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Chapter 21: Assessing Heart and Neck Vessels Prep Questions And 100% Accurate Answers.
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During a physical examination, a nurse notes that the client has a slow, regular pulse. On the cardiac monitor the nurse notes that the QRS complexes are regular and there are normal P waves. The ventricular rate is found to be 54 beats per minute. The nurse recognizes that this client may have an ...

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  • September 13, 2024
  • 18
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • cardiac monitor

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  • Heart and Neck Vessels
  • Heart and Neck Vessels

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Chapter 21: Assessing Heart and Neck
Vessels Prep Questions And 100%
Accurate Answers.
During a physical examination, a nurse notes that the client has a slow, regular pulse. On the cardiac
monitor the nurse notes that the QRS complexes are regular and there are normal P waves. The
ventricular rate is found to be 54 beats per minute. The nurse recognizes that this client may have an
abnormality in which part of the conduction system?

a) bundle of His

b) sinoatrial node

c) atrioventricular node

d) Purkinje fibers - Answer b) sinoatrial node



The client may have problem with the sinoatrial node. The cardiac monitor shows a normal P wave
which indicates that the impulse originated in the sinoatrial node. The QRS complex is regular showing
that the atrioventricular node and the rest of the conduction system are functioning well; and the
problem lies at the higher level of the conduction system. The Bundle of His, Purkinje fibers, and
atrioventricular nodes are lower to the sinoatrial node and therefore have no contribution to impulse
origination in this case.



A nurse monitors a client at risk for the onset of premature ventricular contractions. The nurse should
monitor the client's cardiac rhythm for which characteristic feature?

a) Premature beats followed by compensatory pause

b) P wave preceding every QRS complex

c) QRS complexes that are short and narrow

d) Irregular QRS complexes with absent P wave - Answer a) Premature beats followed by compensatory
pause



Premature ventricular contractions are characterized by premature beats followed by a compensatory
pause. The P waves are absent with wide QRS complexes followed by a compensatory pause. The rhythm
usually resumes with the next beat. QRS complexes are wide and bizarre not narrow and the P wave is
usually absent.

,A nurse cares for a client with acute pericarditis. The nurse should monitor the client for the onset of
which clinical manifestation of cardiac tamponade?

a) Paradoxical pulse

b) Third heart sound

c) Flattened jugular veins

d) Bounding heart sounds - Answer a) Paradoxical pulse



Paradoxical pulse is characterized by a decrease in systolic pressure by more than 10mmHg during
inspiration. Signs of cardiac tamponade are tachycardia, distended not flattened jugular veins, and
muffled heart sounds. The third heart sound or bounding heart sound, an S3 is not normally present.



How should a nurse assess a client for pulse rate deficit?

a) Check for pulse inequality between right and left carotid arteries

b) Auscultate for split S1 at the base and apex

c) Observe for a decrease in jugular venous pressure

d) Assess for a difference between the apical and radial pulse - Answer d) Assess for a difference
between the apical and radial pulse



The nurse should assess the pulse deficit by assessing the difference in the apical and radial pulse. Pulse
deficit is the difference between the apical and peripheral/radial pulses. Differences in the amplitude or
rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles
contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur
with dehydration secondary to a decrease in total blood volume but does not cause a pulse deficit.



In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place
the fingers?

a) right of midclavicular line at the fifth intercostal space

b) right of the midclavicular line at the third intercostal space

c) left midclavicular line at the third intercostal space

d) left midclavicular line at the fifth intercostal space - Answer d) left midclavicular line at the fifth
intercostal space

, The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left
midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the
mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space,
at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the
fifth intercostal space.



In which order should a nurse perform the appropriate physical assessment techniques to assess the
carotid artery?

a) Auscultate then palpate

b) Inspect then auscultate

c) Inspect then palpate

d) Palpate then auscultate - Answer a) Auscultate then palpate



Carotid arteries should always be first auscultated and then palpated because palpation may increase or
slow the heart rate, therefore, changing the strength of the carotid impulse heard. The carotid artery
cannot be inspected, but its pulsation can be.



Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a
client admitted with left ventricular failure?

a) Bisferiens pulse

b) Pulsus alternans

c) Paradoxical pulse

d) Bigeminal pulse - Answer b) Pulsus alternans



The nurse would find pulsus alternans in the client with left ventricular failure. Pulsus alternans is
characterized by changes in amplitude from beat to beat and is usually seen in left ventricular failure.
Paradoxical pulse is a decrease in pulse amplitude on quiet inspiration and is seen in pericardial
tamponade, constrictive pericarditis and obstructive lung disease. Bigeminal pulse has one normal beat
followed by a premature contraction and is seen in premature ventricular contractions. Bisferiens pulse
has a double systolic peak and is seen in aortic regurgitation, combined aortic stenosis and regurgitation.



A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take
during the remainder of the physical assessment of the carotid arteries?

a) Perform only auscultation

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