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

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

1
Q

What does the cardiovascular system consist of?

A

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

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2
Q

What does the peripheral vascular system consist of?

A

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

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3
Q

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

A

Behind and to the left of the sternum.

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4
Q

Where can you find the apex of the heart?

A

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.

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5
Q

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

A

Inspection, palpation, and auscultation

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6
Q

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:

A

The point of maximal impulse or PMI

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7
Q

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

A

precordium

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8
Q

The precordium is palpated why?

A

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

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9
Q

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

A

a lift/heave

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10
Q

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

A

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

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11
Q

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

A

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

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12
Q

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

A

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

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13
Q

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

A

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

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14
Q

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

A

systole

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15
Q

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

A

diastole

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16
Q

The source of blood to the brain is through the:

A

carotid arteries

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17
Q

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:

A

bruit

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18
Q

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

A

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

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19
Q

What drains blood from the brain?

A

jugular vein

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20
Q

Bilateral JVD may indicate what?

A

R-sided heart failure

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21
Q

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

A

with HOB elevated at 30-45 degree angle

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22
Q

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

A

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

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23
Q

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:

A

abnormal and indicative of enlarged heart.

24
Q

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:

A

normal

25
Q

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:

A

abnormal and indicative of aortic aneurysm

26
Q

In what order is the heart auscultated?

A

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

27
Q

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

A

Impaired L cardiac output

28
Q

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

A

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

29
Q

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

A

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

30
Q

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:

A

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

31
Q

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

A

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

32
Q

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

A

abnormal and indicative of impaired circulation

33
Q

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:

A

abnormal and indicative of an arterial spasm or occlusion

34
Q

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

A

abnormal and indicative of impaired cardiac ouptput

35
Q

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

A

abnormal and indicative of HTN

36
Q

What is a positive Homan’s test?

A

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

37
Q

What is the grading for peripheral pulses?

A

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

38
Q

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

A

phlebitis or DVT (deep venous thrombosis)

39
Q

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:

A

abnormal and indicative of venous or arterial insufficiency

40
Q

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

A

nonpitting edema (deviation in the peripheral perfusion)

41
Q

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

A

4+ (8mm)

42
Q

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

A

2+ (4mm)

43
Q

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

A

3+ (6mm)

44
Q

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

A

1+ (2mm)

45
Q

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

A

African American, Puerto Ricans, Cubans, Hispanics

46
Q

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

A

Hispanics

47
Q

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

A

phlebitis

48
Q

aortic valve is located:

A

2nd R ICS

49
Q

Pulmonic valve is located:

A

2nd L ICS

50
Q

Erb’s point is located:

A

3rd L ICS

51
Q

Tricupsid valve is heard:

A

5th L ICS

52
Q

Mitral valve is located at

A

5th L ICS, MCL

53
Q

The S1 is described as what sound:

A

Lub: A-V valves close

54
Q

The S2 is described as what sound:

A

Dub: Semi-lunar valves close

55
Q

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:

A

abnormal and indicative of an enlarged heart.

Health Assessment (13 decks)

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