Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs Test bank

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Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs Test bank

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Chapter 7. Cardiac and Peripheral Vascular Systems

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The first heart sound (S1) occurs because of the closure of the:
A.
Aortic and mitral valves
B.
Mitral and tricuspid valves
C.
Pulmonic valve
D.
Aortic valve

____ 2. The second heart sound (S2) occurs because of the closure of the:
A.
Aortic valve
B.
Tricuspid valve
C.
Aortic and pulmonic valve
D.
A and B

____ 3. To distinguish a physiologic split S2 heart sound, it is best to listen with the stethoscope at:
A.
Left fifth intercostal space midclavicular line
B.
Fourth intercostal space left sternal border with patient holding his or her breath
C.
Second intercostal space left sternal border with inspiration
D.
Fourth intercostal space right sternal border with expiration

____ 4. An S3 gallop is commonly heard in:
A.
Children with fever
B.
Adults with heart failure
C.
Children with aortic stenosis
D.
Adults with hypertension

____ 5. An S4 sound is commonly heard in:
A.
Children with fever
B.
Adults with atrial fibrillation
C.
Adults with hypertension
D.
Children with pulmonic stenosis

____ 6. Which of the following heart sounds is commonly heard after myocardial infarction?
A.
Friction rub
B.
S4
C.
S3
D.
Opening snap

____ 7. Which of the following is the most important question to ask during cardiovascular health history?
A.
Number of offspring
B.
Last physical examination
C.
Sudden death of a family member
D.
Use of caffeine

____ 8. Cardiovascular disease risk increase in women after age:
A.
30
B.
40
C.
45
D.
55

____ 9. Which of the following blood pressure measurements is categorized as prehypertension?
A.
110/78
B.
129/85
C.
142/80
D.
145/92

____ 10. Xanthelasma is a skin condition that should alert the clinician to ____ in a patient.
A.
Familial hyperlipidemia
B.
Type 2 diabetes
C.
Congenital heart disease
D.
Peripheral arterial disease

____ 11. When palpating the chest, you find the point of maximal impulse (PMI) in the left mid-axillary region. This can be indicative of:
A.
Normal PMI
B.
Congenital heart disease
C.
Ventricular hypertrophy
D.
Hypertension

____ 12. Upon inspecting the patient, you find jugular venous distension. This is a sign of:
A.
Left ventricular hypertrophy
B.
Right ventricular failure
C.
Hypertension
D.
Valve disease

____ 13. On an electrocardiogram, you see a deepened Q wave that is greater than one-third the height of the QRS complex. This is indicative of:
A.
Acute myocardial infarction
B.
Acute myocardial ischemia
C.
Left ventricular hypertrophy
D.
Past myocardial infarction

____ 14. Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of:
A.
Anemia
B.
Anxiety
C.
Hyperthyroidism
D.
All of the above

____ 15. A pulse rate of 56 beats per minute can be normal in:
A.
Elderly patients
B.
Newborns
C.
Athletic individuals
D.
Hypertensive patients

____ 16. Your patient has a dysrhythmia and has been on a diuretic for 2 months. Which of the following should be suspected?
A.
Potassium imbalance
B.
Sodium deficit
C.
Calcium imbalance
D.
Insufficient diuretic

____ 17. Your patient has suffered an inferior wall myocardial infarction. This is most commonly due to an obstruction in the:
A.
Posterior branch of the right coronary artery
B.
Circumflex branch of the left coronary artery
C.
Right main coronary artery
D.
Left main coronary artery

____ 18. Cardiac chest pain is most often described as:
A.
Stabbing, piercing pain
B.
Pain with inhalation
C.
Crushing, squeezing pain
D.
Burning, gnawing pain

____ 19. On an electrocardiogram (ECG), an anterior wall myocardial infarction is demonstrated on leads:
A.
II, III, AVR
B.
II, III, AVF
C.
V1, V2, V3, V4
D.
I, AVL, V5, V6

____ 20. Which is the most specific and sensitive test for validating a myocardial infarction?
A.
12-lead EKG
B.
Troponin
C.
CK-MB
D.
CT scan

