Chapter 29 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 29  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
A patient has a split S2 heart sound. Where would the nurse auscultate to best hear this sound?
1. 2nd intercostal space left of the sternum
2. 5th intercostal space midclavicular line
3. 3rd intercostal space right of the sternum
4. 4th intercostal space left midaxillary line
Correct Answer: 1
Rationale 1: A split S2 heart sound is heard best in the pulmonic area, which is the 2nd intercostal space left of the sternum.
Rationale 2: The 5th intercostal space midclavicular line is the mitral area. S1 is heard best at the mitral area.
Rationale 3: It would be more difficult to hear an S2 split to the right of the sternum.
Rationale 4: It would be difficult to hear an S2 split at the midaxillary line in the 4th intercostal space.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29-4

Question 2
Type: MCSA
A patient has a split S1 heart sound. How should the nurse explain this finding to the patient?
1. “Your mitral and tricuspid valves are not closing at exactly the same time.”
2. “You probably have some calcification in the pulmonary valve that slows its closure.”
3. “Your aortic valve is closing more slowly than it should.”
4. “Your atrioventricular valves are not closing at exactly the same time.”
Correct Answer: 1
Rationale 1: The S1 heart sound is caused by closure of the mitral and tricuspid valves. If they do not close at exactly the same time a “splitting” of the sound occurs.
Rationale 2: The pulmonary valve is not associated with the S1 heart sound.
Rationale 3: The aortic valve is not associated with the S1 heart sound.
Rationale 4: The atrioventricular valves are not associated with the S1 heart sound.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29-4

Question 3
Type: MCSA
The nurse is conducting a physical examination of a patient’s heart. Where will the nurse place the stethoscope to best assess the S1 heart sound?
1. Left midclavicular line at the fifth intercostal space
2. Left sternal border at the fifth intercostal space
3. Right midclavicular line at the fifth intercostal space
4. Right sternal border at the third intercostal space
Correct Answer: 1
Rationale 1: S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart.
Rationale 2: The SI sound is audible at the left sternal border but would not be as loud as at another site.
Rationale 3: The S1 sound would not normally be audible at this site.
Rationale 4: The S1 sound would not normally be audible at the sternal border.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29-4

Question 4
Type: MCSA
While auscultating the patient’s heart sounds, the nurse hears an additional sound immediately following S2. The nurse would conduct further assessment for which condition?
1. Ventricular volume overload
2. Ventricular hypertrophy from hypertension
3. Atrial fibrillation
4. A stenotic aortic valve
Correct Answer: 1
Rationale 1: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop and results from conditions such as congestive heart failure (CHF) and mitral or tricuspid valve regurgitation.
Rationale 2: S4 immediately precedes S1 and can result from conditions such as hypertension-associated ventricular hypertrophy.
Rationale 3: S3 heart sounds are not associated with atrial fibrillation.
Rationale 4: Aortic stenosis is associated with S4 heart sounds.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 29-2