Cardiovascular, Peripheral, Vascular, and Vascular Assessment chap 30 (626-635)

Question 1

What does the cardiovascular system consist of?

Answer 1

The cardiovascular system consist of the heart and the central blood vessels (pulmonary, coronary, carotid and jugular)

Question 2

What does the peripheral vascular system consist of?

Answer 2

The arteries and veins distal to the central vessels that extends all the way to the brain and extremities.

Question 3

In the average adult, where does most of the heart lie?

Answer 3

Behind and to the left of the sternum.

Question 4

Where can you find the apex of the heart?

Answer 4

The apex of the L ventricle touches the chest wall medial to the MCL at or near the 5th intercostal space below the L nipple.

Question 5

Assessment of the heart is done by utilizing which methods first?

Answer 5

Inspection, palpation, and auscultation

Question 6

The point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated is known as:

Answer 6

The point of maximal impulse or PMI

Question 7

The area of the chest overlying the heart that can be inspected and palpated is called?

Answer 7

precordium

Question 8

The precordium is palpated why?

Answer 8

The precordium is palpated for the abnormal pulsations of heaves/lifts.

Question 9

A rising along the sternal border w/each HB is called?

Answer 9

a lift/heave

Question 10

Enlargement or overactivity of the L ventricle will produce what type of heave/lift?

Answer 10

Enlargement or overactivity of the heart will produce a heave/lift lateral to the apex at MCL & 5th ICS and causes pulmonary problems

Question 11

Enlargement of the R ventricle will produce what type of heave/lift?

Answer 11

Enlargement of the R ventricle will produce a heave/lift at or near the sternum and cause systemic problems (peripheral edema…)

Question 12

The first sound of the heart (Lub) is produced by what action of the heart?

Answer 12

the closure of the A_V valves (arterioventricular/mitral & tricuspid) due to the sufficient filling of the ventricles

Question 13

The second sound of the heart (Dub) is produced by what action of the heart?

Answer 13

Semilunar valves (aortic & pulmonic) close after the ventricles empty blood into the aorta and pulmonary arteries

Question 14

The period when the ventricles contract beginning at S1 and ending at S2 is called:

Answer 14

systole

Question 15

The period in which the ventricles relax starting with S2 and ending at subsequent S1 is called:

Answer 15

diastole

Question 16

The source of blood to the brain is through the:

Answer 16

carotid arteries

Question 17

A blowing/swishing sound auscultated over the carotid artery caused by a narrowed lumen due to anemia, hyperthyroidism, or common in older people is called:

Answer 17

bruit

Question 18

If a bruit is auscultated from a carotid artery, what should the nurse do next?

Answer 18

Palpate for a thrill which is a vibration sensation like purring and indicative of arterial obstruction

Question 19

What drains blood from the brain?

Answer 19

jugular vein

Question 20

Bilateral JVD may indicate what?

Answer 20

R-sided heart failure

Question 21

When performing an assessment of the heart, how is the pt to be postioned?

Answer 21

with HOB elevated at 30-45 degree angle

Question 22

When palpating the apical area of the heart, you note pulsation in PMI in 5th LICS. This finding is:

Answer 22

normal w/pulsations visible in 50% of adults and palpable in most

Question 23

When palpating the apical area of the heart, you note pulsation at PMI lateral to MCL and a little lower than MCL. This finding is:

Answer 23

abnormal and indicative of enlarged heart.

Question 24

You are inspecting and palpating the epigastric area at the base of the sternum for abdominal aortic pulsations. You feel light aortic pulsations. This finding is:

Answer 24

normal

Question 25

You are inspecting and palpating the epigastric area at the base of the sternum for abdominal aortic pulsations. You feel and see a bounding abd pulsation. This finding is:

Answer 25

abnormal and indicative of aortic aneurysm

Question 26

In what order is the heart auscultated?

Answer 26

APE to MEN= (starting at base of heart at 2nd R ICS) aortic, pulmonic, erb's, tricupsid, mitral (apical)

Question 27

Decreased pulsations to palpation of the carotid artery could be indicative of what?