____ 21. It is important for clinicians to recognize that individuals with ____ often sustain silent myocardial infarction.
A.
Diabetes mellitus
B.
Hypertension
C.
Valvular disorders
D.
Congenital heart defects

____ 22. The pain associated with pericarditis is ____.
A.
Crushing and squeezing
B.
Constant
C.
Worse with inspiration
D.
Only present with fever

____ 23. Pain associated with a dissecting thoracic aortic aneurysm is commonly described as:
A.
Retrosternal crushing and squeezing
B.
Chest stabbing and sharp
C.
Ripping and tearing in the chest or thoracic back
D.
Worse with inspiration

____ 24. The pain of ____ can frequently be mistaken for cardiac chest pain.
A.
Gastroesophageal reflux disease (GERD)
B.
Peptic ulcer disease (PUD)
C.
Cholecystitis
D.
All of the above

____ 25. The pain of pancreatitis is described as:
A.
Abdominal sharp and piercing pain in the left upper quadrant
B.
Dull and cramping pain in the right upper quadrant
C.
Severe, epigastric pain radiating straight into the back
D.
Sharp pain radiating to the shoulder

____ 26. The pain of costochondritis typically ____.
A.
Mimics cardiac crushing and squeezing pain
B.
Worsens with movement and full inspiration
C.
Radiates from epigastrium into the back
D.
Is a tearing and ripping pain

____ 27. The medical record of your patient lists a grade III systolic murmur. This indicates the patient has a heart murmur that is:
A.
Soft and after S2
B.
Loud and crescendo in quality
C.
Moderately loud and after S1
D.
Loud and after S2

____ 28. The radiation of a mitral valve murmur is commonly heard in the:
A.
Carotid arteries
B.
Left mid-axillary line
C.
Base of the heart
D.
Left mid-clavicular line

____ 29. The murmur of aortic stenosis is best heard in the:
A.
Left second intercostal space left sternal border
B.
Left fifth intercostal space mid-clavicular line
C.
Right fourth intercostal space right sternal border
D.
Right second intercostal space right sternal border

____ 30. The pulmonary valve is best heard over the:
A.
left second intercostal space left sternal border
B.
left fifth intercostal space mid-clavicular line
C.
right fourth intercostal space right sternal border
D.
right second intercostal space right sternal border

____ 31. The key sign(s) of aortic stenosis are:
A.
Syncope
B.
Dyspnea
C.
Angina
D.
All of the above

____ 32. Classically in mitral valve prolapse, the clinician can hear a(n) ____.
A.
Mid-systolic click followed by a grade I murmur that crescendos up to S2
B.
Opening snap followed by a grade III holosystolic murmur
C.
Crescendo-decrescendo grade I diastolic murmur after S2
D.
Rough grade III holosystolic murmur that obscures S1 and S2

____ 33. The best diagnostic test that allows analysis of a heart murmur is:
A.
CT scan
B.
Echocardiogram
C.
MRI
D.
ECG

____ 34. The most common cause of tricuspid regurgitation is:
A.
Left ventricular hypertrophy
B.
Left atrial enlargement
C.
Aortic stenosis
D.
Pulmonary hypertension

____ 35. The tricuspid valve is best heard over the:
A.
Third intercostal space left sternal border
B.
Fifth intercostal space right sternal border
C.
Fourth intercostal space left sternal border
D.
Third intercostal space right sternal border

____ 36. From Erbs point, all the heart valves can be heard equally. Erbs point is located over the:
A.
Third intercostal space left sternal border
B.
Fifth intercostal space right sternal border
C.
Fourth intercostal space left sternal border
D.
Third intercostal space right sternal border

____ 37. Upon examination of a child, an innocent systolic murmur is heard at the second intercostal space left sternal border. This is usually due to:
A.
Atrial septal defect
B.
Patent foramen ovale
C.
Low flow velocity
D.
High flow turbulence

____ 38. In mitral stenosis, the murmur occurs:
A.
From S1 through S2 as a holosystolic murmur
B.
After an opening snap that is heard after S2 during diastole
C.
As a soft mid-systolic click
D.
A loud crescendo-decrescendo systolic murmur

