Black & Hawks: Medical-Surgical Nursing, 8th Edition
Test Bank
Chapter 54: Assessment of the Cardiac System
MULTIPLE CHOICE
1. The nurse establishing teaching priorities for a community health program would rank
cardiovascular disease as a cause of death as
a. first.
b. fifth.
c. seventh.
d. tenth.
ANS: A
Cardiovascular disease is the leading cause of illness and death in the United States, affecting
more than one in five people.
DIF: Comprehension/Understanding
REF: p. 1354
OBJ: Intervention
MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health
Problems-Health Promotion Programs
2. The nurse would explain that angina pain usually differs from the pain of a myocardial infarction
(MI) in that angina pain
a. is accompanied by palpitations.
b. is seldom relieved by rest.
c. lasts less than 15 minutes.
d. radiates to the arm, jaw, or throat.
ANS: C
The pain of angina is usually short-lived, lasting less than 15 minutes; does not radiate; can be
relieved by rest, with or without vasodilators; and is not associated with palpitations. Stable
angina is relieved with rest or nitrates. Both types of pain may radiate. Both types of pain may
occur with palpitations, and in women, palpitations may occur instead of chest pain.
DIF: Comprehension/Understanding
REF: p. 1359
MSC: Physiological Integrity-Pathophysiology
The ethnic group with the highest prevalence of CVD is native Hawaiians, followed by
American Indians, whites, and blacks.
DIF: Application/Applying
REF: p. 1355
MSC: Physiological Integrity-Pathophysiology
DIF: Analysis/Analyzing
REF: p. 1363
OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems
7. The finding during a routine assessment that would most strongly suggest to the nurse the
presence of serious heart or lung disease is
a. blanching of nail beds when compressed.
b. broken vessels in the legs.
c. duskiness of the buccal mucosa.
d. pulse rate greater than 90 beats/min.
ANS: C
The nurse should observe the skin and mucous membranes for abnormalities such as central or
peripheral cyanosis. The presence of a bluish tinge or duskiness is indicative of central cyanosis.
Central cyanosis implies serious heart or lung disease because impaired physiologic functioning
is leading to decreased arterial oxygen saturation. Peripheral cyanosis, seen in lips, ear lobes,
and nail beds, suggests peripheral vasoconstriction.
DIF: Comprehension/Understanding
REF: p. 1361
OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems
8. During the physical examination of a client, the nurse checks the client for neck vein distention.
To perform this assessment properly, the client should be positioned
a. first lying, then sitting, then standing.
b. in a side-lying position with knees flexed.
c. lying supine with head of bed elevated 15-30 degrees.
d. sitting upright with neck flexed slightly forward.
ANS: C
The distensibility of the neck veins reflects the pressure and volume changes within the right
atrium in most people. Evaluate neck vein distention by having the client lay supine with the
head of bed elevated 15-30 degrees (for most people), turn the client’s head slightly away from
you, loosen or remove clothing that compresses the neck or upper thorax. Use oblique lighting
and observe both sides of the neck. Measure the highest point of venous pulsation.
DIF: Application/Applying
REF: pp. 1370-1371
OBJ: Assessment
MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health
Problems-Techniques of Physical Assessment
9. The nurse evaluating the head and neck of a client would assess the carotid arteries by
a. asking the client to bear down and hold the breath while observing the arteries.
b. auscultating the arteries with the diaphragm of the stethoscope.
c. instructing the client to lie down and examining the arteries with oblique lighting.
d. palpating the arteries simultaneously, comparing amplitudes, rates, and rhythms.
ANS: B
DIF: Application/Applying
REF: p. 1374
OBJ: Assessment
MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health
Problems-Techniques of Physical Assessment
13. In doing a breath sound assessment on a client who has left ventricular failure, the nurse would
anticipates the finding of
a. audible S3 and S4.
b. crackles in the lung bases.
c. inspiratory wheeze.
d. pericardial friction rub.
ANS: B
Crackles frequently signal left ventricular failure and usually occur just after the onset of an S3
gallop. As pulmonary capillary pressure rises from the backward pressure of left ventricular
failure, fluid shifts into the intra-alveolar spaces, and crackles can be auscultated.
