Chapter 25: Assessment of Cardiovascular Function (Brunner)

1. A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? A) Systole B) Diastole C) Repolarization D) Ejection fraction - Ans: A Feedback: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization (electrical charging). 2. During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum - : B Feedback: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space. 3. The nurse is calculating a cardiac patients pulse pressure. If the patients blood pressure is 122/76 mm Hg, what is the patients pulse pressure? A) 46 mmHg B) 99 mmHg C) 198 mmHg D) 76 mmHg - Ans: A Feedback: Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg. 4. The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A) This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B) Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. C) This is an accurate indicator of myocardial injury. D) This result indicates muscle injury, but does not specify the source. - Ans: C Feedback: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator