Chapter 12 Exam 2 Flashcards
What are the interrelationships of concepts associated with perfusion?
- Oxygenation
- Pain
- Elimination
- Intracranial regulation
- Tissue integrity
- Motion
- Metabolism
- Nutrition
Blood flow supplies oxygen and nutrients continuously to tissues so they can perform their functions. This tissues include?
Skin, the kidneys to produce urine (e.g. caused by poor perfusion of blood to kidneys), the brain for intracranial regulation (e.g. confusion as a result of poor perfusion of oxygenated blood to brain), the gastrointestinal tract for metabolism, and muscles and nerves for motion (e.g poor perfusion of oxygenated blood limits motion because of activity intolerance and fatigue).
Pain results when?
Perfusion is interupted
The cardiovascular system transports?
Oxygen, nutrients, and other substances to body tissues and metabolic waste products to the kidneys and lungs. This dynamic system is able to adjust to changing demands for blood by constricting or dilating blood vessels and altering the cardiac output
The heart is a pump about the size of a fist that beats ___ to ____ times a minute w/out rest, responding to both external and internal demands such as?
60-100
Exercise, temperature changes, and stress
The right side of the heart
Receives blood from the superior and inferior vena cavae and pumps it through the pulmonary arteries to the pulmonary circulation (carries deoxygenated blood away from the heart, to the lungs, and returns oxygenated blood back to the heart)
The left side of the heart
Receives blood from the pulmonary veins and pumps it through the aorta into the systemic circulation (carries oxygenated blood away from the heart to the body, and returns deoxygenated blood back to the heart)
The upper part of the heart is called the _____, and the lower left ventricle is called the ____
Base
Apex
The great vessels
The pulmonary arteries and aorta.
- Aorta curves upward out of the left ventricle and bends posteriorly and downward.
- Pulmonary arteries emerge from the superior aspect of the right ventricle near the third intercostal space
The heart wall has three layers
Pericardium
Myocardium
Endocardium
The heart is encased in the pericardium which has?
A fibrous pericardium or parietal layer, is a fibrous sac of elastic connective tissue that shields the heart from trauma and infection.
- One of the serous layers lies next to the fibrous pericardium, and the other lies next to the myocardium
- between the fibrous pericardium and the serous pericardium is the pericardial space, which contains a small amount of pericardial fluid to reduce friction as the myocardium contracts and relaxes
- serous pericardium (visceral layer or epicardium), covers the heart surface and extends to the great vessels
Middle layer of the heart, or the myocardium, is a?
Thick muscular tissue that contracts to eject blood from the ventricles.
The endocardium
lines the inner chambers and valves
What supplies blood to the pericardium and cardiac muscle?
Coronary arteries
Four valves govern blood flow through the four chambers of the heart.
The tricuspid valve on the right and mitral valve on the left are termed atrioventricular (AV) valves because they separate the atria from the ventricles
-the aortic valve opens from the left ventricle into the aorta; the pulmonic valve opens from the right ventricle into the pulmonary artery. The aortic and pulmonic valves are termed semilunar (SL) valves because of their half-moon shape
What happens during diastole?
The ventricles are relaxed and fill with blood from the atria. The movement of blood from the atria to the ventricles is accomplished when the pressure of the blood in the atria becomes higher than the pressure in the ventricles. The higher atrial pressures passively open the AV valves, allowing blood to fill the ventricles.
-Approximately 80% of blood from the atria flows into relaxed ventricles. A contraction of the atria forces the remaining 20% into the ventricles. This added atrial thrust is termed the atrial kick. At the end of diastole the ventricles are filled with blood
What happens during systole
The ventricles contract, creating a pressure that closes the AV valves, preventing the backflow of blood into the atria. This ventricular pressure also forces the semilunar valves to open resulting in ejection of blood into the aorta (from the left ventricle) and the pulmonary arteries (from the right ventricle)
-As blood is ejected, the ventricular pressure decreased, causing the semilunar valves to close. The ventricles relax to begin diastole
Describe the electric conduction
The heart is stimulated by an electric impulse that originates in the sinoatrial (SA), called cardiac pacemaker, node in the superior aspect of the right atrium and travels in internodal tracts to the AV node.
- SA node normally discharges between 60 and 100 impulses per minute
- the electric impulses stimulate contractions of both atria and then flow to the AV node in the inferior aspect of the right atrium
- impulses are then transmitted through a series of branches (bundle of His) and Purkinje fibers in the myocardium, which results in ventricular contraction.
- AV node prevents excessive atrial impulses from reaching the ventricles
- if SA node fails to discharge, the AV node can generate ventricular contraction at a slower rate, 40-60 impulses per minute
- If both SA and AV nodes are ineffective, the bundle branches may stimulate contraction but at a very slow rate of 20-40 impulses per minute
Peripheral vascular system
Arteries, capillaries, and veins provide blood flow to and from tissues. The tough and tensile arteries and their smaller branches, the arterioles, are subjected to remarkable pressure generated from the myocardial contractions. They maintain BP by constricting or dilating in response to stimuli.
- The veins and their smaller branches, the venules, are less sturdy but more expansible, enabling them to act as a reservoir for extra blood, if needed, to decrease the workload on the heart.
- Pressure w/in the veins is low compared with arterial circulation. The valves in each vein keep blood flowing in a forward direction toward the heart.
Lymph system
- Lymph system works in collaboration w/peripheral vascular system in removing fluid from the interstitial spaces
- As blood flows from arteries into venules, oxygen and nutrient-rich fluid are forced out at the arterial end of the capillary into the interstitial space and then into cells.
- Waste products from cells flow through the interstitial spaces to the venous end of the capillary
- excess fluid left in the interstitial spaces is absorbed by the lymph system and carried to lymph nodes throughout the body.
- Lymphatic fluid is clear, composed mainly of water and a small amount of protein, mostly albumin
- Lymph nodes are tiny oval clumps of lymphatic tissue, usually located in groups along blood vessels
- In the peripheral vascular system the lymph node locations of interest are the arm, groin, and leg
- The brachial (axillary) nodes receive lymph drainage from the neck, chest, axilla, and arm
- the epitrochlear nodes receive fluid via the radial, ulnar, and median lymph vessels
- in the upper thigh the inguinal lymph nodes are superficial; they receive most of the lymph drainage from the great and small saphenous lymphatic vessels in the legs
- in men lymph from the penile and scrotal surfaces drains to the inguinal nodes, but nodes of the testes drain into the abdomen
- In the posterior surface of the leg behind the knee are the popliteal nodes, which receive lymph from the medial portion of the lower leg
- Ducts from the lymph nodes empty into the subclavian veins
Present health status
-Do you have any chronic illnesses such as diabetes mellitus, renal failure, chronic hypoxemia, or hypertension? If yes describe
Chronic illnesses can cause symptoms affecting the cardiovascular system when they increase the workload of the heart by narrowing peripheral vessels (diabetes, hypertension), increasing the fluid volume to be pumped (diabetes, renal failure), increasing the HR, or causing pulmonary capillary vasoconstriction (chronic hypoxemia)
Have you been told that you have high levels of cholesterol or elevated triglycerides?
High levels of serum lipids line the arteries, which may impede blood flow to tissues and increase workload on the heart
Risk factors for hypertension
- Family history
- Age
- Gender
- Race: African american 2x likely over caucasions
- Lack of physical activity
- Poor diet, especially one that includes too much salt calories, fats, and sugars
- Overweight
- Alcohol
- Tobacco smoking: nicotine constricts blood vessels
Risk factors for coronary artery disease
- Family history
- Race: African Americans
- Gender: men greater risk
- Age
- Smoking: 2-4x greater risk
- High blood cholesterol
- Hypertension: high BP increases workload of heart causing myocardium to thicken and become stiffer. Also increases risk of myocardial infarction & heart failure
- Physical inactivity
- Obesity
- Diabetes mellitus
When dyspnea becomes worse on lying down what is the term called?