____ 39. In mitral stenosis, the murmur can be best heard with the patient in the:
A.
Squatting position
B.
Seated position
C.
Left lateral recumbent
D.
Supine position

____ 40. Due to increased left atrial pressure, a patient with mitral stenosis often suffers from:
A.
Pulmonary congestion
B.
Hepatomegaly
C.
Jugular venous distension
D.
Ventricular tachycardia

____ 41. In aortic stenosis, the patients point of maximal impulse is commonly located at the:
A.
Fifth intercostal space mid-clavicular line
B.
Fifth intercostal space mid-axillary line
C.
Second intercostal space left sternal border
D.
Second intercostal space right sternal border

____ 42. Aortic regurgitation occurs after S2 during ____ because there is turbulent flow that refluxes into the left ventricle after the aortic valve closes.
A.
Early diastole
B.
Late diastole
C.
Early systole
D.
Mid-systole

____ 43. The murmur of a ventricular septal defect (VSD) occurs when the ventricle contracts and blood flows from the left ventricle into the right ventricle. This creates a ____ heart murmur.
A.
Holodiastolic
B.
Early diastolic
C.
Holosystolic
D.
Late systolic

____ 44. An atrial septal defect (ASD) causes a left to right shunt, which enlarges the right atrium. Because of this effect, which of the following conditions often occur with ASD?
A.
Asthma
B.
Jugular venous distension
C.
Atrial fibrillation
D.
B & C

____ 45. A patient with hypertension who has hyperlipidemia should aim for LDL measurement to be:
A.
130 mg/dL or less
B.
40 mg/dL or less
C.
100 mg/dL or less
D.
60mg/dL or less

____ 46. Your 47-year-old female patient has a waist to hip ratio of 1. In terms of cardiovascular disease risk, this is considered:
A.
Ideal
B.
Greater than acceptable limits
C.
Less than acceptable limits
D.
Within acceptable limits

____ 47. Which of the following conditions is/are part of metabolic syndrome?
A.
Hypertension
B.
Hyperlipidemia
C.
Insulin resistance
D.
All of the above

____ 48. The target body mass index for women is:
A.
27 kg/m2
B.
25 kg/m2
C.
22 kg/m2
D.
16 kg/m2

____ 49. Dyspnea, cough, and pulmonary crackles are symptoms that can occur in left ventricular failure and respiratory disorders, such as pneumonia. Which of the blood tests below can be used to differentiate cardiovascular from pulmonary disease?
A.
B type natriuretic peptide (BNP)
B.
Pulse oximetry
C.
Arterial blood gases
D.
High sensitivity C reactive protein (hs-CRP)

____ 50. When an examiner presses on the liver and elicits hepato-jugular reflux, which of the following conditions is likely?
A.
Left ventricular failure
B.
Right ventricular failure
C.
Hepatomegaly
D.
Pulmonary edema

____ 51. Your patient has had hypertension for 10 years, a myocardial infarction 5 years ago, and now complains of dyspnea on exertion, cough, and 3-pillow orthopnea. Which of the following conditions is likely?
A.
Right ventricular failure
B.
Pulmonary embolism
C.
Cor pulmonale
D.
Left ventricular failure

____ 52. Your patient complains of worsening ankle edema and weight gain over the last week. On physical examination, you note jugular venous distension, ascites, hepatomegaly, and splenomegaly. These conditions are indicative of:
A.
Left ventricular failure
B.
Pulmonary embolism
C.
Right ventricular failure
D.
Myocardial infarction

____ 53. A 23-year-old patient presents the emergency department with high fever, chills, extreme fatigue, and arthralgias. Your physical examination reveals grade II heart murmur heard loudest over the fourth intercostal space left sternal border. The arms of the patient reveal past intravenous drug abuse. The clinician should recognize these are signs and symptoms of:
A.
Pulmonary embolism
B.
Right ventricular failure
C.
Functional heart murmur
D.
Bacterial endocarditis

____ 54. A 75-year-old patient complains of pain and paresthesias in the right foot that worsens with exercise and is relieved by rest. On physical examination you note pallor of the right foot, capillary refill of 4 seconds in the right foot, +1 dorsalis pedis pulse in the right foot, and +2 pulse in left foot. Which of the following is a likely cause of the signs and symptoms?
A.
Arterial insufficiency
B.
Femoral vein thrombus
C.
Venous insufficiency
D.
Peripheral neuropathy

