Health Assessment Exam 3 test bank
While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a
high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The
nurse would document which of the following?
A) Pericardial friction rub
B) Midsystolic click
C) Summation gallop
D) Aortic ejection click - ANS A) Pericardial friction rub
During chest auscultation, the nurse hears a quiet murmur immediately upon placing the
stethoscope on the client's chest. The nurse interprets this as which grade?
A) I
B) II
C) III
D) IV - ANS B) II
After teaching a group of students about blood flow through the heart, the instructor determines
that the teaching was successful when the students state that after being received by the atria,
the blood goes to which of the following?
A) Chordae tendineae
B) Ventricles
C) Semilunar valves
D) Precordium - ANS B) Ventricles
A group of students is reviewing the structures of the heart, noting that the thickest layer of the
heart is made up of contractile muscle cells. The students are correct in identifying it as which of
the following?
A) Myocardium
B) Epicardium
C) Endocardium
D) Pericardium - ANS A) Myocardium
A nursing student is reviewing the electrical conduction of the heart. The student is correct in
identifying the sinoatrial node of the heart as which of the following?
A) Bundle of His
B) Purkinje fibers
C) Pacemaker
D) Conduction system - ANS C) Pacemaker
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating
which heart action?
,A) Isometric contraction
B) Closure of the semilunar valves
C) Beginning of diastole
D) Closure of the atrioventricular valves - ANS d
A nurse assesses a client's jugular venous pulse to gather information about which of the
following?
A) Left arterial pressure.
B) Left ventricular diastolic filling.
C) Right ventricular pressure.
D) Hemodynamics of the right side of the heart. - ANS d
On examination, the nurse would expect what finding if a client is in right-sided failure?
A) Increased jugular venous pressure
B) Decreased right-sided volume
C) Decreased central venous pressure
D) Decreased stroke volume - ANS a
A client presents with chest pain described as a pressure and squeezing sensation that is
steady and severe. The nurse would suspect which system as the most likely source?
A) Cardiac
B) Gastrointestinal
C) Musculoskeletal
D) Pulmonary - ANS a
A client complains of palpitations and a feeling of anxiety. Which of the following would be most
appropriate for the nurse to keep in mind?
A) This is a normal response by the heart's conduction system.
B) This is the body's response to an increase in cardiac output.
C) The heart is attempting to increase cardiac output.
D) The heart is responding to increased renal perfusion. - ANS c
Which of the following would the nurse suspect when a client with a cardiac condition complains
of not sleeping well and having to get up frequently at night to urinate?
A) This indicates the heart is working efficiently.
B) Increased urination at rest may indicate heart failure.
C) The client has decreased performance levels of activities of daily living.
D) The client most likely sleeps without a pillow at night. - ANS b
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets
this finding as suggesting which of the following?
A) Decreased cardiac output
B) Increased central venous pressure
C) A narrowed vessel
, D) Right ventricular failure - ANS b
Which technique would be most appropriate to use when examining the jugular venous pulse?
A) Perform the exam with the client in a supine position.
B) Have the client look straight ahead with chin slightly lifted.
C) Have the client sit up at a 90-degree angle.
D) Inspect the suprasternal notch or around the clavicles. - ANS d
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which
location?
A) Second intercostal space, left sternal border
B) Third intercostal space, left axillary line
C) Fourth intercostal space, left sternal border
D) Fifth intercostal space, left midclavicular line - ANS d
A nurse is preparing a presentation for a local community group about coronary artery disease
and culture. Which information would the nurse include?
A) Caucasians take higher lifestyle risks than African Americans.
B) Hypertension is more prevalent in African Americans.
C) Hypertension is seen more in white women than in African-American women.
D) Hispanic Americans have a higher rate of coronary artery disease than white Americans. -
ANS b
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The
nurse would suspect which of the following?
A) Hypothyroidism
B) Fever
C) Mitral stenosis
D) Heart murmur - ANS c
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral
insufficiency?
A) Split
B) Diminished
C) Accentuated
D) Varying - ANS b
A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears
this, the nurse would place the client in which position?
A) Supine with head of bed elevated 30 degrees
B) Leaning forward while in a sitting position
C) Flat, left lateral
D) Sitting upright in a straight back chair - ANS b
While auscultating the heart at the third intercostal space, left sternal border, the nurse notes a
high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The
nurse would document which of the following?
