CHAPTER 21 heart assessment Flashcards

1
Q

a cardiac chest pain described as a sensation of squeezing around the heart

A

Angina

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2
Q

a pain radiates to left shoulder down to left arm

A

diaphoresis

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3
Q

palpitations occur with

A

abnormality of heart conduction system

heart attempt to increase cardiac output by increasing heart rate

cause client to feel anxious

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4
Q

a compromised cardiac output indicates

A

fatigue

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5
Q

dyspnea may result from

A

congestive heart failure

pulmonary disorders

coronary artery disease

myocardial ischemia

myocardial infarction

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6
Q

renal perfusion during period at rest /recumbency can cause

A

nocturia

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7
Q

dizziness indicate

A

decreased blood flow due to myocardial damage

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8
Q

edema of lower extremities may occur as

A

a result of heart failure

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9
Q

dyspnea or fatigue may indicate

A

heart failure

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10
Q

what is taken before intercourse as prophylactic for chest pain

A

nitroglycerin

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11
Q

what position is needed to auscultate and palpate neck vessels

A

supine 30 degree with head elevated

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12
Q

what position is required to inspect pulsations

A

supine with head elevated 30-45 degrees

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13
Q

the apical pulse was originally called

A

PMI point of maximal impulse

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14
Q

this is a result of left ventricle moving outward during systole

A

apical impulse

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15
Q

abnormal ventricular impulses

A

lift
thrill
accentuated apical impulse
laterally displaced apical impulse

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16
Q

a forceful cardiac impulse/pump

A

lift or heave

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17
Q

palpable vibration of chest / feels ; grade 4 or higher murmur

A

thrill

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18
Q

in palpating the apical pulse where does the nurse stay

A

clients right side

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19
Q

where do we palpate the apical impulse

A

mitral area ; 5th intercostal space at midclavicular line

20
Q

a not palpable apical impulse may indicate

A

pulmonary emphysema

21
Q

locations in palpation of pulse

A

apex
left sternal border
base

22
Q

a regularly irregular rhythm indicates

A

sinus arrhythmia

23
Q

is sinus arrhythmia an abnormal or normal finding

24
Q

this indicates when hr increases with inspiration and decreases w expiration

A

sinus arrhythmia

25
lesser than 60 bpm indicates
bradycardia
26
greater than 100 bpm indicates
tachycardia
27
regular irregular rhythm
PVC/ ATRIAL CONTRACTION
28
irregular rhythms may indicate
decrease co, heart failure, emboli
29
if you detect a irregular rhythm, do what
auscultate for a pulse rate deficit (palpating radial pulse while ausculatating)
30
the difference between apical and peripheral pulse
pulse deficits
31
this is the quiet sound heard during diastole as ventricl is filled
physiologic s3
32
physiologic s3 resembles rhthm of
tene-es-see
33
physiologic s4 sound like
ken-tuc-ky
34
this is when s3 and s4 sounds together - quadruple rhythm
summation gallop
35
a harsh, grating sound ; abrasion of inflamed pericardial surfaces
friction rub
36
abnormal diastolic sounds heard during av opening
opening snaps
37
result of opening of a rigid and calcified aortic valve
systolic click
38
gradations of murmur
grade 1, 2, 3, 4, 5, 6
39
very faint murmur
grade 1
40
quiet but heard immediately after placing stet
grade 2
41
moderately loud murmur
grade 3
42
loud with palpable thrill murmur
grade 4
43
a very loud with thrill ; stet partly off sa chest
5
44
a very loud and thrill murmur; heard with stet entirely off sa chest
grade 6
45
a visible jugular venous plate may indicate
right ventriclar failure