SOLUTIONS GRADED A+
✔✔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 response? - ✔✔No further response is needed because sinus arrhythmia
can occur normally.
✔✔When listening to heart sounds, the nurse knows that S1: - ✔✔coincides with the
carotid artery pulse.
✔✔During the cardiac auscultation the nurse hears a sound occurring immediately after
S2 at the second left intercostal space. To further assess this sound, what should the
nurse do? - ✔✔Watch the patient's respirations while listening for effect on the sound.
✔✔Which of these findings would the nurse expect to notice during a cardiac
assessment on a 4-year-old child? - ✔✔Murmur at second left intercostal space when
supine
✔✔While auscultating heart sounds on a 7-year-old child for a routine physical, the
nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the
child is standing. Which of these would be a correct interpretation of these findings? -
✔✔These can all be normal findings in a child.
✔✔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: - ✔✔displacement of the heart from
elevation of the diaphragm.
✔✔In assessing for an S4 heart sound with a stethoscope, the nurse would listen with
the: - ✔✔bell at the apex with the patient in the left lateral position.
✔✔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 S1. The sound is heard only with the bell 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): - ✔✔atrial gallop
✔✔The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after
her myocardial infarction. 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: - ✔✔Inflammation of precordium
, ✔✔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? - ✔✔Tetralogy of Fallot
✔✔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 S1. These findings would be most consistent with: -
✔✔mitral regurgitation.
✔✔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 sternal angle when he
is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per
minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation.
Which of these conditions best explains the cause of these findings? - ✔✔Heart failure
✔✔The nurse knows that normal splitting of the second heart sound is associated with:
- ✔✔inspiration.
✔✔During a cardiovascular assessment, the nurse knows that a "thrill" is: - ✔✔a
vibration that is palpable.
✔✔During a cardiovascular assessment, the nurse knows that an S4 heart sound is: -
✔✔heard at the end of ventricular diastole.
✔✔During an assessment, the nurse notes that the patient's apical impulse is displaced
laterally, and it is palpable over a wide area. This indicates: - ✔✔Volume overload, as in
heart failure.
✔✔When the nurse is auscultating the carotid artery for bruits, which of these
statements reflects correct technique? - ✔✔Lightly apply the bell of the stethoscope
over the carotid artery, and while listening, have the patient take a breath, exhale, and
hold it briefly.
✔✔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? - ✔✔African-Americans
✔✔The nurse is assessing a patient with possible cardiomyopathy and assesses the
hepatojugular reflux. If heart failure is present, then the nurse should see which finding
while pushing on the right upper quadrant of the patient's abdomen, just below the rib