A) Pericardial friction rub
B) Midsystolic click
C) Summation gallop
D) Aortic ejection click - ANS A) Pericardial friction rub
During chest auscultation, the nurse hears a quiet murmur immediately upon placing the
stethoscope on the client's chest. The nurse interprets this as which grade?
A) I
B) II
C) III
D) IV - ANS B) II
After teaching a group of students about blood flow through the heart, the instructor determines
that the teaching was successful when the students state that after being received by the atria,
the blood goes to which of the following?
A) Chordae tendineae
B) Ventricles
C) Semilunar valves
D) Precordium - ANS B) Ventricles
A group of students is reviewing the structures of the heart, noting that the thickest layer of the
heart is made up of contractile muscle cells. The students are correct in identifying it as which of
the following?
A) Myocardium
B) Epicardium
C) Endocardium
D) Pericardium - ANS A) Myocardium
A nursing student is reviewing the electrical conduction of the heart. The student is correct in
identifying the sinoatrial node of the heart as which of the following?
A) Bundle of His
B) Purkinje fibers
C) Pacemaker
D) Conduction system - ANS C) Pacemaker
The nurse is assessing a client's first heart sound. The nurse interprets this finding as indicating
which heart action?
,A) Isometric contraction
B) Closure of the semilunar valves
C) Beginning of diastole
D) Closure of the atrioventricular valves - ANS d
A nurse assesses a client's jugular venous pulse to gather information about which of the
following?
A) Left arterial pressure.
B) Left ventricular diastolic filling.
C) Right ventricular pressure.
D) Hemodynamics of the right side of the heart. - ANS d
On examination, the nurse would expect what finding if a client is in right-sided failure?
A) Increased jugular venous pressure
B) Decreased right-sided volume
C) Decreased central venous pressure
D) Decreased stroke volume - ANS a
A client presents with chest pain described as a pressure and squeezing sensation that is
steady and severe. The nurse would suspect which system as the most likely source?
A) Cardiac
B) Gastrointestinal
C) Musculoskeletal
D) Pulmonary - ANS a
A client complains of palpitations and a feeling of anxiety. Which of the following would be most
appropriate for the nurse to keep in mind?
A) This is a normal response by the heart's conduction system.
B) This is the body's response to an increase in cardiac output.
C) The heart is attempting to increase cardiac output.
D) The heart is responding to increased renal perfusion. - ANS c
Which of the following would the nurse suspect when a client with a cardiac condition complains
of not sleeping well and having to get up frequently at night to urinate?
A) This indicates the heart is working efficiently.
B) Increased urination at rest may indicate heart failure.
C) The client has decreased performance levels of activities of daily living.
D) The client most likely sleeps without a pillow at night. - ANS b
When auscultating the left carotid artery, the nurse notes a swishing sound. The nurse interprets
this finding as suggesting which of the following?
A) Decreased cardiac output
B) Increased central venous pressure
C) A narrowed vessel
, D) Right ventricular failure - ANS b
Which technique would be most appropriate to use when examining the jugular venous pulse?
A) Perform the exam with the client in a supine position.
B) Have the client look straight ahead with chin slightly lifted.
C) Have the client sit up at a 90-degree angle.
D) Inspect the suprasternal notch or around the clavicles. - ANS d
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which
location?
A) Second intercostal space, left sternal border
B) Third intercostal space, left axillary line
C) Fourth intercostal space, left sternal border
D) Fifth intercostal space, left midclavicular line - ANS d
A nurse is preparing a presentation for a local community group about coronary artery disease
and culture. Which information would the nurse include?
A) Caucasians take higher lifestyle risks than African Americans.
B) Hypertension is more prevalent in African Americans.
C) Hypertension is seen more in white women than in African-American women.
D) Hispanic Americans have a higher rate of coronary artery disease than white Americans. -
ANS b
A nurse auscultates a client's heart sounds and notes an accentuated first heart sound. The
nurse would suspect which of the following?
A) Hypothyroidism
B) Fever
C) Mitral stenosis
D) Heart murmur - ANS c
Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral
insufficiency?
A) Split
B) Diminished
C) Accentuated
D) Varying - ANS b
A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears
this, the nurse would place the client in which position?
A) Supine with head of bed elevated 30 degrees
B) Leaning forward while in a sitting position
C) Flat, left lateral
D) Sitting upright in a straight back chair - ANS b
