Chapter 8: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder
MULTIPLE CHOICE
1. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s
contraction, is the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.
ANS: D
The myocardium is the specialized muscle layer that allows the heart to contract.
DIF: Cognitive Level: Comprehension REF: Page 308 OBJ: 2
TOP: Myocardium KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His.
ANS: C
The SA node is the master pacemaker of the heart.
DIF: Cognitive Level: Application REF: Page 308 OBJ: 10
TOP: Acute myocardial infarction KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in
women because acute chest pain is not present. Women are frequently misdiagnosed as
having:
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications.
ANS: B
Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for
women having an MI.
DIF: Cognitive Level: Application REF: Page 334 OBJ: 16
TOP: MIs in women KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
4. The nurse identifies the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the
sound of the:
a. AV valves closing.
b. closure of the semilunar valves.
, c. contraction of the papillary muscles.
d. contraction of the ventricles.
ANS: A
The LUBB is the first sound of a low pitch heard when the AV valves close.
DIF: Cognitive Level: Application REF: Page 310 OBJ: 4
TOP: Lubb sound KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. A patient is admitted from the emergency department. The emergency department physician
notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA)
classification of IV. This indicates the patient’s condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.
ANS: B
Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina
or symptoms of cardiac inefficiency may develop at rest.
DIF: Cognitive Level: Knowledge REF: Page 340, Box 8-3
OBJ: 9 TOP: Classification of heart failure
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but
does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus.
The nurse is aware that using the American College of Cardiology and the American Heart
Association (ACC/AHA) staging, this patient would be a:
a. stage A.
b. stage B.
c. stage C.
d. stage D.
ANS: A
The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but
with primary conditions associated with the development of the disease.
DIF: Cognitive Level: Analysis REF: Page 340, Box 8-3
OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a patient recovering from a myocardial infarct who is on remote
telemetry recognizes the need for added instruction when the patient says:
a. “I can ambulate in the hallway with this gadget on.”
b. “I always take off the telemetry device when I shower.”
c. “My EKG is being watched by one of the nurses in CCU on the home unit.”
d. “I am able to sleep just fine with this device on.”
ANS: B
, Remote telemetry allows the patient to be on a separate unit, but be monitored in a central
location. The patients can be ambulatory and can sleep with the monitor on. They should not
remove the monitor to shower.
DIF: Cognitive Level: Application REF: Page 314 OBJ: 6
TOP: Remote telemetry KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
8. The nurse assesses pitting edema that can be depressed approximately inch and refills in 15
seconds. The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema.
ANS: B
A +2 edema can be documented if the skin can be depressed inch and respond within 15
seconds.
DIF: Cognitive Level: Analysis REF: Page 340, Table 8-5
OBJ: 9 TOP: Pitting edema
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. What do dark or “cold” spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion
ANS: D
Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or
“cold spots” indicate tissues that have inadequate perfusion.
DIF: Cognitive Level: Application REF: Page 314 OBJ: 6
TOP: Thallium scan KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
10. The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an
indication of:
a. normal heart action.
b. mild heart failure.
c. moderate heart failure.
d. severe heart failure.
ANS: C
An ejection factor (cardiac output) of 42% indicates moderate heart failure.
DIF: Cognitive Level: Comprehension REF: Page 315 OBJ: 6
TOP: Heart failure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE CHOICE
1. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s
contraction, is the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.
ANS: D
The myocardium is the specialized muscle layer that allows the heart to contract.
DIF: Cognitive Level: Comprehension REF: Page 308 OBJ: 2
TOP: Myocardium KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His.
ANS: C
The SA node is the master pacemaker of the heart.
DIF: Cognitive Level: Application REF: Page 308 OBJ: 10
TOP: Acute myocardial infarction KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in
women because acute chest pain is not present. Women are frequently misdiagnosed as
having:
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications.
ANS: B
Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for
women having an MI.
DIF: Cognitive Level: Application REF: Page 334 OBJ: 16
TOP: MIs in women KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
4. The nurse identifies the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the
sound of the:
a. AV valves closing.
b. closure of the semilunar valves.
, c. contraction of the papillary muscles.
d. contraction of the ventricles.
ANS: A
The LUBB is the first sound of a low pitch heard when the AV valves close.
DIF: Cognitive Level: Application REF: Page 310 OBJ: 4
TOP: Lubb sound KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. A patient is admitted from the emergency department. The emergency department physician
notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA)
classification of IV. This indicates the patient’s condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.
ANS: B
Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina
or symptoms of cardiac inefficiency may develop at rest.
DIF: Cognitive Level: Knowledge REF: Page 340, Box 8-3
OBJ: 9 TOP: Classification of heart failure
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but
does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus.
The nurse is aware that using the American College of Cardiology and the American Heart
Association (ACC/AHA) staging, this patient would be a:
a. stage A.
b. stage B.
c. stage C.
d. stage D.
ANS: A
The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but
with primary conditions associated with the development of the disease.
DIF: Cognitive Level: Analysis REF: Page 340, Box 8-3
OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a patient recovering from a myocardial infarct who is on remote
telemetry recognizes the need for added instruction when the patient says:
a. “I can ambulate in the hallway with this gadget on.”
b. “I always take off the telemetry device when I shower.”
c. “My EKG is being watched by one of the nurses in CCU on the home unit.”
d. “I am able to sleep just fine with this device on.”
ANS: B
, Remote telemetry allows the patient to be on a separate unit, but be monitored in a central
location. The patients can be ambulatory and can sleep with the monitor on. They should not
remove the monitor to shower.
DIF: Cognitive Level: Application REF: Page 314 OBJ: 6
TOP: Remote telemetry KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
8. The nurse assesses pitting edema that can be depressed approximately inch and refills in 15
seconds. The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema.
ANS: B
A +2 edema can be documented if the skin can be depressed inch and respond within 15
seconds.
DIF: Cognitive Level: Analysis REF: Page 340, Table 8-5
OBJ: 9 TOP: Pitting edema
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. What do dark or “cold” spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion
ANS: D
Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or
“cold spots” indicate tissues that have inadequate perfusion.
DIF: Cognitive Level: Application REF: Page 314 OBJ: 6
TOP: Thallium scan KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
10. The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an
indication of:
a. normal heart action.
b. mild heart failure.
c. moderate heart failure.
d. severe heart failure.
ANS: C
An ejection factor (cardiac output) of 42% indicates moderate heart failure.
DIF: Cognitive Level: Comprehension REF: Page 315 OBJ: 6
TOP: Heart failure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
