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Chapter 30: Assessment of the Cardiovascular System questions with 100% correct answers
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Chapter 30: Assessment of the Cardiovascular System questions with 100% correct answers
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Chapter 30: Assessment of theCardiovascular System
Chapter 30: Assessment of the Cardiovascular System Ignatavicius: Medical-Surgical Nursing, 10th
Edition
MULTIPLE CHOICE
1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg.
Which additional assessment finding would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min - correct answer ✔✔ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in
the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial
node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response
and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate
will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client
may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur
later.
2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the
nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min. - correct answer ✔✔ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-
flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure,
increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites.
Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and
better cardiac output.
, 3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the
greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates. - correct answer ✔✔ANS: C
Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to
cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer,
and bisphosphonate therapy do not increase the risk for cardiovascular disease.
4. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48
beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine. - correct answer ✔✔ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in
bradycardia. However, the nurse would first check the medication reconciliation for medications that
might cause such a drop in heart rate, and then would inform the primary health care provider.
Documentation is important, but it is not the first action. The heart rate is not low enough for atropine
or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.
5. An emergency department nurse obtains the health history of a client. Which statement by the client
would alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month." - correct answer ✔✔ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as
stair climbing. The other findings are not specific to early occurrence of heart failure.
6. A nurse obtains the health history of a client who is newly admitted to the medical unit. Which
statement by the client would alert the nurse to the presence of edema?
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