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Unformatted text preview: Jarvis: Physical Examination & Health Assessment, 7th Edition
Chapter 19: Heart and Neck Vessels
1. The sac that surrounds and protects the heart is called the:
d Pleural space.
The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It
has two layers that contain a few milliliters of serous pericardial fluid.
2. The direction of blood flow through the heart is best described by which of these?
a Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle
b Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle
c Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava
d Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle
Returning blood from the body empties into the right atrium and flows into the right ventricle
and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is
then returned to the left atrium through the pulmonary vein. The blood goes from there to the left
ventricle and then out to the body through the aorta.
3. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement
best describes what is meant by atrial kick?
a The atria contract during systole and attempt to push against closed valves.
b Contraction of the atria at the beginning of diastole can be felt as a palpitation.
c Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.
d The atria contract toward the end of diastole and push the remaining blood into the ventricles.
Toward the end of diastole, the atria contract and push the last amount of blood (approximately
25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial
systole, or sometimes the 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:
a Mitral and tricuspid. b Tricuspid and aortic.
c Aortic and pulmonic.
d Mitral and pulmonic.
The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic)
valves and signals the end of systole. Although it is heard over all the precordium, the S2 is
loudest at the base of the heart.
5. Which of these statements describes the closure of the valves in a normal cardiac cycle?
a The aortic valve closes slightly before the tricuspid valve.
b The pulmonic valve closes slightly before the aortic valve.
c The tricuspid valve closes slightly later than the mitral valve.
d Both the tricuspid and pulmonic valves close at the same time.
Events occur just slightly later in the right side of the heart because of the route of myocardial
depolarization. As a result, two distinct components to each of the heart sounds exist, and
sometimes they can be heard separately. In the first heart sound, the mitral component (M1)
closes just before the tricuspid component (T1).
6. The component of the conduction system referred to as the pacemaker of the heart is the:
a Atrioventricular (AV) node.
b Sinoatrial (SA) node.
c Bundle of His.
d Bundle branches.
Specialized cells in the SA node near the superior vena cava initiate an electrical impulse.
Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart.
7. The electrical stimulus of the cardiac cycle follows which sequence?
a AV node SA node bundle of His
b Bundle of His AV node SA node
c SA node AV node bundle of His bundle branches
d AV node SA node bundle of His bundle branches
ANS: C Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The
current flows in an orderly sequence, first across the atria to the AV node low in the atrial
septum. There it is delayed slightly, allowing the atria the time to contract before the ventricles
are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches,
and then through the ventricles.
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:
a Decreased fluid volume.
b Increased cardiac output.
c Narrowing of jugular veins.
d Elevated pressure related to heart failure.
Because no cardiac valve exists to separate the superior vena cava from the right atrium, the
jugular veins give information about the activity on the right side of the heart. They reflect filling
pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal
angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with
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?
a Increase in resting heart rate
b Increase in systolic blood pressure
c Decrease in diastolic blood pressure
d Increase in diastolic blood pressure
With aging, an increase in systolic blood pressure occurs. No significant change in diastolic
pressure and no change in the resting heart rate occur with aging. Cardiac output at rest is does
not changed with aging.
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 can’t get my breath.” The nurse’s best response to this
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?”
Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with
heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart
cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep,
arises, and flings open a window with the perception of needing fresh air.
13. In assessing a patient’s major risk factors for heart disease, which would the nurse want to
include when taking a history?
a Family history, hypertension, stress, and age
b Personality type, high cholesterol, diabetes, and smoking
c Smoking, hypertension, obesity, diabetes, and high cholesterol
d Alcohol consumption, obesity, diabetes, stress, and high cholesterol
To assess for major risk factors of coronary artery disease, the nurse should collect data
regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100
mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post
menopausal women, cigarette smoking, and low activity level.
15. In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse
a Palpate the artery in the upper one third of the neck.
b Listen with the bell of the stethoscope to assess for bruits.
c Simultaneously palpate both arteries to compare amplitude.
d Instruct the patient to take slow deep breaths during auscultation.
If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the
presence of a bruit. The nurse should avoid compressing the artery, which could create an
artificial bruit and compromise circulation if the carotid artery is already narrowed by
atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided,
and excessive vagal stimulation could slow down the heart rate, especially in older adults.
Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain.
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:
a Valvular disorder.
b Blood flow turbulence. c Fluid volume overload.
d Ventricular hypertrophy.
A bruit is a blowing, swishing sound indicating blood flow turbulence; normally, none is present.
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):
a Normal heart.
b Systolic murmur.
c Enlargement of the left ventricle.
d Enlargement of the right ventricle.
Normally, the examiner may or may not see an apical impulse; when visible, it occupies the
fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained
forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a
result of increased workload. A right ventricular heave is seen at the sternal border; a left
ventricular heave is seen at the apex.
18. During an assessment of a healthy adult, where would the nurse expect to palpate the apical
a Third left intercostal space at the midclavicular line
b Fourth left intercostal space at the sternal border
c Fourth left intercostal space at the anterior axillary line
d Fifth left intercostal space at the midclavicular line
The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be
at or medial to the midclavicular line.
19. The nurse is examining a patient who has possible cardiac enlargement. Which statement
about percussion of the heart is true?
a Percussion is a useful tool for outlining the heart’s borders.
b Percussion is easier in patients who are obese.
c Studies show that percussed cardiac borders do not correlate well with the true cardiac border.
. d Only expert health care providers should attempt percussion of the heart.
. ANS: C
Numerous comparison studies have shown that the percussed cardiac border correlates only
moderately with the true cardiac border. Percussion is of limited usefulness with the female
breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray
images or echocardiographic examinations are significantly more accurate in detecting heart
20. The nurse is preparing to auscultate for heart sounds. Which technique is correct?
a Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas
b Listening by inching the stethoscope in a rough Z pattern,
from the base of the heart across and down, then over to the apex
c Listening to the sounds only at the site where the apical pulse is felt to be the strongest
d Listening for all possible sounds at a time at each specified area
Auscultation of breath sounds should not be limited to only four locations. Sounds produced by
the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z
pattern from the base of the heart across and down, then over to the apex; or, starting at the apex,
it should be slowly worked up (see Figure 19-22). Listening selectively to one sound at a time is
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 nurse’s
a Talk with the patient about his intake of caffeine.
b Perform an electrocardiogram after the examination.
c No further response is needed because sinus arrhythmia can occur normally.
d Refer the patient to a cardiologist for further testing.
The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and
children. With sinus arrhythmia, the rhythm varies with the person’s breathing, increasing at the
peak of inspiration and slowing with expiration.
22. When listening to heart sounds, the nurse knows that the S1:
a Is louder than the S2 at the base of the heart.
b Indicates the beginning of diastole. c Coincides with the carotid artery pulse.
d Is caused by the closure of the semilunar valves.
The S1 coincides with the carotid artery pulse, is the start of systole, and is louder than the S2 at
the apex of the heart; the S2 is louder than the S1 at the base. The nurse should gently feel the
carotid artery pulse while auscultating at the apex; the sound heard as each pulse is felt is 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?
a Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.
b Ask the patient to hold his or her breath while the nurse listens again.
c No further assessment is needed because the nurse knows this sound is an S3.
d Watch the patient’s respirations while listening for the effect on the sound.
A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A
split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is
first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the
nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right
and left sides of the heart and cause the split to go away. Rather, the nurse should concentrate on
the split while watching the person’s chest rise up and down with breathing.
27. In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
a Bell of the stethoscope at the base with the patient leaning forward.
b Bell of the stethoscope at the apex with the patient in the left lateral position.
c Diaphragm of the stethoscope in the aortic area with the patient sitting.
d Diaphragm of the stethoscope in the pulmonic area with the patient supine.
The S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is
heard immediately before the S1. The S4 is a very soft sound with a very low pitch. The nurse
needs a good bell and must listen for this sound. An S4 is heard best at the apex, with the person
in the left lateral position.
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):
a Split S1. b Atrial gallop.
c Diastolic murmur.
d Summation sound.
A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance
of the ventricle and with systolic overload (afterload), including outflow obstruction to the
ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these
conditions and is heard best at the apex with the patient in the left lateral position.
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:
a Increased cardiac output.
b Another MI.
c Inflammation of the precordium.
d Ventricular hypertrophy resulting from muscle damage.
Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and
scratchy, similar to sandpaper being rubbed. A friction rub is best heard with the diaphragm of
the stethoscope, with the person sitting up and leaning forward, and with the breath held in
expiration. A friction rub can be heard any place on the precordium. Usually, however, the sound
is best heard at the apex and left lower sternal border, which are places where the pericardium
comes in close contact with the chest wall.
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:
a Heart failure.
b Aortic stenosis.
c Pulmonary edema.
d Mitral regurgitation.
These findings are consistent with mitral regurgitation. Its subjective findings include fatigue,
palpitation, and orthopnea, and its objective findings are: (1) a thrill in systole at the apex; (2) a
lift at the apex; (3) the apical impulse displaced down and to the left; (4) the S1 is diminished, the S2 is accentuated, and the S3 at the apex is often present; and (5) a pansystolic murmur that
is often loud, blowing, best heard at the apex, and radiating well to the left axilla.
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?
a Fluid overload
b Atrial septal defect
d Heart failure
Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation
becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion;
jugular vein distention; and fatigue. The S3 is associated with heart failure and is always
abnormal after 35 years of age. The S3 may be the earliest sign of heart failure.
33. The nurse knows that normal splitting of the S2 is associated with:
c Exercise state.
d Low resting heart rate.
Normal or physiologic splitting of the S2 is associated with inspiration because of the increased
blood return to the right side of the heart, delaying closure of the pulmonic valve.
34. During a cardiovascular assessment, the nurse knows that a thrill is:
a Vibration that is palpable.
b Palpated in the right epigastric area.
c Associated with ventricular hypertrophy.
d Murmur auscultated at the third intercostal space.
A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud
murmurs. The absence of a thrill does not rule out the presence of a murmur. 35. During a cardiovascular assessment, the nurse knows that an S4 heart sound is:
a Heard at the onset of atrial diastole.
b Usually a normal finding in the older adult.
c Heard at the end of ventricular diastole.
d Heard best over the second left intercostal space with the individual sitting upright.
An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when
the ventricles are resistant to filling. The S4 occurs just before the S1. 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:
a Systemic hypertension.
b Pulmonic hypertension.
c Pressure overload, as in aortic stenosis.
d Volume overload, as in heart failure.
With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally
displaces the apical impulse and is palpable over a ...
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- Fall '19