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HA > CHAPTER 21 heart assessment > Flashcards

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

A

normal

24
Q

this indicates when hr increases with inspiration and decreases w expiration

A

sinus arrhythmia

25
Q

lesser than 60 bpm indicates

A

bradycardia

26
Q

greater than 100 bpm indicates

A

tachycardia

27
Q

regular irregular rhythm

A

PVC/ ATRIAL CONTRACTION

28
Q

irregular rhythms may indicate

A

decrease co, heart failure, emboli

29
Q

if you detect a irregular rhythm, do what

A

auscultate for a pulse rate deficit (palpating radial pulse while ausculatating)

30
Q

the difference between apical and peripheral pulse

A

pulse deficits

31
Q

this is the quiet sound heard during diastole as ventricl is filled

A

physiologic s3

32
Q

physiologic s3 resembles rhthm of

A

tene-es-see

33
Q

physiologic s4 sound like

A

ken-tuc-ky

34
Q

this is when s3 and s4 sounds together - quadruple rhythm

A

summation gallop

35
Q

a harsh, grating sound ; abrasion of inflamed pericardial surfaces

A

friction rub

36
Q

abnormal diastolic sounds heard during av opening

A

opening snaps

37
Q

result of opening of a rigid and calcified aortic valve

A

systolic click

38
Q

gradations of murmur

A

grade 1, 2, 3, 4, 5, 6

39
Q

very faint murmur

A

grade 1

40
Q

quiet but heard immediately after placing stet

A

grade 2

41
Q

moderately loud murmur

A

grade 3

42
Q

loud with palpable thrill murmur

A

grade 4

43
Q

a very loud with thrill ; stet partly off sa chest

A

5

44
Q

a very loud and thrill murmur; heard with stet entirely off sa chest

A

grade 6

45
Q

a visible jugular venous plate may indicate

A

right ventriclar failure

HA (36 decks)

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