombosis.
DIF: Cognitive Level: Apply REF: 255
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

27. Which patient does the nurse identify as the one at greatest risk for hypertension?
a. Woman with coronary artery disease
b. Hispanic male
c. Obese male with diabetes mellitus
d. Postmenopausal woman
ANS: C

Feedback
A Although hypertension is a risk factor for coronary artery disease, coronary artery disease is not a risk factor for hypertension.
B Although male gender is a risk factor, African-American men have a greater risk than Hispanic men.
C Obese men with diabetes mellitus have three risk factors: obesity, gender, and comorbidity of diabetes mellitus.
D Postmenopausal women do not have an increased risk for developing hypertension.
DIF: Cognitive Level: Apply REF: 260
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs

28. After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings?
a. Visit 1, 118/78; Visit 2, 116/76
b. Visit 1, 130/88; Visit 2, 134/88
c. Visit 1, 144/92; Visit 2, 150/90
d. Visit 1, 162/100; Visit 2, 166/104
ANS: C

Feedback
A These readings are within normal limits.
B These readings are prehypertension because the systolic pressures are 120 to 139 and diastolic pressures are greater than 80 mm Hg.
C These readings are stage 1 because the systolic pressures are 140 to 159 and diastolic pressures are 90 mm Hg or greater.
D These readings are stage 2 because the systolic pressures are greater than 160 and diastolic pressures are 100 mm Hg or greater.
DIF: Cognitive Level: Analyze REF: 261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

MULTIPLE RESPONSE

1. During a health fair, the nurse is alert for which risk factors for hypertension? Select all that apply.
a. Excessive protein intake
b. Having parents with hypertension
c. Excessive alcohol intake
d. Being Asian
e. Experiencing persistent stress
f. Elevated serum lipids
ANS: B, C, E, F
Correct: These are all risk factors for hypertension.
Incorrect: Excessive protein is not a risk factor for hypertension, but excessive sodium intake is a risk factor. Being Asian is not a risk factor, but being African-American is a risk factor.

DIF: Cognitive Level: Analyze REF: 261
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems

2. A patient with heart failure reports having a cough with frothy sputum and awakening during the night to urinate. Based on this information, what abnormal data might this nurse expect to find during an examination? Select all that apply.
a. S4 heart sound
b. Dyspnea
c. Jugular vein distention
d. Pericardial friction rub
e. Edema of ankle and feet at the end of the day
f. S3 heart sound
ANS: B, C, E, F
Correct: All of these manifestations are consistent with fluid overload that occurs in heart failure because the cardiac output is decreased.
Incorrect: S4 heart sounds signifies a noncompliant or “stiff’’ ventricle. Hypertrophy of the ventricle precedes a noncompliant ventricle. Also, coronary artery disease is a major cause of a stiff ventricle. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac.

DIF: Cognitive Level: Analyze REF: 230| 233| 238| 247| 252-253| 260
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

3. What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply.
a. Heart rate of 102 beats/min
b. S1 and S2 present with regular rhythm
c. Capillary refill greater than 3 seconds
d. Blood pressure of 124/86
e. Warm, elastic turgor
f. Pulse of smooth contour with 2+ amplitude
ANS: B, E, F
Correct: These are all expected findings.
Incorrect: A heart rate of 102 beats/min is tachycardia. Capillary refill should be 2 seconds or less. Blood pressure of 124/86 is prehypertension. Normal is less than 120 and less than 80 mm Hg.

DIF: Cognitive Level: Analyze REF: 238-239| 241| 244| 259
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

COMPLETION

1. A patient’s blood pressure using the posterior tibial pulse is 104/72 while blood pressure using the brachial pulse is 112/84. This patient’s ankle-brachial index (ABI) is _____.

ANS:
0.92
Posterior tibial systolic pressure (104) divided by the brachial systolic pressure (112) = 0.92. The systolic pressures are the numbers used to calculate the ABI.

DIF: Cognitive Level: Apply REF: 256
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments