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Bates Test questions The Cardiovascular System

Health Assessment (Northeastern University)

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Bates’ Guide to Physical Examination and History Taking, 12th Edition

Chapter 9: The Cardiovascular System

Multiple Choice

1. You are performing a thorough cardiac examination. Which of the following chambers of the
heart can you assess by palpation?
A) Left atrium
B) Right atrium
C) Right ventricle
D) Sinus node

Ans: C
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: The right ventricle occupies most of the anterior cardiac surface and is easily
accessible to palpation. The other structures are less likely to have findings on palpation and the
sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused
by the sinus node indirectly by palpation, but this is less obvious.

2. What is responsible for the inspiratory splitting of S2?

A) Closure of aortic, then pulmonic valves
B) Closure of mitral, then tricuspid valves
C) Closure of aortic, then tricuspid valves
D) Closure of mitral, then pulmonic valves

Ans: A
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic
valve separate slightly, and this may be heard as two audible components, instead of a single
sound. Current explanations of inspiratory splitting include increased capacitance in the

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pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right
ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you
may not hear it away from the left second intercostal space. Because it is a low-pitched sound,
you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in
school-aged children, and it is easy to notice the respiratory variation of the splitting.

3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your
physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which
valve is most likely to be involved, based on the location of the murmur?
A) Mitral
B) Tricuspid
C) Aortic
D) Pulmonic

Ans: A
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.

4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity.
The patient has no chronic conditions and does not take any medications, herbs, or supplements.
Which of the following symptoms is appropriate to ask about in the cardiovascular review of
systems?
A) Abdominal pain
B) Orthopnea
C) Hematochezia
D) Tenesmus

Ans: B
Chapter: 09
Page and Header: 337, The Health History
Feedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and
improves when the patient sits up, is part of the cardiovascular review of systems and, if positive,
may indicate congestive heart failure.

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5. You are screening people at the mall as part of a health fair. The first person who comes for
screening has a blood pressure of 132/85. How would you categorize this?
A) Normal
B) Prehypertension
C) Stage 1 hypertension
D) Stage 2 hypertension

Ans: B
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a
diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking
action at this point to prevent worsening hypertension. Research shows that this population is
likely to progress to more serious stages of hypertension.

6. You are participating in a health fair and performing cholesterol screens. One person has a
cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the
following factors is used to estimate the 10-year risk of developing coronary heart disease?
A) Ethnicity
B) Alcohol intake
C) Gender
D) Asthma

Ans: C
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Gender is used in the calculation of the 10-year risk for developing coronary heart
disease, because men have a higher risk than women.

7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a
history of hypertension, which is well-controlled on his current medications. He does not smoke;
he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year
coronary heart disease risk. Which of the following conditions is considered to be a coronary
heart disease risk equivalent?
A) Hypertension
B) Peripheral arterial disease
C) Systemic lupus erythematosus
D) Chronic obstructive pulmonary disease (COPD)

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Ans: B
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent,
as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of
your instruction, you tell the students to make sure that they can distinguish between the jugular
venous pulsation and the carotid pulse. Which one of the following characteristics is typical of
the carotid pulse?
A) Palpable
B) Soft, rapid, undulating quality
C) Pulsation eliminated by light pressure on the vessel
D) Level of pulsation changes with changes in position

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The
carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or
bounding as in aortic insufficiency.

9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are
concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated.
Which one of the following conditions is a potential cause of elevated JVP?
A) Left-sided heart failure
B) Mitral stenosis
C) Constrictive pericarditis
D) Aortic aneurysm

Ans: C
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others
include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may
wish to read about these conditions.

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10. You are palpating the apical impulse in a patient with heart disease and find that the
amplitude is diffuse and increased. Which of the following conditions could be a potential cause
of an increase in the amplitude of the impulse?
A) Hypothyroidism
B) Aortic stenosis, with pressure overload of the left ventricle
C) Mitral stenosis, with volume overload of the left atrium
D) Cardiomyopathy

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in
an increase in amplitude of the apical impulse. The other conditions should decrease amplitude
of the apical impulse or not be palpable at all.

11. You are performing a cardiac examination on a patient with shortness of breath and
palpitations. You listen to the heart with the patient sitting upright, then have him change to a
supine position, and finally have him turn onto his left side in the left lateral decubitus position.
Which of the following valvular defects is best heard in this position?
A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid

Ans: C
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: The left lateral decubitus position brings the left ventricle closer to the chest wall,
allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position
with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such
as mitral stenosis.

12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best
position to accentuate the murmur?
A) Upright

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B) Upright, but leaning forward

C) Supine
D) Left lateral decubitus

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Leaning forward slightly in the upright position brings the aortic valve and the left
ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic
decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear
this soft murmur by having the patient hold his breath in exhalation.

13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a
cardiac examination and find that his pulse rate is less than 60. Which of the following
conditions could be responsible for this heart rate?
A) Second-degree A-V block
B) Atrial flutter
C) Sinus arrhythmia
D) Atrial fibrillation

Ans: A
Chapter: 09
Page and Header: 375, Table 9–1
Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and
atrial fibrillation do not cause bradycardia unless there is a significant accompanying block.
Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart
rate.

14. Where is the point of maximal impulse (PMI) normally located?

A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum
B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum
C) In the left 5th intercostal space, in the anterior axillary line
D) In the left 5th intercostal space, in the midaxillary line

Ans: A
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral

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to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its
size should not be greater than the size of a US quarter, or about an inch. Left ventricular
enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral
valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.

15. Which of the following events occurs at the start of diastole?

A) Closure of the tricuspid valve
B) Opening of the pulmonic valve
C) Closure of the aortic valve
D) Production of the first heart sound (S1)

Ans: C
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It
is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of
the mitral valve is thought to produce the first heart sound (S1).

16. Which is true of a third heart sound (S3)?

A) It marks atrial contraction.
B) It reflects normal compliance of the left ventricle.
C) It is caused by rapid deceleration of blood against the ventricular wall.
D) It is not heard in atrial fibrillation.

Ans: C
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall.
S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually
indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.

17. Which is true of splitting of the second heart sound?

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A) It is best heard over the pulmonic area with the bell of the stethoscope.
B) It normally increases with exhalation.
C) It is best heard over the apex.
D) It does not vary with respiration.

Ans: A
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: S2 splitting is best heard over the pulmonic area because this is the only place where
both of its components can be heard well. The closure of the pulmonic valve is normally not
loud because the right heart is a low-pressure system. The bell is best used because it is a low-
pitched sound. S2 splitting normally increases with inhalation.

18. Which of the following is true of jugular venous pressure (JVP) measurement?
A) It is measured with the patient at a 45-degree angle.
B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
C) A JVP below 9 cm is abnormal.
D) It is measured above the sternal notch.

Ans: B
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: Measurement of the JVP is important to assess a patient's fluid status. Although it
may be measured at 45°, it is important to adjust the level of the patient's torso so that the blood
column is visible. This may be with the patient completely supine or sitting completely upright,
depending on the patient. Any measurement greater than 4 cm above the sternal angle is
abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is
an estimate of the height of the sternal notch above the right atrium.

19. Which of the following regarding jugular venous pulsations is a systolic phenomenon?
A) The “y” descent
B) The “x” descent
C) The upstroke of the “a” wave
D) The downstroke of the “v” wave

Ans: B
Chapter: 09

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Page and Header: 323, Anatomy and Physiology

Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena.
These can be timed using the carotid pulse. The only event listed above which is a systolic
phenomenon is the “x” descent.

20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and
10 mm Hg diastolic in blood pressure?
A) 25%
B) 50%
C) 75%
D) 100%

Ans: D
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular
disease. Being “low risk” by JNC 7 criteria confers a 72%–85% reduction in CVD mortality and
40%–58% reduction in overall mortality.

21. In healthy adults over 20, how often should blood pressure, body mass index, waist
circumference, and pulse be assessed, according to American Heart Association guidelines?
A) Every 6 months
B) Every year
C) Every 2 years
D) Every 5 years

Ans: C
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood
pressure, body mass index, waist circumference, and pulse.

22. Which of the following is a clinical identifier of metabolic syndrome?

A) Waist circumference of 38 inches for a male
B) Waist circumference of 34 inches for a female

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C) BP of 134/88 for a male

D) BP of 128/84 for a female

Ans: C
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: The physical examination criteria for identifying metabolic syndrome include a waist
of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood
pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150
mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less
than 50 for women.

23. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as
necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What
heart rate should she achieve?
A) 80
B) 100
C) 120
D) 140

Ans: B
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Maximum heart rate is calculated by subtracting the patient's age from 220. For Mrs.
Adams, 60% of this number is about 100. She must also be instructed in how to measure her
own pulse or have a device to do so. Most people are able to carry on a conversation at this level
of exertion.

24. In measuring the jugular venous pressure (JVP), which of the following is important?
A) Keep the patient's torso at a 45-degree angle.
B) Measure the highest visible pressure, usually at end expiration.
C) Add the vertical height over the sternal notch to a 5-cm constant.
D) Realize that a total value of over 12 cm is abnormal.

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: In measuring JVP, the angle of the patient's torso must be varied until the highest

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oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal
angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this
landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle,
plus the 5 cm constant) is considered abnormal.

25. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you
search out?
A) Mitral valve prolapse
B) Pulmonic stenosis
C) Tricuspid insufficiency
D) Aortic insufficiency

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Bounding carotid pulses would be found in aortic insufficiency. This should be
sought by listening over the third left intercostal space, with the patient leaning forward in held
exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in
any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism,
fever, etc.

26. To hear a soft murmur or bruit, which of the following may be necessary?
A) Asking the patient to hold her breath
B) Asking the patient in the next bed to turn down the TV
C) Checking your stethoscope for air leaks
D) All of the above

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: All examiners should carefully search for soft murmurs and bruits. These can have
great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly
increase your ability to hear soft sounds.

27. Which of the following may be missed unless the patient is placed in the left lateral

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decubitus position and auscultated with the bell?

A) Mitral stenosis murmur
B) Opening snap of the mitral valve
C) S3 and S4 gallops
D) All of the above

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Placing the patient in the left lateral decubitus position and auscultating with the bell
will enable you to hear these sounds, which would otherwise be missed.

28. How should you determine whether a murmur is systolic or diastolic?

A) Palpate the carotid pulse.
B) Palpate the radial pulse.
C) Judge the relative length of systole and diastole by auscultation.
D) Correlate the murmur with a bedside heart monitor.

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Timing of a murmur is crucial for identification. The carotid pulse should be used
because there is a delay in the radial pulse relative to cardiac events, which can lead to error.
Some clinicians can estimate timing by the relative length of systole and diastole, but this
method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all
designed to correlate in time with the actual pulse.

29. Which of the following correlates with a sustained, high-amplitude PMI?

A) Hyperthyroidism
B) Anemia
C) Fever
D) Hypertension

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure

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work by the heart, as seen in hypertension, causes the PMI to be sustained.

30. You are examining a patient with emphysema in exacerbation and are having difficulty
hearing his heart sounds. What should you do to obtain a good examination?
A) Listen in the epigastrium.
B) Listen to the patient in the left lateral decubitus position.
C) Ask the patient to hold his breath for 30 seconds.
D) Listen posteriorly.

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of
the chest as well as the interfering lung noise make examination challenging. By listening in the
epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of
breath to hold his breath for a prolonged period. Listening posteriorly would make the heart
sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus
position, but in this case it would not make auscultation easier.

31. You are listening carefully for S2 splitting. Which of the following will help?
A) Using the diaphragm with light pressure over the 2nd right intercostal space
B) Using the bell with light pressure over the 2nd left intercostal space
C) Using the diaphragm with firm pressure over the apex
D) Using the bell with firm pressure over the lower left sternal border

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: S2 splitting is composed of an aortic and pulmonic component. Because the
pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It
is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely,
the diaphragm is best used with firm pressure.

32. Which of the following is true of a grade 4-intensity murmur?

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A) It is moderately loud.
B) It can be heard with the stethoscope off the chest.
C) It can be heard with the stethoscope partially off the chest.
D) It is associated with a “thrill.”

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: The grade 4 murmur is differentiated from those below it by the presence of a
palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a “buzzing”
feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over
a dialysis fistula.

33. Which valve lesion typically produces a murmur of equal intensity throughout systole?
A) Aortic stenosis
B) Mitral insufficiency
C) Pulmonic stenosis
D) Aortic insufficiency

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: This description fits a holosystolic murmur. Because aortic and pulmonic stenosis
murmurs vary with the flow of blood during systole, they typically produce a crescendo–
decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in
diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient
decreases.

34. You notice a patient has a strong pulse and then a weak pulse. This pattern continues.
Which of the following is likely?
A) Emphysema
B) Asthma exacerbation
C) Severe left heart failure
D) Cardiac tamponade

Ans: C
Chapter: 09
Page and Header: 348, Techniques of Examination

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Feedback: This finding is consistent with pulsus alternans, which is associated with severe left
heart failure. Occasionally, a monitor will read only half of the beats because half are too weak
to detect. There may also be electrical alternans on EKG. This can be detected by using a blood
pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will
double, because the weaker beats can then “make it through.” The other findings are associated
with paradoxical pulse.

35. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent
and is located to the left of her sternum. There are no associated symptoms. On examination,
you hear a short, high-pitched sound in systole, followed by a murmur which increases in
intensity until S2. This is heard best over the apex. When she squats, this noise moves later in
systole along with the murmur. Which of the following is the most likely diagnosis?
A) Mitral stenosis
B) Mitral insufficiency
C) Mitral valve prolapse
D) Mitral valve papillary muscle ischemia

Ans: C
Chapter: 09
Page and Header: 382, Table 9–8
Feedback: The description above is classic for mitral valve prolapse. The extra sound is a
midsystolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, low-
pitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral
decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and
papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.

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