Answer 27

Impaired L cardiac output

Question 28

In what position should the pt be in when assessing the jugular veins?

Answer 28

Pt should be in a semi-Fowler's position to assess the heart in general

Question 29

If you notice unilateral JVD, what could this indicate? If you notice bilateral JVD, what could this indicate?

Answer 29

unilateral JVD=local obstruction. Bilateral JVD=R-sided heart failure. Measure the highest point of JVD of internal jugular from sternal angle and document.

Question 30

You are assessing the heart of an elderly pt and you notice that the PMI is auscultated at the 6th ICS instead of the 5th ICS. This finding is:

Answer 30

normal due to age-related downward displacement of the heart.

Question 31

What is included in the assessment of the peripheral vascular system:

Answer 31

BP, peripheral pulses, inspecting skin and tissue for perfusion to extremities

Question 32

You're assessing the peripheral pulses of your pt and notice that there's asymmetric volumes of the radial pulses. This finding is:

Answer 32

abnormal and indicative of impaired circulation

Question 33

You're assessing the peripheral pulses of your pt and notice that there's an absence of pulsation of the L posterior tibial. This finding is:

Answer 33

abnormal and indicative of an arterial spasm or occlusion

Question 34

You're assessing the peripheral pulses of your pt and notice a weak, thready pulse. This finding is:

Answer 34

abnormal and indicative of impaired cardiac ouptput

Question 35

You're assessing the peripheral pulses of your pt and notice that there's an increase pulse volume. This finding is:

Answer 35

abnormal and indicative of HTN

Question 36

What is a positive Homan's test?

Answer 36

Upon firmly dorsiflexing the pt's foot with leg supported but extended, pain in the calf muscles would be a positive Homan's test.

Question 37

What is the grading for peripheral pulses?

Answer 37

0=absent, 1+=weak/thready, 2+=normal, 3+=strong pulse, 4+=full/bounding pulse

Question 38

Pain, tenderness, or swelling of the leg is indicative to what?

Answer 38

phlebitis or DVT (deep venous thrombosis)

Question 39

You're assessing the peripheral perfusion of your pt and you notice that the skin is thin, waxy shiny with reduced hair. This finding is:

Answer 39

abnormal and indicative of venous or arterial insufficiency

Question 40

Edema of the hands or feet that feels hard to the touch with no indentation when firm pressure is applied is called?

Answer 40

nonpitting edema (deviation in the peripheral perfusion)

Question 41

Pitting that's very deep, where the indentation lasts a long time is graded as:

Answer 41

4+ (8mm)

Question 42

Pitting that's moderate where the indentation resolves rapidly is graded:

Answer 42

2+ (4mm)

Question 43

Pitting that's deep where the indentation remains for a short time and leg appears swollen is graded:

Answer 43

3+ (6mm)

Question 44

Pitting that's mild where there's a slight indentation is graded:

Answer 44

1+ (2mm)

Question 45

What ethnicities have a higher risk for HTN than when compared to Caucasians?

Answer 45

African American, Puerto Ricans, Cubans, Hispanics

Question 46

What ethnicity has 3 times more risk of developing diabetes than other ethnicities?

Answer 46

Hispanics

Question 47

Inflammation of the vein caused by thrombosis or other reason is defined as?

Answer 47

phlebitis

Question 48

aortic valve is located:

Answer 48

2nd R ICS

Question 49

Pulmonic valve is located:

Answer 49

2nd L ICS

Question 50

Erb's point is located:

Answer 50

3rd L ICS

Question 51

Tricupsid valve is heard:

Answer 51

5th L ICS

Question 52

Mitral valve is located at

Answer 52

5th L ICS, MCL

Question 53

The S1 is described as what sound:

Answer 53

Lub: A-V valves close

Question 54

The S2 is described as what sound:

Answer 54

Dub: Semi-lunar valves close

Question 55

You're assessing your pt and you notice that his PMI is placed a little lower than the 5th and more laterally. This finding is:

Answer 55

abnormal and indicative of an enlarged heart.