Chapter 19 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 19 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

The nurse educator is teaching a group of nursing students to assess heart sounds. Which response by a student indicates appropriate understanding of how S2 heart sounds are produced?

1. “It results from the closure of the mitral valve.”
2. “It is a result from the closure of the semilunar valves.”
3. “It results from the closure of the tricuspid valve.”
4. “It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.”

Correct Answer: 2

Rationale 1: The S1 sounds results from the closure of the atrioventricular (AV) valves. The atrioventricular valves include the mitral and tricuspid valves.

Rationale 2: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonic valves close.

Rationale 3: The S1 sounds results from the closure of the atrioventricular (AV) valves. The atrioventricular valves include the mitral and tricuspid valves.

Rationale 4: The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.

Global Rationale: The S2 sounds results from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the times the aortic and pulmonic valves close. The S1 heart sound results from closure of the atrioventricular (AV) valves. The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.1: Describe the anatomy and physiology of the cardiovascular system.

MNL Learning Outcome: 7.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: 455

 

Question 2

Type: HOTSPOT

The client’s healthcare provider determines that the client’s left ventricle is functioning adequately. When teaching the client about the left ventricle, which location will the nurse include in the educational session?

 

A

C

D

B

 

 

1. A.
2. B.
3. C.
4. D.

Correct Answer: 4

Rationale 1: The left ventricle is located on the lower left side of the heart.  Option 1 does not indicate the left ventricle.

Rationale 2: The left ventricle is located on the lower left side of the heart.  Option 2 does not indicate the left ventricle.

Rationale 3: The left ventricle is located on the lower left side of the heart.  Option 3 does not indicate the left ventricle.

Rationale 4: The left ventricle is located on the lower left side of the heart.  Option 4 indicates the left ventricle.

Global Rationale: The left ventricle is located on the lower left side of the heart. The nurse would point to option 4 to teach the client about the left ventricle.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19.1: Describe the anatomy and physiology of the cardiovascular system.

MNL Learning Outcome: 7.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 454

 

Question 3

Type: FIB

The client’s stroke volume is 72 ml/beat. The client’s heart rate is 82 beats per minute. What is the client’s cardiac output? ____________mL/min.

Standard Text: Record the response using a whole number.

Correct Answer: 5904 mL per minute.

Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is four to eight liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for 1 minute: 72 ml/ beat × 82 beats/ minute = 5904 mL/ minute.

Global Rationale: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is 4 to 8 liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for 1 minute.
72 ml/ beat x 82 beats/ minute= 5904 mL/ minute

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19.1: Describe the anatomy and physiology of the cardiovascular system.

MNL Learning Outcome: 7.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: 466