Priorities In Critical Care Nursing 7th Edition By Urden – Stacy – Lough -Test Bank

Chapter 11: Cardiovascular Clinical Assessment and Diagnostic Procedures
Test Bank

MULTIPLE CHOICE

1. Which of the following conditions is usually associated with clubbing?
a. Central cyanosis
b. Peripheral cyanosis
c. Carbon monoxide poisoning
d. Acute hypoxemia

ANS: A
Clubbing in the nail bed is a sign associated with longstanding central cyanotic heart disease or pulmonary disease with hypoxemia. Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output. Central cyanosis is a bluish discoloration of the tongue and sublingual area. Multiracial studies indicate that the tongue is the most sensitive site for observation of central cyanosis.

2. The abdominojugular reflux test determines the presence of
a. right ventricular failure.
b. hypoxemia.
c. liver failure.
d. pitting edema.

ANS: A
The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. A positive abdominojugular reflux sign is an increase in the jugular venous pressure (CVP equivalent) of greater than 3 cm sustained for at least 15 seconds.

3. The purpose of the Allen test is to
a. assess adequate blood flow through the ulnar artery.
b. occlude the brachial artery and evaluate hypoxemia to the hand.
c. test the patency of an internal graft.
d. determine the size of needle to be used for puncture.

ANS: A
The Allen test assesses the adequacy of blood flow to the hand through the ulnar artery.

4. Evaluation of arterial circulation to an extremity is accomplished by assessing which of the following?
a. Homans sign
b. Skin turgor
c. Peripheral edema
d. Capillary refill

ANS: D
Capillary refill assessment is a maneuver that uses the patient’s nail beds to evaluate both arterial circulation to the extremity and overall perfusion. The severity of arterial insufficiency is directly proportional to the amount of time necessary to re-establish flow and color.

5. When checking the patient’s back, the nurse pushes her thumb into the patient’s sacrum. An indentation remains. The nurse charts that the patient has
a. sacral compromise.
b. delayed skin turgor.
c. pitting edema.
d. dehydration.

ANS: C
Pitting edema occurs when an impression is left in the tissue when the thumb is removed. The dependent tissues within the legs and sacrum are particularly susceptible. Edema may be dependent, unilateral, or bilateral and pitting or nonpitting.

6. An assessment finding of pulsus alternans may indicate evidence of
a. left-sided heart failure.
b. jugular venous distention.
c. pulmonary embolism.
d. myocardial ischemia.

ANS: A
Pulsus alternans describes a regular pattern of pulse amplitude changes that alternate between stronger and weaker beats. This finding is suggestive of end-stage left ventricular heart failure.

7. The presence of a carotid or femoral bruit may be evidence of
a. left-sided heart failure.
b. blood flow through a partially occluded vessel.
c. the early onset of pulmonary embolism.
d. myocardial rupture.

ANS: B
A bruit is an extracardiac vascular sound that results from blood flow through a tortuous or partially occluded vessel.

8. A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs. The patient is admitted with a diagnosis of “rule out myocardial infarction.” The history portion of the assessment should be guided by
a. medical history.
b. history of prior surgeries.
c. presenting symptoms.
d. a review of systems.

ANS: C
For a patient in acute distress, the history taking is shortened to just a few questions about the patient’s chief complaint, precipitating events, and current medications. For a patient who is not in obvious distress, the history focuses on the following four areas: review of the patient’s present illness; overview of the patient’s general cardiovascular status; review of the patient’s general health status, including family history of coronary artery disease (CAD), hypertension, diabetes, peripheral arterial disease, or stroke; and survey of the patient’s lifestyle, including risk factors for CAD.

9. A 68-year-old patient is admitted to the critical care unit with reports of midchest pressure radiating into the jaw and shortness of breath when walking up stairs. The patient is admitted with a diagnosis of “rule out myocardial infarction.” When inspecting the patient, the nurse notes that the patient needs to sit in a high Fowler position to breathe. This may indicate
a. pericarditis.
b. anxiety.
c. heart failure.
d. angina.

ANS: C
Sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning forward may be the least painful position for a patient with pericarditis.

10. An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. The nurse knows that the presence of an S3 heart sound is
a. normal for a person this age.
b. a ventricular gallop.
c. a systolic sound.
d. heard best with the diaphragm of the stethoscope.

ANS: B
The abnormal heart sounds are labeled the third heart sound (S3) and the fourth heart sound (S4) and are referred to as gallops when auscultated during an episode of tachycardia. Not unexpectedly, the development of an S3 heart sound is strongly associated with elevated levels of brain natriuretic peptide.