____ 55. Which of the following ankle-brachial index measurements require a referral to a vascular consultant?
A.
ABI 1.2
B.
ABI 1
C.
ABI 0.9
D.
ABI 0.5

____ 56. Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms?
A.
Femoral vein thrombosis
B.
Femoral artery thrombus
C.
Venous insufficiency
D.
Musculoskeletal injury

____ 57. After multiple pregnancies, the following vascular disorder is common:
A.
Deep venous thrombosis
B.
Varicose veins
C.
Peripheral arterial disease
D.
Aortic aneurysm
Chapter 7. Cardiac and Peripheral Vascular Systems
Answer Section

MULTIPLE CHOICE

1. ANS: B
S1 is the closing of the mitral valve and with the tricuspid (T1) valve; together they are known as the atrioventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

PTS: 1

2. ANS: C
S1 is the closing of the mitral valve and with the tricuspid (T1) valve; together they are known as the atrioventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

PTS: 1

3. ANS: C
Normally, the S1 and S2 occur as single sounds. In some conditions, these sounds may be split and occur as two sounds. In healthy young adults, a physiologic split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and therefore increased stroke volume of the right ventricle, which can delay closure of the pulmonic valve, causing the second heart sound to be split. This physiologic split differs from other splits that are pathologic in origin in that it occurs with inspiration and disappears with expiration.

PTS: 1

4. ANS: B
Pathologic S3, also called a ventricular gallop, is heard in adults and is associated with decreased myocardial contractility, HF, and volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiologic S3 and is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft and can be difficult to hear.

PTS: 1

5. ANS: C
S4, also called an atrial gallop, occasionally occurs in a normal adult or well-trained athlete but is usually due to increased resistance to filling of the ventricle. Possible causes of a left-sided S4 include HTN, CVD, cardiomyopathy, and aortic stenosis. Possible causes of a right-sided S4 include pulmonic stenosis and pulmonary HTN. S4 is heard just before S1 with the patient supine or in the left lateral recumbent position. The sound can be as loud as S1 and S2. S4 is not heard in patients with chronic atrial fibrillation due to no distinct atrial kick.

PTS: 1

6. ANS: A
Opening snap is caused by the opening of a stenotic mitral or tricuspid valve and is heard early in diastole along the lower left sternal border. It is high pitched and heard best with the diaphragm of the stethoscope. Friction rubs occur frequently after a myocardial infarction (MI) or with pericarditis. The sound is a high-pitched grating, scratching soundresulting from inflammation of the pericardial sacthat issues from the parietal and visceral surfaces of the inflamed pericardium as they rub together.

PTS: 1

7. ANS: C
The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke.

PTS: 1

8. ANS: D
In men, cardiovascular risk increases after age 45; however, in women, the risk of cardiovascular disease increased after age 55. Estrogen is cardioprotective and so women are at highest risk for cardiovascular disease after menopause. The average age of natural menopause for women is age 55.

PTS: 1

9. ANS: B
Ideal blood pressure is less than 120/80, pre-hypertension is regarded as 120 to 139 systolic / 80 to 89, and hypertension is greater than or equal to 140/90.

PTS: 1

10. ANS: A
When conducting the inspection part of a physical examination, inspect the skin around the eyes for xanthelasma. Xanthelasma is a skin condition that occurs in familial hyperlipidemia that causes high cholesterol levels and early cardiovascular disease in patients. Small, yellow fatty deposits are located around the eyes.

PTS: 1

11. ANS: C
The examiner should palpate the point of maximal impulse (PMI) and the precordium for heaves or lifts, seen in ventricular hypertrophy. The apical impulse is easily observed in the pediatric client but not always visible in the adult. An accentuated or displaced apical impulse may indicate ventricular hypertrophy.

