Guyton & Hall: Textbook of Medical Physiology, 11th Edition

UNIT III: The Heart

MULTIPLE CHOICE

1. A 13-year-old boy is found to have a persistent atrial septal defect, a large left-to-right
intracardiac shunt, and right ventricular hypertrophy. Which one of the following is a
major pathophysiological consequence of this type of intracardiac shunt?
a. Decreased right atrial pressure
b. Increased right ventricular preload
c. Decreased systemic arterial PO2
d. Decreased pulmonary blood flow

ANS: B
An atrial septal defect allows blood to flow from the left atrium into the right atrium,
increasing right atrial pressure and right ventricular filling pressure (i.e., preload). Right
ventricular output exceeds left ventricular output, increasing pulmonary blood flow.
Because there is no venous admixture due to right-to-left shunting, arterial Po2 is not
decreased.

2. The greatest left ventricular volume is achieved during which one of the following
periods of the cardiac cycle?
a. Isovolumetric ventricular relaxation
b. Rapid filling
c. Diastasis
d. Atrial systole

ANS: D
Atrial contraction during the last part of diastole increases ventricular filling beyond the
level achieved up to that point with simple passive filling.

3. An elderly female patient with a childhood history of rheumatic fever is found to have
a stenotic mitral valve. Diagnostic studies reveal a reduced left ventricular stroke
volume that is most likely caused by which one of the following?
a. Increased left ventricular afterload
b. Increased left ventricular compliance
c. Decreased myocardial contractility
d. Decreased left ventricular filling (i.e., decreased preload)

ANS: D
The patient would have decreased left ventricular filling and decreased preload because
of the elevated resistance to flow through the stenotic mitral valve during diastole. The
valvular disorder would not decrease myocardial contractility, increase ventricular
compliance, or affect afterload and ventricular emptying.

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Additional Test Bank 2

4. The v wave of the atrial pressure curve corresponds most closely to which one of the
following?
a. Atrial contraction
b. Ventricular contraction and bulging of the A-V valves back into the atria
c. Continued filling of the atria from the veins during ventricular contraction
d. Closure of the semilunar valves

ANS: C
During ventricular contraction and ejection, blood continues to flow into the atria from
the systemic and pulmonary veins, causing atrial pressure to rise and producing the v
wave. When the ventricles relax and begin to fill, atrial pressures fall, and the v wave
disappears.

5. Which one of the following periods of the cardiac cycle is the first period normally
associated with ventricular diastole?
a. Atrial contraction
b. Isovolumic relaxation
c. Rapid inflow or rapid filling
d. Diastasis

ANS: B
Relaxation of the ventricles and closure of the semilunar valves mark the end of systole.
After closure of the aortic valve, left ventricular pressure falls rapidly during the
isovolumic period, the beginning of diastole.

6. The third heart sound, S3, is most closely associated with which one of the following
periods of the cardiac cycle?
a. Atrial contraction
b. Isovolumic contraction
c. Rapid ejection
d. Rapid filling

ANS: D
The third heart sound is thought to be associated with rapid ventricular filling in the first
third of diastole. Atrial contraction is associated with the fourth heart sound, S4;
isovolumic contraction follows the onset of ventricular contraction and S1; and the rapid
ejection period is not associated with any of the heart sounds.

7. Which one of the following is most useful for the quantitative depiction of the net
external work of the left ventricle during the cardiac cycle?
a. Cardiac cycle diagram
b. Ventricular pressure-volume loop
c. Cardiac output/venous return graph
d. Starling's law

ANS: B

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 Additional Test Bank 3

The area within the ventricular pressure-volume loop represents the net external work of
the ventricle. The cardiac cycle diagram depicts the changes in pressures and volumes
within the heart over time, but it cannot be used to calculate or depict work. The cardiac
output/venous return graphs and the graphical depiction of Starling's law likewise cannot
quantitatively depict cardiac work.

8. The incisura, or dicrotic notch, in the arterial pressure curve is most closely
associated with which one of the following events of the cardiac cycle?
a. Closure of the atrioventricular valves
b. Rapid ejection of blood from the left ventricle
c. Closure of the aortic valve
d. Rapid filling of the left ventricle

ANS: C
The incisura of the arterial pressure tracing is caused by the sudden cessation of a brief
period of backflow associated with closure of the aortic valve, marking the end of systole.

9. Which one of the following best represents the degree of tension in cardiac muscle
just before the onset of contraction?
a. Afterload
b. Maximum isometric tension
c. Contractility
d. Preload

ANS: D
The preload represents the passive tension in the wall of the ventricle associated with
filling of the ventricle during diastole, and it is usually associated with ventricular end-
diastolic pressure.

10. Electrical conduction between myocardial cells occurs through

a. Intercalated discs
b. Intervertebral discs
c. Interforamen discs
d. Interthecal discs

ANS: A
B is incorrect because intervertebral discs are fluid-filled structures that provide space
between vertebrae in the spine. C is incorrect because there are no interforamen discs. D
is incorrect because there are no discs in the interthecal space.

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 Additional Test Bank 4

11. Action potentials through the heart are propagated by ion flux, which results in
depolarization in an organized fashion. The sequential nature of electrical conduction
of the heart occurs because of which of the following?
a. There are two separate syncytia, separated by fibrous, nonconductile tissue.
b. The atrial and ventricular syncytia are separated by fibrous, noncontractile tissue.
c. The atrial and ventricular syncytia are connected by quickly conducting, excitable
tissue.
d. The conduction system depolarizes based on the movement of calcium ions.

ANS: A
B is incorrect because it does not answer the question correctly, although the statement
itself is true. C is incorrect because the A-V bundle is a slowly conducting, excitable
tissue bundle. D is incorrect because depolarization occurs by the movement of sodium
ions.

12. The difference between depolarization of cardiac muscle and skeletal muscle is that
the depolarization of cardiac muscle occurs because of which of the following?
a. Depolarization occurs by opening many fast sodium channels.
b. Depolarization occurs by opening fast sodium channels and calcium-sodium
channels.
c. Depolarization occurs by opening fast potassium channels.
d. Depolarization occurs by opening fast potassium channels and potassium-calcium
channels.

ANS: B
A is incorrect because skeletal muscles depolarize by opening fast sodium channels. C is
incorrect because opening potassium channels causes hyperpolarization of the cell
membrane. D is incorrect because of the reason for C and because no such potassium-
calcium channel has been identified.

13. As a myocardial cell depolarizes, it enters a refractory period. Which of the following
occurs during the absolute refractory period?
a. The cell cannot be depolarized for approximately 0.25 to 0.30 second.
b. The cell can be depolarized if there is a very strong excitatory signal.
c. A premature depolarization can be stimulated.
d. Contractions can be "stacked" to result in tetany.

ANS: A
B is incorrect because this is the definition of the relative refractory period. C is incorrect
because this happens during the relative refractory period. D is incorrect because tetany
occurs only in skeletal muscle.

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 Additional Test Bank 5

14. A patient is admitted to the intensive care unit and is found to have a resting heart rate
of 110. A potential cause of this heart rate is
a. Sympathetic stimulation to the S-A node
b. Sympathetic stimulation to the A-V node
c. Parasympathetic stimulation to the S-A node
d. Parasympathetic stimulation to the A-V node

ANS: A
B is incorrect because, although sympathetic stimulation to the A-V node would result in
increased heart rate, the most efficient way to increase heart rate is through the S-A node.
C and D are incorrect because the parasympathetic nervous system slows down the heart.

15. The Frank-Starling mechanism states the following:

a. As venous return increases, the stretch on the heart often exceeds optimal
myofibril overlap.
b. As venous return increases, heart rate and contraction strength increases.
c. Increased venous return results in increased heart rate only.
d. Increased venous return results in increased contractility by sympathetic
stimulation.

ANS: B
A is incorrect because the Frank-Starling mechanism results in optimization of the
myofibril overlap. C is incorrect because the Frank-Starling mechanism results in
increased heart rate and contractility. D is incorrect because the Frank-Starling
mechanism operates independent of nervous stimulation.

16. The depolarization phase of the atrioventricular (A-V) nodal action potential is most
closely associated with the movement of cations through which one of the following
types of channels?
a. Sodium "leak" channels
b. Fast voltage-gated sodium channels
c. Slow voltage-gated calcium channels
d. Potassium channels

ANS: C
Nodal cells do not normally have functional fast voltage-gated sodium channels. The
slow depolarization caused by sodium influx through sodium "leak" channels brings the
nodal cell membrane to the threshold potential for voltage-gated calcium channels,
causing rapid depolarization due to the influx of calcium ions. Delayed opening of
potassium channels allows potassium efflux and membrane repolarization.

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 Additional Test Bank 6

17. The binding of acetylcholine to cardiac muscarinic cholinergic receptors causes a

decrease in the heart rate that results from an increase in which one of the following?
a. Calcium influx
b. Potassium efflux
c. Sodium influx
d. Chloride efflux

ANS: B
Increased potassium efflux causes hyperpolarization of the nodal cells, requiring a longer
time for inward sodium leakage to depolarize the cell membrane and reach the threshold
potential for excitation.

18. Which one of the following portions of the cardiac conduction system normally has
the fastest rate of spontaneous depolarization?
a. Sinoatrial (S-A) node
b. Atrioventricular (A-V) node
c. Bundle of His
d. Purkinje fibers

ANS: A
The rapid, spontaneous depolarization of the S-A nodal cells due to the inward "leak" of
sodium ions brings this part of the heart to the threshold potential for the slow calcium
channels first. The resulting action potential then spreads throughout the heart, generating
the heartbeat.

19. Sympathetic stimulation causes an increase in heart rate that is most likely caused by
which one of the following?
a. Hyperpolarization due to increased potassium efflux
b. More rapid spontaneous depolarization due to increased sodium influx
c. Decreased contractility due to decreased calcium influx
d. More rapid depolarization due to opening of "fast" sodium channels

ANS: B
In the S-A node, increased sodium influx through "leak" channels causes a more rapid
spontaneous depolarization of the membrane to the threshold voltage for self-excitation.

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 Additional Test Bank 7

20. The increase in the contractile strength of heart muscle associated with sympathetic
stimulation of the heart is most likely caused by which one of the following?
a. Changes in initial fiber length (Starling's law)
b. Increased intracellular calcium concentration
c. Decreased intracellular cAMP concentration
d. Increased membrane potassium permeability

ANS: B
With sympathetic stimulation, more calcium ions enter the myocardial cells, and more
calcium ions are released from intracellular stores, increasing calcium concentration in
the vicinity of the contractile myofilaments and thereby increasing contractile force.

21. Which one of the following portions of the cardiac conduction system normally
demonstrates the slowest velocity of action potential conduction?
a. S-A node
b. Atrial conduction pathways
c. A-V node
d. Purkinje fibers

ANS: C
The small size of the A-V nodal cells and the high resistance to impulse conduction from
one cell to the next are associated with a slow velocity of conduction through the A-V
node, which provides an opportunity for atrial contraction to be completed before
ventricular contraction begins.

22. The specialized excitation conduction system of the heart exhibits automaticity that
originates in the
a. A-V node
b. S-A node
c. Purkinje fibers
d. Myocardial myocytes

ANS: B
A is incorrect because the spontaneous depolarization rate of the A-V node is
approximately 60 times per minute. C is incorrect because the spontaneous depolarization
rate of the Purkinje fibers is approximately 10 to 40 times per minute. D is incorrect
because ventricular myocytes do not spontaneously depolarize.

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 Additional Test Bank 8

23. The component of the myocardial conduction system that has the fastest rate of
spontaneous depolarization is the
a. S-A node
b. A-V node
c. Purkinje fibers
d. Myocytes

ANS: A
B is incorrect because the spontaneous depolarization rate of the A-V node is
approximately 60 times per minute. C is incorrect because the spontaneous depolarization
rate of the Purkinje fibers is approximately 10 to 40 times per minute. D is incorrect
because ventricular myocytes do not spontaneously depolarize. Also, the spontaneous rate
of depolarization of the S-A node is between 60 and 100 times per minute.

24. The correct order of depolarization through the myocardium is

a. S-A node, A-V node, bundle of His, Purkinje fibers, myocardial myocytes
b. A-V node, S-A node, bundle of His, Purkinje fibers, myocardial myocytes
c. Bundle of His, A-V node, S-A node, Purkinje fibers, myocardial myocytes
d. Purkinje fibers, S-A node, bundle of His, A-V node, myocardial myocytes

ANS: A
B is incorrect since the spontaneous rate of depolarization of the A-V node is
approximately 40-60 times per minute. C is incorrect; the correct order is S-A node, A-V
node, bundle of His, bundle branches, Purkinje fibers, and cell-to-cell conduction
through the myocytes. D is incorrect; the correct order is S-A node, A-V node, bundle of
His, bundle branches, Purkinje fibers, and cell-to-cell conduction through the myocytes.

25. The membrane potential of the S-A node is approximately

a. -25 to -30 mV
b. -55 to 60 mV
c. -85 to -90 mV
d. -125 to -130 mV

ANS: B
C is incorrect because -85 to -90 mV is the membrane potential for ventricular myocytes.
A is too close to 0, and D is too far from 0.

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 Additional Test Bank 9

26. The ion that is responsible for the slow potential of the S-A node is
a. Sodium
b. Potassium
c. Calcium
d. Chloride

ANS: A
B is incorrect because potassium is the ion that rapidly moves out of the cell to repolarize
the cell. C is incorrect because calcium is the ion responsible for the actin-myosin cross-
bridging needed to cause muscle cell contraction. D is incorrect because chloride is an
ion in very low concentration, and it is not active in myocyte depolarization.

27. The______ ions diffuse _______ of the cell to cause repolarization of the S-A node.
a. Sodium out of
b. Potassium into
c. Calcium into
d. Chloride out of

ANS: B
A is incorrect because sodium is the ion that slowly diffuses into the S-A node, bringing
the resting membrane potential closer to 0 mV. C is incorrect because calcium is the ion
responsible for the actin-myosin cross-bridging needed to cause muscle cell contraction.
D is incorrect because chloride is an ion in very low concentration and is not active in
myocyte depolarization.

28. A patient presents to the emergency room with poor ventricular contractility and a
slowed heart rate. A potential reason for this is
a. Hyperkalemia
b. Hypokalemia
c. Hypernatremia
d. Hypocalcemia

ANS: A
B is incorrect because hypokalemia results in decreased extracellular concentration of
potassium, which pushes the resting membrane potential toward depolarization. C is
incorrect because hypernatremia is increased extracellular sodium concentration, which
increases the potential for sodium leakage and increased heart rate. D is incorrect because
hypocalcemia is decreased extracellular calcium concentration, which can result in
decreased myocardial contractility.

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 Additional Test Bank 10

29. A patient exhibits normal atrial depolarization but poor ventricular depolarization. A
potential reason for this is which of the following?
a. Depolarization of the atria is separated from the ventricles by nonconductive
fibrous tissue.
b. Depolarization is delayed by 0.16 second as it moves through the A-V node.
c. There is too much extracellular sodium.
d. Depolarization is delayed by 0.03 second as it moves through the A-V node.

ANS: A
B is incorrect because 0.16 second is the normal conduction delay through the A-V node.
C is incorrect because high extracellular levels of sodium increase the extracellular
membrane potential toward depolarization. D is incorrect because a delay that is less than
normal increases, not decreases, conduction through the A-V node.

30. Depolarization travels through specialized conduction pathways from the S-A node to
the A-V node. This atrial depolarization occurs at a maximum rate of
a. 0.3 m/sec
b. 0.2 m/sec
c. 0.4 m/sec
d. 0.5 m/sec

ANS: A
B, C, and D are incorrect because they are wrong numbers.

