Assessing Heart & Neck Vessels Flashcards
A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client’s history should the nurse recognize as the reason for this finding?
Client has an increased chest diameter
The apical impulse may not be palpable in clients with increased anteroposterior diameters. Irregular heart rate should not interfere with the ability to palpate an apical impulse. Respiratory rate does not impact the apical impulse. Heart enlargement would displace the apical impulse but not cause it to be nonpalpable.
A client with heart disease is a current cigarette smoker. What should the nurse include when caring for this client? Select all that apply.
- Advise to quit
- Arrange for follow-up
- Assess willingness to quit
- Acknowledge dependence
- Assist with finding resources
- Advise to quit
- Arrange for follow-up
- Assess willingness to quit
- Assist with finding resources
The nurse can follow the 5 A’s when assisting a client with smoking cessation. These A’s include advising to quit, arranging for follow-up, assessing the client’s willingness to quit, and assisting with finding resources. Acknowledging dependence is not an intervention for smoking cessation
A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?
Cardiac cycle
The continuous rhythmic movement of blood during contraction and relaxation of the heart is the cardiac cycle.
A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?
A thrill
Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.
When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?
S2
Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators.
When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply.
- Quit or do not start smoking
- Exercise regularly
- Undergo regular cholesterol screening
- Eat a low-fiber diet
- Undergo regular screening for diabetes
- Quit or do not start smoking
- Exercise regularly
- Undergo regular cholesterol screening
- Undergo regular screening for diabetes
Important healthy habits to emphasize include following a low-fat diet, regularly exercising, undergoing regular screening for diabetes and cholesterol, and quitting (or continuing not) smoking.
During the health history interview with a 40-year-old male client, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?
Heart attacks in parents and siblings
Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.
The nurse is having difficulty locating a client’s point of maximum impulse. What should the nurse do to facilitate this assessment?
Assist the client into a left lateral decubitus position
If unable to identify the apical impulse with the client supine, assist the client to roll partly onto the left side or the left lateral decubitus position. The nurse was unable to locate the client’s point of maximum impulse in the supine position. Sitting with the legs dangling and the high-Fowler’s position are not positions that will help locate the point of maximum impulse.
Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client’s report?
Inspect for dependent edema
Dependent edema results from sodium and water reabsorption through the kidneys, leading to extracellular expansion. Increased frequency of nocturia results from the redistribution of fluid at night, forcing the client to get up to void more frequently. The client should only be told to lie flat for the physical examination if the client is hypovolemic and the neck veins need to be visualized. Palpation of the carotid pulse is useful for determining whether a murmur is systolic or diastolic. Thrills are formed by the turbulence of underlying murmurs and are associated with other cardiac conditions.
Which of the following events occurs at the start of diastole?
Closure of the aortic valve
At the beginning of diastole, the valves that 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)
A ___________ is characterized by turbulent blood flow, which creates a swooshing or blowing sound over the precordium.
Murmur
The tricuspid valve and the bicuspid (mitral) valve are semilunar valves.
True or False
False
The tricuspid valve and the bicuspid (mitral) valve are atrioventricular valves
______________________ anchor the AV valve flaps to papillary muscles within the ventricles.
Chordae tendineae
Distended jugular veins with the client’s torso elevated more than 45 degrees indicate left ventricular failure.
True or False
False
Distended jugular veins with the client’s torso elevated more than 45 degrees indicate right ventricular failure.
Weak _______ may indicate hypovolemia, shock, or decreased cardiac output.
Pulses
The pulmonary artery exits the left ventricle, bifurcates, and carries blood to the lungs.
True or False
False
The pulmonary artery exits the right ventricle, bifurcates, and carries blood to the lungs.
_____________________ is the amount of blood pumped from the heart with each contraction.
Stroke volume
The third heart sound is also called a ventricular gallop.
True or False
True
The ___________________ is a thin layer of endothelial tissue that forms the innermost layer of the heart.
Endocardium
The most common type of heart failure is _______ sided heart failure
Left
If a patient is dehydrated, when assessing the cardiovascular system, what finding should the nurse expect?
Barely visible neck veins
The nurse wants to visualize pulsations of a dehydrated patient’s jugular veins. What will the nurse do to best facilitate this inspection?
Lower the bead of the bed
Pulsation may be difficult to visualize in a dehydrated patient. If pulsation is not readily visible, it may be necessary to lower the bead of the bed.
What characteristics are true of pulses of BOTH jugular veins?
- They are subtle
- They reflect pressure in the right atrium
- They are easily confused with cafrotid artery pulsation
- they may appear differently in patients with differing chest size and shape
Where are pulsations from the internal jugular vein visible?
Suprasternal notch, spuraclavicular fossa, just below the earlobe
With what conditions is jugular vein distention associated?
Heart failure, fluid volume excess, tricuspid regurgitation