PTS: 1

12. ANS: B
In right ventricular failure, hydrostatic pressure builds up back into the right atrium and superior as well as inferior vena cava. Venous congestion occurs throughout the body. A sign of venous congestion of the superior vena cava is jugular vein distension. Signs of right ventricular failure include jugular venous distension, ascites, hepatomegaly, splenomegaly, and ankle edema.

PTS: 1

13. ANS: D
A pathologic Q wave, indicative of a past myocardial infarction, measures greater than 0.04 seconds and is greater than one-third the height of the QRS complex.

PTS: 1

14. ANS: D
Palpitations sensed by the patient are commonly indicative of atrial fibrillation, tachycardia, or premature ventricular contractions. Anemia, anxiety, and hyperthyroidism are all possible etiologies of these cardiac rhythm disturbances.

PTS: 1

15. ANS: C
Athletic individuals commonly have a low pulse rate because their heart is well-conditioned and physiologically more efficient. A strong heart has physiologically enlarged muscle chambers which contract slowly and efficiently deliver an adequate blood volume to the body with each contraction. In an elderly or untrained individual, bradycardia is more concerning. Although normal aging includes a decrease in SA node and AV node conduction, thus increasing the likelihood of bradycardia, sinus node pathology and heart blocks should be suspected in the elderly. Newborns have a normal pulse rate of 120 beats per minute. If the patient has hypertension, this does not decrease the heart rate.

PTS: 1

16. ANS: A
The most common electrolyte disturbance in patients on diuretics is hypokalemia. Hypokalemia is a common cause of cardiac rhythm disturbance.

PTS: 1

17. ANS: A
Blockage in the right coronary artery (RCA) results in damage to the posterior/inferior area of the heart. The left main coronary artery (LCA) branches off to the left anterior descending artery (LAD) and the left circumflex artery (LCX). A highly stenotic LCA or proximal LAD can cause significant heart damage and is often termed the widow maker. Blockage in the LAD results in damage to the anterior portion of the heart. Blockage in the circumflex branch artery (CFX) results in damage to the posterior and lateral areas.

PTS: 1

18. ANS: C
Typical characteristics that indicate acute coronary syndrome (ACS) include crushing, squeezing substernal chest pain with radiation to the neck or left arm, a score of greater than 7 on the pain scale, an association with exertion or stress with relief on rest, a duration of minutes, and associated symptoms of nausea, diaphoresis, weakness, or shortness of breath.

PTS: 1

19. ANS: C
With angina and MI, acute ischemic changes may be seen on the 12-lead EKG. Each lead reflects an area of the heart, and an EKG can determine the location of the ischemia. The lateral wall of the heart is reflected in leads I, aVL, V5, and V6. The inferior wall is reflected in leads II, III, and a VF. The anterior wall is reflected in leads V1, V2, V3, and V4. The posterior wall is reflected in leads V1, V2, and V3. With ischemia, an EKG changes need to occur in two contiguous leads. Reciprocal EKG changes can be seen in the area of the heart opposite the injured area.

PTS: 1

20. ANS: B
Diagnostic studies of myocardial infarction include:
CK-MBThe serum level of CK-MB is elevated above normal in the first few hours after MI and returns to normal within 72 hours. The levels can also be elevated following trauma or with progressive muscular dystrophy.
TroponinAn inhibitory protein found in muscle fibers, troponin is elevated within 4 hours of an MI and stays elevated for 7 to 10 days. It is more sensitive and specific than creatine kinase for cardiac muscle but may be falsely elevated in patients with kidney dysfunction.
12-lead EKGThe practitioner should look for signs of acute ischemia, such as ST-segment elevation or depression, arrhythmias, and conduction delays. An EKG is minimally helpful in diagnosing pericarditis except in the case of cardiac tamponade or constrictive pericarditis where decreased amplitude may be seen.
ImagingStudies such as computed tomography (CT) scan, electron beam computed tomography (EBCT) scan, positron emission tomography (PET) scan, magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT) scan can assist in diagnosing CAD, aortic aneurysms, cardiac masses, myocardial disease, and pericardial disease.

PTS: 1

21. ANS: A
Pain sensitivity may be blunted in persons with diabetes. Peripheral and autonomic neuropathy is common in long-term diabetes. Individuals with diabetes often suffer infection or other disorders without sensing the pain and sustain complications without warning.