31. Depolarization travels through Purkinje fibers at a rate of

a. 1.5 to 4.0 m/sec
b. 1 to 3.5 m/sec
c. 0.5 to 3.0 m/sec
d. 3 to 5 m/sec

ANS: A
B, C, and D are incorrect because they are wrong numbers.

32. A patient presents to the emergency room with an atrial heart rate of 75 beats per
minute. The classification for a patient with this heart rate is
a. Normal
b. Bradycardic
c. Tachycardic

ANS: A
B is incorrect because bradycardia is defined as a heart rate of less than 60 beats per
minute. C is incorrect because tachycardia is defined as a heart rate of more than 100
beats per minute.

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 Additional Test Bank 11

33. A patient presents with increased sympathetic stimulation to the heart. This is
manifested by
a. Increased heart rate and strength of contraction
b. Increased heart rate and decreased strength of contraction
c. Decreased heart rate and increased strength of contraction
d. Decreased heart rate and strength of contraction

ANS: A
B is incorrect because sympathetic stimulation increases myocardial contractility. C is
incorrect because sympathetic stimulation increases heart rate and contractility. D is
incorrect because this is the function of parasympathetic stimulation.

34. A patient sustains a myocardial infarction. The branch of the autonomic nervous
system that is aroused uses _____ as the neurotransmitter.
a. Norepinephrine
b. Acetylcholine
c. Serotonin
d. Dopamine

ANS: A
B is incorrect because acetylcholine is the parasympathetic neurotransmitter. C and D are
incorrect because serotonin and dopamine are neurotransmitters in the brain.

35. Which one of the following electrocardiographic leads is a bipolar lead?

a. Lead aVR
b. Lead V4
c. Lead III
d. Lead aVF

ANS: C
Lead III is a bipolar lead, with the negative electrode on the left arm and the positive
electrode on the left leg. The other leads are augmented unipolar limb leads (aVR and
aVF) or precordial leads (V4).

36. Which one of the following best represents the period of ventricular activation from
the time of initial septal depolarization until the ventricles are completely
repolarized?
a. P-R interval
b. S-T segment
c. Q-T interval
d. QRS duration

ANS: C
The beginning of the QRS complex represents the onset of septal and ventricular
depolarization, and the end of the T-wave represents ventricular repolarization; the Q-T
interval would therefore encompass this entire period.

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 Additional Test Bank 12

37. Which one of the following best represents the time between the beginning of
electrical excitation of the atria and the beginning of excitation of the septum and
ventricles?
a. P wave
b. P-R interval
c. QRS complex duration
d. S-T segment

ANS: B
The P-R interval is the interval between the beginning of the P wave and atrial excitation
and the beginning of the QRS complex or ventricular excitation. The P wave alone
represents atrial depolarization; the duration of the QRS complex represents the duration
of septal and ventricular depolarization; and the S-T segment represents the interval
between the end of the QRS complex and the beginning of the T wave.

38. The P wave on an electrocardiogram is caused by

a. The rapid influx of sodium into the atria, causing depolarization and subsequent
atrial contraction
b. The rapid influx of potassium into the atria, causing hyperpolarization and
subsequent atrial contraction
c. The slow influx of calcium into the ventricles, causing depolarization and
subsequent ventricular contraction
d. The slow influx of chloride into the ventricles, causing depolarization and
subsequent ventricular contraction

ANS: A
B is incorrect because hyperpolarization of the atria does not result in contraction. C is
incorrect because calcium causes contraction, but not depolarization. D is incorrect
because chloride is an ion that stabilizes membrane charges.

39. Depolarization occurs by ion movement, resulting in the advancement of _________

potential inside the atrial cell. The change in intracellular charge results in deflection
of a meter. If the wave of depolarization is toward the electrode, the deflection
registered is _________.
a. Negative positive
b. Negative negative
c. Positive positive
d. Positive negative

ANS: C
A and B are incorrect because a depolarizing potential causes a wave of positivity, not
negativity. D is incorrect because the deflection is in a positive, not negative, direction.