Orthopnea. It occurs when a person must sit up or stand to breath easily. The number of pillows necessary to relieve the orthopnea is documented (e.g two pillow orthopnea)
Coughing up blood is a symptom of?
mitral stenosis and pulmonary disorders
Coughing more when lying down may indicate?
Heart failure
Leg pain that occurs while walking and that is relieved by rest is termed
Intermittent claudication. This occurs when the artery is about 50% occluded
Chest pain: Stable angina Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Pressure, burning, dull, or sharp
Quantity of pain: Variable, usually worse w/activity
Associated manifestations: Dyspnea, diaphoresis, palpiations, nausea, weakness
Aggravating factors: Physical exertion, emotional stress, cold
Alleviating factors: Rest, nitroglycerin, beta-blocker, calcium channel blocker
Chest pain: Unstable angina/myocardial infarction MI Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Pressure, squeezing, crushing; burning, dull, or sharp
Quantity of pain: 10 of 10 on pain scale
Associated manifestations: Dyspnea, diaphoresis, palpitations, nausea, weakness
Aggravating factors: chest pain during exercise or at rest
Alleviating factors: Beta-blocker, heparin, oxygen
Chest pain: Cocaine-induced chest pain Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Sharp, pressure like, squeezing
Quantity of pain: Severe, 8 on pain scale
Associated manifestations: Tachycardia, tachypnea, hypertension
Aggravating factors: During and shortly after cocaine use
Alleviating factors: Nitroglycerin or calcium channel blockers
Chest pain: Mitral valve prolapse Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: variable, often sharp or “kick”
Quantity of pain: variable w/in same patient
Associated manifestations: often asymptomatic; palpitaitons when lying on left side, dyspnea, dizziness
Aggravating factors: Usually nonexertional, occasionally positional
Alleviating factors: Position change, nitroglycerin, analgesics
Chest pain: Acute pericarditis Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Boring, oppressive, pleuritic, or postional
Quantity of pain: moderate, 4 on pain scale
Associated manifestations: Fever, dyspnea, orthopnea, friction rub
Aggravating factors: Reclining
Alleviating factors: Leaning forward
Chest pain: Panic disorder Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Tightness, vague, diffuse; inrelated to exertion
Quantity of pain: may be described as disabling
Associated manifestations: hyperventilation, fatigue, anorexia, emotional strain
Aggravating factors: emotional strain
Alleviating factors: variable by patient
Chest pain: Peptic ulcer disease Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Burning, gnawing
Quantity of pain: moderate, 4 on pain scale
Associated manifestations: Nausea, abdominal tenderness
Aggravating factors: empty stomach
Alleviating factors: food, antacids, histamine blocker, proton pump inhibitor
Chest pain: Esophageal reflux Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Burning, pressure like, squeezing
Quantity of pain: moderate to severe
Associated manifestations: Dysphagia
Aggravating factors: Spicy or acidic meal, alcohol, lying supine
Alleviating factors: Oral fluids, belching, antacids, nitroglycerin, H2 blocker
Chest pain: Costochondritis (inflammation of rib or cartilage) Quality of pain Quantity of pain Associated manifestations Aggravating factors Alleviating factors
Quality of pain: Variable
Quantity of pain: variable
Associated manifestations: none
Aggravating factors: coughing, deep breathing, laughing, sneezing
Alleviating factors: Localized heat, analgesics, anti-inflammatory
Recommendations to reduce risk for cardiovascular disease (primary prevention) American Heart Association
- Smoking cessation
- Diet
- Blood lipid management: total cholesterol less than 200 mg/dL
- Fasting serum glucose: less than 100 mg/dl
- Weight: BMI between 18.5 and 24.9
- Physical activity: @ least 150 mins a week
Screening recommendations for cardiovascular disease (secondary prevention) U.S. Preventive Services Task Force
Blood pressure screening
Lipid screening level
Use of Aspirin
Cardiovascular examination
