Sherpath Chapter 20, Heart and Neck Vessels: Findings for the Heart

Question 1 of 16

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The nurse determines that the point of maximal impulse (PMI) occupies a radius of approximately 1 cm. What is the concern regarding this finding?

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  • No concernNo concern is required because the PMI is usually palpable in a diameter of no more than 1 cm. This is a normal finding.
• • Left ventricle enlargementAn enlargement of the left ventricle would cause the PMI to expand more than 1 cm.
• • Right ventricle enlargementIt is hard to identify the borders of the right ventricle because it is in an anterior position in the chest. Therefore the nurse would need to identify the left ventricle borders to determine normal position of the PMI.
• • Right atrial enlargementThe right atrium is at the base of the heart and is not the appropriate area in which to identify the PMI.

Question 2 of 16

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Which heart rate would be cause for concern if measured in a 19-year-old patient who regularly participates in track and football?

• • 48 beats/minA heart rate less than 60 beats/min is normal in a young, well-conditioned athlete.
• • 55 beats/minA heart rate less than 60 beats/min is normal in a young, well-conditioned athlete.
• • 60 beats/minThe normal heart rate for a healthy adult may range from 60-100 beats/min.
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  • 100 beats/minA young, well-conditioned athlete would usually have a lower heart rate, 60 beats/min or below, because the cardiac muscle has been strengthened through exercise to pump more forcibly at a slower rate.

Question 3 of 16

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Which finding is expected on palpation of the epigastric region of the chest?

• • Lateral pulsationA lateral pulsation in the epigastric region of the chest is an abnormal finding and could indicate an abdominal aortic aneurysm.
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  • No palpable pulsationsNormally, pulsations are slight or not palpable in the epigastric region of the chest.
• • Increased aortic pulsationsIncreased aortic pulsations are an abnormal finding and may indicate an abdominal aortic aneurysm.
• • Decreased thrillsThrills are not expected to be palpated in the epigastric region of the chest.

Question 4 of 16

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When the nurse auscultates the heart, the first heart sound (S₁) is typically synchronous with which pulse?

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  • CarotidDuring auscultation of the heart for the first heart sound (S₁), it is synchronous with the carotid pulse.
• • TemporalThe temporal artery pulse is not typically auscultated and therefore has not been identified as synchronous with the first heart sound (S₁).
• • Dorsalis pedisThe dorsalis pedis is typically not auscultated but palpated and has not been identified as synchronous with the first heart sound (S₁).
• • InguinalThe inguinal pulse is usually palpated and not auscultated and therefore has not been identified as synchronous with the first heart sound (S₁).

Question 5 of 16

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Which findings are normal for the apical pulse?

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  • Regular rhythmA regular rhythm describes how evenly the heart is beating and is a normal finding of the apical pulse.
• Correct
  • Rate of 60-100 beats/minA normal pulse rate for adults is 60-100 beats/min.
• Correct
  • Full and boundingThe amplitude or strength of the pulse is normally described as full or bounding.
• Correct
  • Located at the apexThe normal location for the apical pulse is at the apex, although pregnancy and obesity may cause it to be displaced.
• • Located at the baseThe apical pulse is not located at the base of the heart.

Question 6 of 16

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The nurse auscultates the heart sounds of a patient and identifies a split on inspiration that disappears on expiration. What does the nurse recognize this finding as?

• • Paradoxical splittingA paradoxical split disappears with inspiration and reappears with expiration.
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  • Physiologic splittingA physiologic split of the second heart sound occurs on inspiration and disappears on expiration. The splitting occurs as a result of a delayed closure of the pulmonic valve and is a normal finding.
• • Pathologic splittingA pathologic split may be heard with both inspiration and expiration and occurs with late closure of the pulmonic valve.
• • Fixed splittingA fixed split occurs when the emptying of the right ventricle is prolonged and is considered pathologic.

Question 7 of 16

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Which condition is suggested by cyanosis of the tongue and lips in a 1-month-old patient?

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  • Tetralogy of FallotTetralogy of Fallot involves four cardiac defects, causing the infant to be cyanotic.
• • Kawasaki diseaseKawasaki disease can result in vascular stenosis and formation of aneurysms in the coronary arteries. Infants may present with a strawberry (red) tongue.
• • Aortic regurgitationAortic regurgitation results from an incompetent valve that causes blood from the aorta to flow back into the ventricles, but it is not associated with cyanosis of the tongue and lips.
• • Bacterial endocarditisBacterial endocarditis is an infection of the endothelial layer of the heart and valves. Common symptoms include fever and fatigue, not cyanosis of the tongue and lips.