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 Additional Test Bank 13

40. Atrial repolarization begins approximately _____ second after the completion of atrial
depolarization.
a. 0.10 to 0.15
b. 0.15 to 0.20
c. 0.20 to 0.25
d. 0.25 to 0.30

ANS: B
A is incorrect because the time is too short. C and D are incorrect because the time is too
long.

41. The paper that records an electrocardiogram (ECG) advances at a uniform speed such
that the smallest of boxes take _____ seconds.
a. 0.02
b. 0.04
c. 0.06
d. 0.08

ANS: B
A is incorrect because the time is too short. C and D are incorrect because the time is too
long.

42. The QRS complex on an ECG signifies the onset of

a. Electrical depolarization of the ventricles
b. Electrical hyperpolarization of the ventricles
c. Mechanical contraction of the ventricles
d. Mechanical contraction of the atria

ANS: A
B is incorrect because electrical hyperpolarization is the T wave. C and D are incorrect
because an ECG is a record of electrical potentials, not mechanical events.

43. Assuming normal electromechanical coupling, which mechanical events occur during
the QT interval?
a. Atrial contraction and relaxation
b. Ventricular contraction and relaxation
c. Atrial relaxation only
d. Ventricular relaxation only

ANS: B
A is incorrect because all visible atrial ECG events are completed by the Q wave. C is
incorrect because atrial repolarization is not easily visible on the ECG. D is incorrect
because ventricular repolarization is the T wave.

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 Additional Test Bank 14

44. As the heart is depolarized, the trajectory of the mean potential travels from the base
to apex initially. The heart is oriented in the chest such that
a. The base is closest to the shoulders and to the xyphoid process, and the vector of
depolarization travels anteriorly and inferiorly.
b. The base is closest to the xyphoid process, the apex is closest to the scapulae, and
the vector of depolarization travels superiorly and posteriorly.
c. The base is closest to the right axillary line, the apex is closest to the vertebrae, and
the vector of depolarization travels anteriorly and inferiorly.
d. The base is closest to the left axillary line, the apex is closest to the vertebrae, and
the vector of depolarization travels posteriorly and superiorly.

ANS: A
B is incorrect because the base is closest to the shoulders and the apex is the pointy part
made up of ventricles behind the body of the sternum. C and D are incorrect because the
vector of depolarization in the heart would not follow the trajectory in the distractor.

45. When examining ECGs produced by monitoring the first three limb leads, the
positive electrode on lead II is located
a. Over the right shoulder
b. Over the left shoulder
c. Near the right wrist
d. Near the left ankle

ANS: D
Leads are made up of two electrodes, and by convention, lead II follows the trajectory of
the normal ventricular depolarization, such that the inferior pole is positive, resulting in
an upward deflection on the ECG.

46. The deflection of the QRS complex on lead V2 is mainly

a. Positive because of the location of the chest leads in relation to the vector of
depolarization
b. Positive because of the relationship between the two electrodes that make up lead
V2
c. Negative because of the location of the chest leads in relation to the vector of
depolarization
d. Negative because of the relationship between the two electrodes that make up lead
V2

ANS: A
B is incorrect because there are not two electrodes that make up lead V2. C is incorrect
because the deflection is predominantly positive. D is incorrect because the deflection is
predominantly positive and there are not two electrodes that make up lead V2.

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 Additional Test Bank 15

47. Which one of the following electrocardiographic leads is perpendicular to lead aVL in
the hexagonal reference system?
a. Lead I
b. Lead aVR
c. Lead II
d. Lead aVF

ANS: C
Lead aVL has an axis of 30 degrees; the lead that would be perpendicular to it would be
the lead with an axis of +60 degrees, or lead II.

48. The major electrical axis of a patient is determined to be 115 degrees. This is closest
to the angle of which one of the following standard electrocardiographic limb leads?
a. Lead aVR
b. Lead II
c. Lead aVF
d. Lead III

ANS: D
An axis of 115 degrees is between leads aVF and III, but it is closer to lead III (120
degrees).

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