PTS: 1

22. ANS: C
Unlike the symptoms associated with ACS, the pain associated with pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise.

PTS: 1

23. ANS: C
Aortic aneurysms are often asymptomatic. However, in a dissecting aortic aneurysm , symptoms are often described as tearing or ripping in the chest, back, or abdomen.

PTS: 1

24. ANS: D
It is often difficult to differentiate the symptoms of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD) from cardiac symptoms. A thorough history and diagnostic tests are necessary. Patients with a history of GERD or PUD should still be worked up for a cardiac etiology, particularly if the characteristics of the symptoms or the history have changed to raise the index of suspicion for cardiac disease. The pain of cholecystitis, also sometimes mistaken for cardiac pain, typically presents with right upper quadrant pain with radiation to the thoracic region of the back.

PTS: 1

25. ANS: C
The pain of pancreatitis is severe, steady, and boringradiating from the epigastric region through to the back. It is often accompanied by nausea and vomiting, tachycardia, hypotension, and diaphoresis. These symptoms are also seen in MI; however, the exquisite abdominal tenderness present in pancreatitis assists in differentiating it from cardiac pain.

PTS: 1

26. ANS: B
Costochondritis, which is inflammatory pain of the chest wall, can often be differentiated from cardiac pain through history. A history of injury, heavy lifting, contact sports, excessive coughing, or late-stage pregnancy (which stretches the intercostal muscles) leads the examiner to consider chest wall pain. This often occurs in a younger population with no cardiac risk factors. One of the most helpful differentiating symptoms is that the pain is increased with movement, cough, or, in some cases, respiration.

PTS: 1

27. ANS: C
A grade III murmur is moderately loud and a systolic murmur immediately follows S1.

PTS: 1

28. ANS: B
A thorough cardiac examination is performed with the patient sitting, leaning forward, lying, and in the left lateral recumbent position. Some murmurs are heard better in different positions. Listen over the carotids for radiation of an aortic or pulmonic murmur, in the left mid-axillary line for radiation of a mitral murmur, and in the epigastric area for a bruit, indicating an aneurysm.

PTS: 1

29. ANS: D
Aortic stenosis is heard best in the second right intercostal space with the client leaning forward. The murmur is harsh, loud, and often associated with a thrill. It may radiate to the neck, left sternal border, and, in some cases, to the apex.

PTS: 1

30. ANS: A
The valves are best heard over the chest at specific areas. The aortic valve is best heard over the second intercostal space right sternal border and the pulmonic valve is best heard over the second intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space mid-clavicular line.

PTS: 1

31. ANS: D
Syncope, angina, and dyspnea (remembered with the acronym SAD) on exertion are the classic symptoms of aortic stenosis. If syncope occurs with exertion, the aortic stenosis is typically severe. Angina may be present because of decreased perfusion of the left ventricle due to LVH rather than CAD, but both exist in many cases.

PTS: 1

32. ANS: A
In mitral valve prolapse (MVP), a portion of the mitral valve flops open up into the left atrium, giving rise to a classic mid-systolic click followed by a soft grade I murmur that crescendos up to S2. It is high pitched and is heard best at the apex or left sternal border.

PTS: 1

33. ANS: B
Echocardiography is the best diagnostic test for assessing a heart murmur. In addition to visualizing the diseased valve, echocardiography can assist in determining the size of the heart chambers involved in the heart murmur in real time.

PTS: 1

34. ANS: D
The murmur of tricuspid regurgitation is heard best at the left sternal border and may radiate to the right of the sternum. It is pansystolic, high pitched, and blowing and increases with respiration. Tricuspid regurgitation may be associated with right ventricular hypertrophy resulting in a right parasternal lift. When right ventricular failure occurs, jugular venous distention occurs with a prominent v wave, and liver enlargement may be present. There may be secondary right atrial enlargement owing to backflow into the right atrium. The most common initiator is pulmonary HTN.