DIF: Comprehension/Understanding
REF: p. 1372
OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems
14. The nurse would explain to a client that the isoenzyme most useful in the diagnosis of
myocardial infarction is
a. CK-MB.
b. CK-MM
c. myoglobin.
d. troponin
ANS: D
The enzymes most often used to detect MI are myoglobin, creatine kinase, and troponin.
Myoglobin is released rapidly, but its short half-life makes it less useful in clients who present
several hours after an infarction. CK-MB is specific for cardiac muscle. Troponin is as sensitive
as CK-MB but is more specific and is more useful in excluding myocardial infarction when CKMB is falsely elevated. CK-MM is a measure of skeletal muscle enzymes.
DIF: Comprehension/Understanding
REF: p. 1382
OBJ: Intervention
MSC: Physiological Integrity Reduction of Risk Potential-Laboratory Values
15. A client who had a myocardial infarction has an elevated blood glucose level and is getting
insulin. The client asks why this is occurring because the client does not have diabetes. The best
answer by the nurse is
a. “I am not sure, but I will ask the doctor and let you know.”
b. “It is an expected side effect of the medications we gave you.”
c. “The stress of your heart attack makes blood sugar rise.”
d. “You probably are a diabetic and weren’t diagnosed until now.”
ANS: C
The stress of the illness and damage to the myocardium often raise blood glucose level. If the
nurse does not know the answer to a question, option a is a good choice. If you do not know, find
out and tell the client.
DIF: Application/Applying
REF: p. 1383
MSC: Physiological Integrity-Pathophysiology
OBJ: Assessment
16. The nurse would explain to a client that an electrical representation of the cardiac cycle shows
that a normal PR interval is between 0.12 second and
a. 0.15 second.
b. 0.16 second.
c. 0.18 second.
d. 0.20 second.
ANS: D
The normal PR interval is between 0.12 and 0.20 second, averaging 0.16 second.
DIF: Comprehension/Understanding
REF: pp. 1376-1377
OBJ: Intervention
MSC: Physiological Integrity Reduction of Risk Potential-Diagnostic Tests
17. A nurse understands that the basic premise of an ECG is that it shows
a. altered electrical activity from pathologic changes.
b. damage to the valves inside the heart.
c. the status of the client’s coronary arteries.
d. the approximate time since a myocardial infarction occurred.
ANS: A
The ECG provides multidirectional examination of electrical events in the heart. Myocardial
infarction causes tissue damage/death, which alters the electrical activity in predictable patterns.
This altered electrical activity shows up on the ECG as abnormalities that help diagnose the
occurrence and location of an infarction.
DIF: Comprehension/Understanding
MSC: Physiological Integrity
REF: p. 1377
OBJ: Intervention
18. In evaluating a client’s ECG tracing, the nurse notes three small squares between the upstroke
and downstroke of the QRS wave. The nurse would record the QRS interval as
a. 0.04 second.
b. 0.06 second.
c. 0.08 second.
d. 0.12 second.
ANS: D
Each small square on ECG tracing paper is 0.04 second, making the QRS interval in this client
0.12 second.
DIF:
ANS: A
Bilberry and evening primrose are among several anti-anginal herbal supplements.
DIF: Application/Applying
REF: p. 1365
OBJ: Assessment
MSC: Physiological Integrity Basic Care and Comfort-Complementary and Alternative
Therapies
MULTIPLE RESPONSE
1. Important information the nurse should collect when a client complains of chest pain includes
(Select all that apply)
a. aggravating and relieving factors.
b. associated manifestations.
c. characteristics.
d. duration.
e. location.
ANS: A, B, C, D, E
All components are important to assess when the client complains of chest pain.
DIF: Application/Applying
REF: pp. 1355-1360
OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-Potential for Alteration in Body
Systems
2. Women with heart disease often present with which symptom? (Select all that apply.)
a. Chest pain
b. Dyspnea
c. Fatigue
d. Nausea
e. Palpitations
ANS: B, C, D, E
Women can experience chest pain, but most often present with complaints of dyspnea, nausea
and vomiting, fatigue, neck or jaw pain, back pain, dizziness, or palpitations. This is a
contributing factor to women’s higher death rate from heart disease.
DIF: Knowledge/Remembering
REF: pp. 1355-1359
OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems