Comprehensive Health Assessment 3 Exam
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1. 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 this layer as which of the following?
o A) Myocardium
o B) Epicardium
o C) Endocardium
o D) Pericardium
o Correct Answer: A) Myocardium
o Rationale: The myocardium is the muscular middle layer of the heart,
responsible for contraction and pumping blood.
2. A nurse is reviewing the electrical conduction system of the heart in preparation for
assessing a client with a conduction problem. The nurse should be aware that the
electrical signal originates in which of the following locations?
o A) Bundle of His
o B) Purkinje fibers
o C) Sinoatrial node
o D) AV node
o Correct Answer: C) Sinoatrial node
o Rationale: The sinoatrial (SA) node is the primary pacemaker of the heart,
generating electrical impulses that initiate each heartbeat.
3. The nurse is analyzing the data from the assessment of a client's heart and neck vessels.
The client's first heart sound corresponds with what event in the cardiac cycle?
o A) Isometric contraction
o B) Closure of the semilunar valves
, o C) Beginning of diastole
o D) Closure of the atrioventricular valves
o Correct Answer: D) Closure of the atrioventricular valves
o Rationale: The first heart sound (S1) occurs with the closure of the AV valves
(mitral and tricuspid), marking the beginning of ventricular contraction.
4. The nurse is assessing a client who is in uncompensated right-sided heart failure. What
assessment finding should the nurse anticipate?
o A) Increased jugular venous pressure
o B) Bradycardia
o C) Decreased blood pressure
o D) Dysrhythmias
o Correct Answer: A) Increased jugular venous pressure
o Rationale: In right-sided heart failure, blood backs up into the venous system,
leading to elevated jugular venous pressure.
5. The nurse is assessing a client with a cardiac condition who complains of not sleeping
well and of having to get up frequently at night to urinate. The nurse should recognize
what implication of this statement?
o A) The client may have developed a cardiac conduction problem.
o B) The client may be experiencing symptoms of heart failure.
o C) The client's cardiac problem is being adequately compensated for.
o D) The client may be at increased risk for myocardial infarction.
o Correct Answer: B) The client may be experiencing symptoms of heart failure.
o Rationale: Nocturia and difficulty sleeping can be symptoms of heart failure due
to fluid overload.
6. The nurse is assessing a client's heart and neck vessels. Which technique would be most
appropriate to use when examining the client's jugular venous pulse?
o A) Perform the exam with the client in a supine position.
o B) Have the client look straight ahead with chin slightly lifted.
o C) Have the client sit up at a 90-degree angle.
, o D) Inspect the suprasternal notch or around the clavicles.
o Correct Answer: D) Inspect the suprasternal notch or around the clavicles.
o Rationale: To assess jugular venous pressure, the client should be in a semi-
upright position, and the veins should be visible in the suprasternal notch.
7. A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which
component as indicating ventricular repolarization?
o A) P wave
o B) QRS complex
o C) ST segment
o D) T wave
o Correct Answer: D) T wave
o Rationale: The T wave represents the repolarization of the ventricles.
8. The nurse is preparing to assess a client's carotid arteries. Which of the following actions
would be most appropriate?
o A) Palpate each artery individually to compare.
o B) Palpate the arteries before auscultating them.
o C) Use the diaphragm of the stethoscope.
o D) Ask the client to breathe in and out deeply.
o Correct Answer: A) Palpate each artery individually to compare.
o Rationale: Palpating each carotid artery individually helps to assess for symmetry
and strength.
9. The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The
nurse would document this as which of the following?
o A) 1+
o B) 2+
o C) 3+
o D) 4+
o Correct Answer: B) 2+
, o Rationale: A 2+ pulse indicates a normal amplitude, which is considered a
healthy pulse.
10. A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2.
Which of the following would be most appropriate for the nurse to do?
o A) Use the bell of the stethoscope to help distinguish the sounds.
o B) Palpate the carotid pulse while auscultating the heart.
o C) Determine the pulse deficit.
o D) Palpate the apical impulse.
o Correct Answer: B) Palpate the carotid pulse while auscultating the heart.
o Rationale: Palpating the carotid pulse while auscultating helps the nurse
correlate the heart sounds with the pulse.
11. A client has sought care with complaints of increasing swelling in her feet and ankles,
and the nurse's assessment confirms the presence of bilateral edema. The nurse's
subsequent assessments should focus on the signs and symptoms of what health
problem?
o A) Myocardial infarction
o B) Heart failure
o C) Atherosclerosis
o D) Heart block
o Correct Answer: B) Heart failure
o Rationale: Bilateral edema in the extremities is often a sign of heart failure due
to fluid retention.
12. The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain.
What interview question addresses the "A" in this assessment model?
o A) "Do you have any other symptoms together with your chest pain, such as
nausea, sweating?"
o B) "In your experience, what kinds of activities tend to cause your chest pain?"
o C) "Would you describe your chest pain as being acute, or is it chronic?"
o D) "What changes do you have to make in order to accommodate your chest
pain?"
Test Bank: All Versions and Modules Included |
Accurate, Verified Questions and Answers for
Guaranteed Success | Latest Update
1. 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 this layer as which of the following?
o A) Myocardium
o B) Epicardium
o C) Endocardium
o D) Pericardium
o Correct Answer: A) Myocardium
o Rationale: The myocardium is the muscular middle layer of the heart,
responsible for contraction and pumping blood.
2. A nurse is reviewing the electrical conduction system of the heart in preparation for
assessing a client with a conduction problem. The nurse should be aware that the
electrical signal originates in which of the following locations?
o A) Bundle of His
o B) Purkinje fibers
o C) Sinoatrial node
o D) AV node
o Correct Answer: C) Sinoatrial node
o Rationale: The sinoatrial (SA) node is the primary pacemaker of the heart,
generating electrical impulses that initiate each heartbeat.
3. The nurse is analyzing the data from the assessment of a client's heart and neck vessels.
The client's first heart sound corresponds with what event in the cardiac cycle?
o A) Isometric contraction
o B) Closure of the semilunar valves
, o C) Beginning of diastole
o D) Closure of the atrioventricular valves
o Correct Answer: D) Closure of the atrioventricular valves
o Rationale: The first heart sound (S1) occurs with the closure of the AV valves
(mitral and tricuspid), marking the beginning of ventricular contraction.
4. The nurse is assessing a client who is in uncompensated right-sided heart failure. What
assessment finding should the nurse anticipate?
o A) Increased jugular venous pressure
o B) Bradycardia
o C) Decreased blood pressure
o D) Dysrhythmias
o Correct Answer: A) Increased jugular venous pressure
o Rationale: In right-sided heart failure, blood backs up into the venous system,
leading to elevated jugular venous pressure.
5. The nurse is assessing a client with a cardiac condition who complains of not sleeping
well and of having to get up frequently at night to urinate. The nurse should recognize
what implication of this statement?
o A) The client may have developed a cardiac conduction problem.
o B) The client may be experiencing symptoms of heart failure.
o C) The client's cardiac problem is being adequately compensated for.
o D) The client may be at increased risk for myocardial infarction.
o Correct Answer: B) The client may be experiencing symptoms of heart failure.
o Rationale: Nocturia and difficulty sleeping can be symptoms of heart failure due
to fluid overload.
6. The nurse is assessing a client's heart and neck vessels. Which technique would be most
appropriate to use when examining the client's jugular venous pulse?
o A) Perform the exam with the client in a supine position.
o B) Have the client look straight ahead with chin slightly lifted.
o C) Have the client sit up at a 90-degree angle.
, o D) Inspect the suprasternal notch or around the clavicles.
o Correct Answer: D) Inspect the suprasternal notch or around the clavicles.
o Rationale: To assess jugular venous pressure, the client should be in a semi-
upright position, and the veins should be visible in the suprasternal notch.
7. A nurse is reviewing a client's electrocardiogram (ECG). The nurse should identify which
component as indicating ventricular repolarization?
o A) P wave
o B) QRS complex
o C) ST segment
o D) T wave
o Correct Answer: D) T wave
o Rationale: The T wave represents the repolarization of the ventricles.
8. The nurse is preparing to assess a client's carotid arteries. Which of the following actions
would be most appropriate?
o A) Palpate each artery individually to compare.
o B) Palpate the arteries before auscultating them.
o C) Use the diaphragm of the stethoscope.
o D) Ask the client to breathe in and out deeply.
o Correct Answer: A) Palpate each artery individually to compare.
o Rationale: Palpating each carotid artery individually helps to assess for symmetry
and strength.
9. The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. The
nurse would document this as which of the following?
o A) 1+
o B) 2+
o C) 3+
o D) 4+
o Correct Answer: B) 2+
, o Rationale: A 2+ pulse indicates a normal amplitude, which is considered a
healthy pulse.
10. A nurse is having difficulty identifying a client's heart sounds, specifically S1 and S2.
Which of the following would be most appropriate for the nurse to do?
o A) Use the bell of the stethoscope to help distinguish the sounds.
o B) Palpate the carotid pulse while auscultating the heart.
o C) Determine the pulse deficit.
o D) Palpate the apical impulse.
o Correct Answer: B) Palpate the carotid pulse while auscultating the heart.
o Rationale: Palpating the carotid pulse while auscultating helps the nurse
correlate the heart sounds with the pulse.
11. A client has sought care with complaints of increasing swelling in her feet and ankles,
and the nurse's assessment confirms the presence of bilateral edema. The nurse's
subsequent assessments should focus on the signs and symptoms of what health
problem?
o A) Myocardial infarction
o B) Heart failure
o C) Atherosclerosis
o D) Heart block
o Correct Answer: B) Heart failure
o Rationale: Bilateral edema in the extremities is often a sign of heart failure due
to fluid retention.
12. The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain.
What interview question addresses the "A" in this assessment model?
o A) "Do you have any other symptoms together with your chest pain, such as
nausea, sweating?"
o B) "In your experience, what kinds of activities tend to cause your chest pain?"
o C) "Would you describe your chest pain as being acute, or is it chronic?"
o D) "What changes do you have to make in order to accommodate your chest
pain?"