General Appearance - Inspect for general appearance, skin color, and breathing effort Peripheral vascular system - palpate the temporal and carotid pulses - inspect the jugular vein - measure BP - inspect and palpate upper extremities - palpate upper extremity pulses - inspect and palpate lower extremities Heart - inspect anterior chest wall - palpate apical pulse - auscultate heart sounds - calculate pulse deficit - interpret the electrocardiogram Techniques for special circumstances Peripheral vascular system - auscultate the carotid pulse - palpate the epitrochlear lymph nodes - palpate inguinal lymph nodes - measure leg circumference - calculate the ankle-brachial index Techniques performed by an APRN - Estimate jugular vein pressure - Assess for varicose veins - Palpate the precordium
Abnormal findings for general appearance
Dyspnea, cyanosis, pallor, and use of accessory muscles to breath
Abnormal findings when palpating the temporal and carotid pulses for amplitude
Pain and edema may be found in temporal arteries
Pulse amplitude ratings 2+ normal
o+ absent
1+ diminished, barely palpable
3+ full volume
4+ full volume, bounding hyperkinetic
Normal and abnormal findings when inspecting jugular vein for pulsations
Normal: pulsations of the vein are visible, but not the vein itself
Abnormal: any fluttering or oscillating of the pulsations. Not irregular rhythms or unusually prominent waves. These may indicate right-sided heart failure
Classifications of BP for adults age 18 and older
Normal <120/<80
Prehypertension 120-139/ 80-89
Stage 1 hypertension 140-159/90-99
Stage 2 hypertension >160/>100
Abnormal findings for BP
A decrease in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg w/in 3 minutes of standing indicates orthostatic (postural) hypotension. THis may be caused by a fluid volume deficit, drugs (e.g. antihypertensive), or prolonged bed rest
Abnormal findings when inspecting and palpating the upper extremities
- When edema is found, notice if it is unilateral or bilateral, the consistency is soft, firm or hard; or there is tenderness
- lymphedema could cause one arm to be larger
- Tenting: when skin does not immediately fall back into place & is an indication of reduced fluid in the interstitial space from fluid volume deficit
- pitting edema is when indentation of the thumb remains in the skin and is an indication of excess fluid in the interstitial space
Pitting edema scale
1+ Barely perceptible pit, depth of edema 2 mm
2+ Deeper pit, rebounds in a few seconds, 4 mm
3+ Deep pit, rebounds in 10-20 seconds, 6mm
4+ Deeper pit, rebounds in >30 seconds, 8mm
Abnormalities when inspecting and palpating lower extremities
Arterial insufficiency may cause a decrease in or lack of hair peripherally or skin that appears thin, shiny, and taut.
- varicose veins appear as dilated, often tortuous veins when legs are in a dependent position
- pain on palpation or the sensation of “stocking anesthesia” wherein the legs feel numb in a pattern resembling stockings
Mnemonic to locate femoral pulse NAVEL
Nerve Artery Vein Empty space Lymph
Normal and abnormal findings when inspecting heart
Normal: chest should be rounded. slight retraction medial to the left midclavicular line at the fourth and fifth intercostal space is expected; this is the apical pulse
Abnormal: a retraction is noted when some of the tissue is pulled into the chest on the precordium. Marked retraction of apical space may indicate pericardial disease or right ventricular hypertrophy
Abbreviations for topographic landmarks
ICS- Intercostal space RICS- Right intercostal space LICS- Left intercostal space SB- Sternal border RSB- Right sternal border LSB- Left sternal border MCL- Midclavicular line RMCL- Right midclavicular line LMCL- Left midclavicular line
Define lift
Feels like a more sustained thrust than an expected apical pulse and is felt during systole
Define heave
A more prominent thrust of the heart agains the chest wall during systole. Lifts and heaves may occur from left or right ventricular hypertrophy caused by increase workload
Define thrill
A palpable vibration over the precordium or artery: if feels like a fine, palpable, rushing vibration. Is associated with a loud murmur
Define retraction
Of the chest is a visible sinking in of tissues between and around the ribs. Begins in the intercostal spaces. Occurs with increased respiratory effort. If additional effort is needed to fill the lungs, supravlavicular (above the clavicle) and infraclavicular (below the clavicle) retraction may be seen
S1 heart sound is?
Lower pitch than S2 or that S2 is higher pitch than S1
-bruits are low pitched
Tip to help you remember which valve you are listening to
APT M or APE to MAN
Aortic Pulmonic Tricuspid Mitral or Aortic Pulmonic Erb's point Tricuspid Mitral
Friction rub
Low-pitched, coarse rubbing or grating sound heard throughout inspiration and expiration. The source (lung or heart) can be determined by having patient hold their breath. If sound not heard, it is a pleura rub. If sound heard it is a pericardial
Define pulse deficit
The difference in the apical rate and the peripheral pulse rates. It is determined by auscultating the apical pulse and palpating the radial pulse rates simultaneously
What creates diastolic murmurs?
Incompetent semilunar valves or stenotic AB valves. Almost always indicate heart disease
Aortic stenosis
Detection
Quality/pitch
Detection: Heard over aortic valve area; ejection sound at second right intercostal border. Radiates to neck, down left sternal border
Quality/pitch: Medium pitch, coarse, with crescendo-decrescendo pattern. Pitch low
Pulmonic stenosis
Detection
Quality/pitch
Detection: Heard over pulmonic valve; radiates left to neck; thrill at second and third left intercostal spaces
Quality/pitch: same as for aortic stenosis, pitch medium
Aortic regurgitant
Detection
Quality/pitch
Detection: Diaphragm, patient sitting and leaning forward; second right intercostal space radiates to left sternal border
Quality/pitch: Blowing in early diastole, pitch high
Pulmonic regurgitation
Detection
Quality/pitch
Detection: Diaphragm, patient sitting or leaning forward; third and fourth left intercostal spaces
Quality/pitch: blowing, pitch high or low
Mitral stenosis
Detection
Quality/pitch
Detection: Bell at apex with patient in left lateral decubitus position
Quality/pitch: Low rumble more intense in early and late diastole, pitch low
Tricuspid stenosis
Detection
Quality/pitch
Detection: Bell over tricuspid area
Quality/pitch: Similar to mitral stenosis but louder on inspiration, pitch low
Mitral regurgitation
Detection
Quality/pitch
Detection: Diaphragm at apex, radiates to left axilla or base
Quality/pitch: harsh blowing quality, pitch high
Tricuspid regurgitation
Detection
Quality/pitch
Detection: Fifth intercostal space, left lower sternal border
Quality/pitch: blowing, pitch high
P wave represents?
The atrial contraction or depolorization
The QRS complex represents?
The ventricular contraction or depolorization
The T wave represents the?
Repolarization of the ventricle
Define bruits
Low-pitched blowing sounds usually heard during systole that indicate occlusion of the vessel. Occlusion of a carotid artery may impair perfusion of the brain & increase the risk for transient ischemic attack (TIA)
There are several differences in the assessment of the cardiovascular system for infants and young children.
-The equipment used to measure BP is smaller, the sequence of examination may be different, findings may differ based on anatomical differences
Hypertension
Diagnosis is based on the mean of two or more properly measured seated BP readings on each of two or more occasions that are above 120/80 in an adult over 18.