PTS: 1

35. ANS: C
The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erbs point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the mid-clavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

PTS: 1

36. ANS: A
The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erbs point is where all valves can be heard equally well. Erbs point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the mid-clavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

PTS: 1

37. ANS: D
An innocent murmur is a type of systolic murmur that results from turbulent blood flow and is not associated with heart disease. Innocent murmurs occur commonly in children and young adults and reflect the contractile force of the heart, resulting in greater velocity of flow during early systole. They are heard best in the second and third left interspaces along the left sternal border or at the apex.

PTS: 1

38. ANS: B
Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

PTS: 1

39. ANS: C
Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

PTS: 1

40. ANS: A
In mitral stenosis, the most common presenting symptoms are dyspnea on exertion and hemoptysis due to pulmonary congestion. The pulmonary congestion is caused by increased left atrial pressure related to the decrease in left atrial emptying. Crackles may be heard at the lung bases but are not present in all patients with pulmonary congestion. Orthopnea may be present because the lungs become more congested in the recumbent position. In addition, atrial fibrillation often develops in patients with mitral stenosis, which, in turn, worsens the pulmonary congestion.

PTS: 1

41. ANS: B
In aortic stenosis, the left ventricle has to work against high resistance and eventually, left ventricular hypertrophy (LVH) develops. The LVH causes an enlarged left ventricle, and the point of maximal impulse located at the fifth intercostal space moves leftward toward the mid-axillary line.

PTS: 1

42. ANS: A
The aortic valve closes creating S2. After the aortic valve closes, in aortic regurgitation, some blood flows back into the left ventricle. S1 through S2 is the systolic time frame. S2 through S1 is the diastolic time frame. The sound of a leaky aortic valve would be heard after the aortic valve closes (S2) during early diastole.

PTS: 1

43. ANS: C
Ventricular septal defect (VSD) is a congenital heart defect in which oxygenated blood is shunted from a higher-pressured left ventricle to a lower-pressured right ventricle through an abnormal opening in the ventricular septum. This left-to-right shunt causes an increased blood flow across the pulmonic valve. The signs and symptoms depend on the size of the defect and the age of the patient. A VSD murmur occurs after the mitral valve closes (S1). Characteristic of a VSD is a loud, harsh, pansystolic murmur at the lower left sternal border, usually accompanied by a thrill.

PTS: 1

44. ANS: D
ASD is a congenital abnormality in which oxygenated blood is shunted from a higher-pressured left atrium to a lower-pressured right atrium through an abnormal opening in the atrial septum. Atrial arrhythmias, especially atrial fibrillation, are common in the adult population with ASD. ASDs are often accompanied by other congenital heart defects, but in an uncomplicated lesion, patients are often asymptomatic until early adulthood, when they present with dyspnea on exertion or palpitations resulting from atrial arrhythmia. Because patients may be asymptomatic for many years, right HF can be the first sign, and patients may present with jugular venous distension, edema, and ascites.

PTS: 1

45. ANS: C
The aim for primary prevention is to keep LDL levels below 130 mg/dL and HDL levels above 40 mg/dL. Although primary prevention lowers a persons risk of heart disease and MI, it has shown only small, if any, effect on all-cause mortality. In patients with known CVD or diabetes, the target cholesterol levels are more stringent, aiming for an LDL level below 100 mg/dL and an HDL level above 60 mg/dL.

PTS: 1

46. ANS: B
The physical examination includes measurement of height and weight to calculate body mass index (BMI). The formula for calculating BMI is wt(kg)/ht(m2). A waist/hip ratio is also an indicator for risk of heart disease. A ratio greater than 0.85 for women and greater than 0.95 for men is considered to place individuals at increased risk, especially if accompanied by hyperinsulinemia or diabetes. These are part of a constellation of symptoms termed metabolic syndrome that indicates the greatest risk for the development of heart disease.

PTS: 1

47. ANS: D
Characteristics of Metabolic Syndrome
Hypertension
Dyslipidemia
Central obesity
Glucose intolerance with hyperinsulinemia (insulin resistance)

PTS: 1

48. ANS: C
Weight loss through diet and exercise has been found to be the most important factor in the prevention of the progression of metabolic syndrome. Insulin sensitivity increases with weight loss and is thought to be due to the loss of visceral fat. The target BMI is less than 22 kg/m2 for women and less than 27 kg/m2 for men. BMI of 16 kg/m2 is considered too low.

