Week 4

Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 320

Chapter 19: Heart and Neck Vessels

1. The sac that surrounds and protects the heart is called the:
2. The direction of blood flow through the heart is best described by which of these?
3. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?
4. When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:
5. Which of these statements describes the closure of the valves in a normal cardiac cycle?
6. The component of the conduction system referred to as the pacemaker of the heart is the:
7. The electrical stimulus of the cardiac cycle follows which sequence?
8. The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
9. When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?
10. 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?
11. In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age?
12. 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 cant get my breath. The nurse's best response to this would be:
13. In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a  history?
14. The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
15. In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:
16. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
17. During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
18. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
19. The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
20. The nurse is preparing to auscultate for heart sounds. Which technique is correct?
21. While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurses response?
22. When listening to heart sounds, the nurse knows that the S1:
23. During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
24. Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?
25. While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?
26. During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:
27. In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
28. 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. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n):
29. The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:
30. The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?
31. 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. These findings would be most consistent with:
32. During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?
33. The nurse knows that normal splitting of the S2 is associated with:
34. During a cardiovascular assessment, the nurse knows that a thrill is:
35. During a cardiovascular assessment, the nurse knows that an S4 heart sound is:
36. During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:
37. When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?
38. The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?
39. The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage?
40. The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

MULTIPLE RESPONSE

1. The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply.

SHORT ANSWER

1. The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit?

Chapter 20: Peripheral Vascular System and Lymphatic System

MULTIPLE CHOICE

1. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.
2. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?
3. A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg.
4. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
5. Which vein(s) is(are) responsible for most of the venous return in the arm?
6. A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed? The nurse should reply:
7. The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?
8. The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
9. When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?
10. A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
11. The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?
12. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?
13. A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
14. A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:
15. During an assessment, the nurse uses the profile sign to detect:
16. The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
17. When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
18. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
19. The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse.
20. The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
21. A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?
22. The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
23. When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:
24. How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
25. A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:
26. When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:
27. During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:
28. During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?
29. During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with non pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?
30. The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?
31. The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?
32. When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?
33. The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?
34. During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
35. During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that won't heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well- defined edges, and no drainage. The nurse should assess for other signs and symptoms of:
36. The nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse?

MULTIPLE RESPONSE

1. A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply.
2. A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply.