Holistic Health Assessment Exam 3
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What heart action creates the first heart sound?
A. Contraction of the heart
B. Closure of semilunar valves
C. Beginning of diastole
D. Closure of the atrioventricular valves
✓ D. Closure of the atrioventricular valves
The apex of the heart is located at the:
A. Right sternal border
B. Left sternal border
C. Lower left ventricle
D. Top of the right atrium
✓ C. Lower left ventricle
The S2 sound is caused by the:
A. Closing of the aortic and pulmonic valves
B. Opening of the mitral and tricuspid valves
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C. Opening of the aortic and pulmonic valves
D. Closing of the mitral and tricuspid valves
✓ A. Closing of the aortic and pulmonic valves
Which report by a client would suggest chest pain is cardiac in origin?
A. "My chest hurts when I cough."
B. " My chest feels really tight and heavy."
C. "I have sharp pains in my chest when I eat raw vegetables."
D. "I fell on some ice yesterday. Today my chest hurts when I breathe."
✓ B. " My chest feels really tight and heavy."
While inspecting the legs of a male client, the nurse notes the skin is shiny and taut with little
hair growth. What additional data would the nurse find to indicate that this client has
peripheral arterial disease?
A. Pitting edema of one or both feet or legs
B. Increased circumference of thighs bilaterally
C. Pale, cool legs with diminished to absent dorsalis pedis pulses
D. Pain when legs are dependent that is relieved when legs are elevated
✓ C. Pale, cool legs with diminished to absent dorsalis pedis pulses
A client has 3+ pitting edema in her feet and ankles. What does this finding mean?
A. The client has a heart murmur
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B. The client has excess fluid in the interstitial space
C. The client is having a myocardial infarction
D. The client has an elevated cholesterol
✓ B. The client has excess fluid in the interstitial space
A client reports bilateral lower extremity pain when standing but it is relieved when the legs
are elevated. On exam, the lower extremities are edematous, with rough appearing,
discolored skin. The nurse suspects:
A. Arterial insufficiency
B. Leg edema
C. Venous stasis
D. Hypertension
✓ C. Venous stasis
The primary reason to palpate the dorsalis pedis pulse is to evaluate:
A. Perfusion to the foot
B. The client's heart rate
C. Sensation to the foot
D. Reflexes within the foot
✓ A. Perfusion to the foot
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