PTS: 1

49. ANS: A
Brain natriuretic peptide (BNP)For patients with cardiovascular disease and comorbid respiratory disease, BNP can help differentiate a cardiac from a respiratory etiology of dyspnea. High levels of BNP in the blood, greater than 400 mg/dL, occur if heart failure is present.

PTS: 1

50. ANS: B
In right ventricular failure, the abdomen should be examined particularly for right upper quadrant discomfort related to hepatic congestion and enlargement. The examiner can also check for hepatic jugular reflux by placing sustained pressure on the liver while observing for jugular venous distention. In right HF, ascites may also be present. Examine the extremities for edema seen in right HF.

PTS: 1

51. ANS: D
Left ventricular failure is most commonly characterized by dyspnea on exertion, cough, fatigue, orthopnea, PND, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Right ventricular failure is commonly characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with shortness of breath and tachycardia. Cor pulmonale is a heart disorder that occurs because of lung disease. The lungs are dysfunctioning which causes hypoxia and reflex pulmonary artery vasoconstriction. The right ventricle has to eject blood into the pulmonary artery, however, there is high afterload to deal because of pulmonary vasoconstriction. The high workload against the right ventricle eventually causes the right ventricle to fail. This right ventricular failure because of lung disease is called cor pulmonale.

PTS: 1

52. ANS: C
Right ventricular failure is characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with sudden shortness of breath and tachycardia. Left ventricular failure is characterized by dyspnea on exertion, cough, fatigue, orthopnea, PND, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Myocardial infarction presents with crushing retrosternal chest pain, pallor, dyspnea, and diaphoresis.

PTS: 1

53. ANS: D
Bacterial endocarditis is a microbial infection of the endocardium. The most common causative organisms are Staphylococcus aureus, group A streptococcus, pneumococcus, and gonococcus. Risk factors include valvular disease, intravenous drug use, dental disease, and invasive diagnostic procedures. Initially, the signs and symptoms are similar to those of other systemic illnesses, including fever, chills, arthralgias, malaise, and fatigue. Petechiae, anemia, weight loss, new or worsening heart murmur, and emboli alert the examiner to a more serious disease process.

PTS: 1

54. ANS: A
Intermittent claudication is pain in the leg or foot that becomes worse with exercise and is relieved by rest. The classic signs of peripheral arterial disease include pain, pallor, weak pulse, paresthesias, and palpable coolness. The signs of venous thrombosis are erythema, ropiness, as well as warmth and tenderness along the course of the vein. Edema of the leg and Homans sign of the foot are also common.

PTS: 1

55. ANS: D
The ankle-brachial index (ABI) is currently the easiest, least expensive noninvasive method for diagnosing PAD and is particularly helpful in the office and home settings. The ABI is obtained by the following steps:
1. Obtain brachial systolic pressure in both arms. Select the higher of these two values.
2. Use Doppler stethoscope to obtain systolic pressure in the dorsalis pedis or posterior tibialis vessel.
3. Divide ankle pressure by the higher brachial pressure.
The index should be 1 or higher. If it is less than 0.5, impairment to blood flow is significant. An abnormal ABI indicates the need for a vascular consult.

PTS: 1

56. ANS: C
Chronic venous insufficiency can be a long-term complication of venous thrombosis, owing to the destruction of valves in the deep veins. The calf muscle pump that returns blood from the lower legs is damaged, increasing ambulatory pressure in the calf veins. A constellation of symptoms is set up: aching or pain in the lower legs, edema, thinning and hyperpigmentation of the skin, superficial varicosities, venous stasis, and ulceration. Ankle edema is often the earliest sign.

PTS: 1

57. ANS: B
Often a precursor to chronic venous insufficiency, varicose veins are usually caused by occupations that involve prolonged standing or sitting in one place, overweight, pregnancy, or a familial tendency. They may increase the patients risk for DVT, or they may occur secondary to a DVT. Blockage to lymphatic flow can cause varicosities as seen with pelvic neoplasm. They appear as long, dilated, tortuous veins in the lower extremities.

PTS: 1

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