NUR103- Ch 20 Heart and Neck Vessel

Which heart sound occurs because of the closure of the semilunar valves?

• First heart sound (S₁)

  
  

• Second heart sound (S₂)

  
  

• Third heart sound (S₃)

  
  

• Fourth heart sound (S₄)

  
  

Which finding in the cardiac assessment of a middle-aged patient would the nurse consider to be abnormal?

• Jugular venous pulse

  
  

• Third heart sound

  
  

• Venous hum

  
  

• Apical impulse

  
  

Which blood vessel drains the blood from the head and upper extremities?

• Superior vena cava

  
  

• Pulmonary vein

  
  

• Internal jugular vein

  
  

• Inferior vena cava

  
  

Which statement describes the pericardium?

• Thin layer of endothelial tissue lining the inner surface of the heart

  
  

• Muscular wall of the heart

  
  

• Area of the chest overlying the heart

  
  

• Tough, fibrous double walled sac surrounding the heart

  
  

Which area is best for auscultating the sound of the mitral valve?

• Second left intercostal space at the sternal border

  
  

• Fourth left intercostal space at the left sternal border

  
  

• Second right intercostal space at the sternal border

  
  

• Fifth left intercostal space at the midclavicular line

  
  

Which method would the nurse use to detect a pericardial friction rub?

• Evaluate heart sounds with the ear near the patient’s chest.

  
  

• Listen to the heart with the bell of a stethoscope.

  
  

• Auscultate with the diaphragm of a stethoscope.

  
  

• Use a bedside Doppler ultrasound.

  
  

Which assessment finding indicates abnormally elevated pressures in the right side of the heart?

• Pulmonary congestion

  
  

• Pulmonary hypertension

  
  

• Distended neck veins and abdomen

  
  

• Systolic blood pressure higher than diastolic blood pressure

  
  

Which action made by the nurse while palpating the patient’s carotid artery needs correction?

• Having the patient sit during the examination

  
  

• Refraining from excess vagal stimulation

  
  

• Palpating both carotid arteries at once

  
  

• Not compressing the carotid sinuses

  
  

Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart and valves?

• Myocardium

• Epicardium

  
  

• Endocardium

  
  

• Pericardium

Which intervention would the nurse perform during a cardiac assessment? Select all that apply. One, some, or all responses may be correct.

• Compress on the carotid artery.

  
  

• Have the patient sit during the carotid artery assessment.

  
  

• Put the patient in a supine position to assess the precordium.

  
  

• Maintain a warm room temperature.

  
  

• Assess the neck vessels first.