Venous thromboembolism and thrombophlebitis
When a thrombus (clot) develops w/in a vein, it is called a deep vein thrombus (DVT)
- Thrombophlebitis is inflammation of a vein that may or may not be accompanied by a clot
Peripheral artery and venous insufficiencies
Peripheral arterial disease (PAD) develops from arterial insufficiency. Peripheral venous insufficiency develops when venous valves of the legs are damaged or the patient has had previous VTE
Aneurysm
A localized dilation of an artery caused by weakness in the arterial wall and is referred to as an aneurysm. It occurs anywhere along the aorta and iliac and cerebral vessels
Cardiac disorders: Valvular heart disease
An acquired or congenital disorder of a heart valve. Can be characterized by a heart valve that does not either open completely (stenotic valve) or close completely (incompetent valve)
-Rheumatic fever and endocarditis account for most cases of acquired VHD
Cardiac disorders: Angina pectoris
Chest pain that is caused by ischemia of the myocardium. Can occur during activity, stress, or exposure to intense cold because of an increased demand on the heart. Can also occur during rest as a result of spasms of the coronary arteries
Acute coronary syndrome
When ischemia is prolonged and not immediately relieved, it is called unstable angina, from which acute coronary syndrome may develop. This syndrome includes a spectrum from unstable angina to MI.
Unstable angina
Chest pain described as a new onset, experienced at rest, or a worsening pattern than previously experienced
Myocardial infarction
Occurs when myocardial ischemia is sustained, resulting in death of myocardial cells (necrosis). The left ventricle is more commonly affected, but the right ventricle may also be affected
Heart failure
When either ventricle fails to pump blood efficiently into the aorta or pulmonary arteries, the condition is termed heart failure. May occur in the left or right ventricle or both
Left ventricular failure
This cardiac condition is caused by
- increased resistance that occurs with aortic stenosis or hypertension when the ventricle can no longer contract effectively due to the increased workload
- weakening of the left ventricular contraction that occurs after a MI when the death of myocardial cells causes an ineffective contraction. Because the left ventricle cannot pump sufficient blood forward, some blood backs up into left atrium and eventually into the pulmonary capillaries causing pulmonary edema
Right ventricular failure
Caused by hypertrophy from pulmonary hypertension or necrosis from a MI. Failure of right ventricle to pump blood into pulmonary arteries causes a backflow of blood into the inferior and superior vena cavae. Right ventricular failure caused by pulmonary disease is termed cor pulmonale
-peripheral edema
Infective endocarditis
Infection of the endothelial layer of the heart, including the cardiac valves
Pericarditis
Inflammation of the parietal and visceral layers of the pericardium and outer myocardium
The nurse is listening to the patient’s heart at the left sternal border (LSB) at the second interclabicular space (ICS). Which area is being auscultated?
Pulmonic area
A patient complains of pain in the calf when walking. Which question should the nurse ask for further data?
Does the pain go away when you stop walking?
When a patient complains of chest pain, which question is pertinent to ask to gain additional data?
What does the pain feel like?
How does a nurse determine jugular vein pulsations?
Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle
Where does a nurse palpate to assess the posterior tibial pulse?
The inner aspect of the ankle below and slightly behind the medial malleolus
On auscultation of the heart, the nurse recognizes which expected finding?
The S1 heart sound is louder at the apex of the heart
What is the most accurate technique for detecting a venous thrombosis at the bedside?
Measure the thigh circumference to detect an increased from the baseline
While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease?
Pale, cool legs with diminished-to-absent dorsalis pulses
The nurse is listening to a patient’s heart and hears an S2 sound. The S2 heart sound is caused by which of the following?
Opening of the aortic and pulmonic valves
Opening of the mitral and tricuspid valves
Closing of the aortic and pulmonic valves
Closing of the mitral and tricuspid valves
Closing of the aortic and pulmonic valves
The aortic and pulmonic valves close after contraction of the ventricles. No sound is made when aortic and pulmonic valves open. No sound is made when mitral and tricuspid valves open. The mitral and tricuspid valves produce the S1 sound.
The nurse assesses a pulse at 3+ amplitude. Which word best describes a pulse with 3+ amplitude? Diminished Normal Full volume Bounding
Full volume
3+ is a very strong, easily palpable pulse. A diminished pulse is documented as 1+. A normal amplitude is documented as 2+. A bounding pulse is documented as 4+.
A patient reports that he has intermittent chest pain. Which is the most appropriate question to ask next?
“Do you work in a stressful environment?”
“Have you told your physician about the chest pain?”
“What other symptoms do you have when the chest pain occurs?”
“Do you have high cholesterol levels?”
“What other symptoms do you have when the chest pain occurs?”
Complete a symptom analysis to learn more about the pain. Do not look for the cause of the pain until you know more about the pain. This may or may not be new pain, but it must not be passed off. Do not look for the cause of the pain until you know more about the pain.
The nurse is percussing the heart. Percussion of the heart could be performed to:
estimate the heart’s size and borders. Correct
determine fluid levels in the heart.
locate the presence of a murmur.
identify congenital heart defects.
estimate the heart’s size and borders. identify congenital heart defects.
Estimating the heart’s size and borders is not often performed when x-rays are available. Determining fluid levels in the heart is best done by internal cardiac monitoring. Locating the presence of a murmur is best done through auscultation. A variety of symptoms and other findings identify congenital heart problems.
A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the chest pain is cardiac in origin?
“My chest hurts every time I cough.”
“My chest feels really tight and heavy.”
“I have sharp pains in my chest when I eat raw vegetables.”
“I fell on some ice yesterday. Today, my chest hurts when I breathe.”
“My chest feels really tight and heavy.” when I breathe.”
Tightness, squeezing, or heaviness are classic descriptions of cardiac pain. Pain associated with coughing suggests that it is pulmonary. Option C suggests pain that is esophageal. Option D suggests musculoskeletal pain.
A patient has 3+ pitting edema in her feet and ankles. The nurse suspects:
the patient has a heart murmur.
the patient has excess fluid in the interstitial space. the patient is having a myocardial infarction.
the patient has elevated cholesterol levels.
the patient has excess fluid in the interstitial space.
Interstitial edema can manifest as pitting edema. A heart murmur would be determined by auscultation. One may or may not have pitting edema associated with a heart attack. Elevated cholesterol levels are determined by laboratory testing.
A patient reports shortness of breath with a gradual onset. The nurse suspects: heart failure. dysrhythmia. deep vein thrombosis. myocardial infarction.
heart failure.
Dyspnea of gradual onset that is accompanied by swelling and nocturia suggests congestive heart failure. Dysrhythmia would cause a sudden onset of shortness of breath. Deep vein thrombosis would not cause shortness of breath. Myocardial infarction would cause a sudden onset of shortness of breath.
A patient reports leg and foot pain with activity that resolves with rest. With what type of problem is this consistent? Arterial insufficiency Leg edema Venous thrombosis Hypertension
Arterial insufficiency
Also ask the patient if the pain increases when the legs are elevated; this is another common finding. Leg edema may be uncomfortable, but it is not usually described as painful. Also ask the patient if the pain increases when the venous thrombosis causes an inflammatory pain that does not go away with rest. Leg pain is not associated with hypertension.
The nurse is assessing a patient’s dorsalis pedis pulse. What is the primary reason for this assessment? The patient’s heart rate Perfusion to the foot Sensation to the foot Reflexes within the foot
Perfusion to the foot
An absent pulse along with a foot that is cold and dusky indicates a lack of blood flow to the foot. Heart rate should be evaluated using carotid, brachial, radial, or apical pulses. Peripheral sensation is evaluated by different methods. Foot reflexes may be checked but not by taking a pulse.
The nurse is palpating a patient’s pericardium. What may be detected by palpating the pericardium? An inflammation of the heart Incorrect An increased heart size An increase in cardiac output A thrill
A thrill
A thrill is detected as a vibration sensation on the chest wall and may indicate a murmur. Inflammation of the heart may be noted by fever or by a change in cardiac output. An increased heart size is determined by percussion or a chest x-ray. An increase in cardiac output cannot be measured by palpation.