Question 8 of 16

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Which assessment finding is normal for a 3-day old newborn on auscultation of the heart?

• • Heart rate of 100 beats/minThe normal heart rate for a newborn is 120 to 170 beats/min.
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  • Sinus arrhythmiaSinus arrhythmia, or a cardiac rhythm that changes with respiration, is a normal finding in infants and may be benign.
• • Heart murmurMurmurs are normal in newborn babies; however, they typically disappear within 48 hours.
• • An apex beat that is slightly lower than that in adultsThe apex beat in infants may be slightly higher than in adults, in the fourth or fifth left intercostal space medial to the midclavicular line.

Question 9 of 16

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Which finding in a 6-week-old infant is cause for concern?

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  • Sustained tachycardiaSustained tachycardia may be the first indication of an infection or a paroxysmal atrial tachycardia.
• • Heart rate of 120 beats/minThe normal heart rate for a newborn is 120-170 beats/min.
• • Capillary refill of 0.9 secondCapillary refill in the infant is usually very quick, less than 1 second. A prolonged capillary refill indicates poor perfusion.
• • Blood pressure of 60 systolic and 30 diastolicBlood pressure of 60 systolic and 30 diastolic is a normal finding in a newborn.

Question 10 of 16

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Select the heart sound that occurs because of a delay in right ventricular depolarization and does not vary with respirations.

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  • Pathologic splitting of the second heart sound (S₂)A pathologic split of S₂ occurs because of a delay in right ventricular depolarization and late closure of the pulmonic valve and does not vary with respiration.
• • GallopA gallop is an extra heart sound that is intense and easily heard. Gallops occur during ventricular filling.
• • Pericardial friction rubA pericardial friction rub can occur during ventricular systole or diastole and is heard throughout the respiratory cycle.
• • Ejection clickAn ejection click is a high-pitched sound that is heard during the opening of the aortic or pulmonary valves. Pulmonary ejection clicks often become less intense during inspiration.

Question 11 of 16

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Match the heart sound with the associated cause.

• S₁
• S₂
• S₃
• S₄

Question 12 of 16

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Select the sound that results from high ventricular pressure and valvular stenosis.

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  • MurmurValvular stenosis, resulting in high ventricular pressure, may cause aortic stenosis, which may result in a heart murmur.
• • GallopA gallop results from the rapid filling of a ventricle with blood.
• • ClickA click is an extra systolic sound that may be caused by mitral valve prolapse.
• • SnapA snap is heard when a thickened or diseased mitral valve opens.

Question 13 of 16

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Match the murmur with its characteristics.

• Grade 1
• Grade 2
• Grade 3
• Grade 5

Question 14 of 16

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Which response describes the quality of the ejection-type systolic murmur?

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  • HarshEjection murmurs have a medium pitch and harsh quality.
• • BlowingA blowing quality occurs from high blood flow across normal valves.
• • RadiatingEarly diastolic murmurs have a blowing quality and radiate down the left sternal border.
• • RumblingA rumbling sound is produced in a diastolic murmur.

Question 15 of 16

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Select the murmur that is low pitched and accompanied by an opening snap.

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  • Diastolic rumbleDiastolic rumbles are low pitched and have an opening snap. This murmur is caused by blood flowing across stenotic atrioventricular valves.
• • Early diastolic murmurEarly diastolic murmurs are high pitched and are caused by semilunar valve insufficiency.
• • Early systolic murmurEarly systolic murmurs are medium pitched and are caused by the flow of blood over normal semilunar valves.
• • Pansystolic regurgitant murmurPansystolic regurgitant murmurs are high pitched with a blowing quality that results from blood regurgitating though incompetent mitral and tricuspid valves.

Question 16 of 16

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An infant presents with cyanosis and a weak pulse in the femoral arteries. The nurse finds that the infant’s capillary refill time is 3.5 seconds. Which disorder does the nurse suspect?

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  • Coarctation of the aortaCoarctation of the aorta is a stenosis seen in the descending aorta and is suspected when the femoral pulses are absent and capillary refill is prolonged more than 2 seconds.
• • Kawasaki diseaseKawasaki disease is a vascular disease of unknown cause that accounts for most acquired murmurs. This condition is not known to affect capillary refill time.
• • Ventricular septal defectA ventricular septal defect will cause a slow murmur in infants, as well as slow weight gain and dyspnea.
• • HypertensionHypertension occurs from increased fluid in the vascular spaces that increases the workload of the heart. There are no specific symptoms associated with this condition, so screening is important for identification.