Chapter 32: Nursing Assessment: Cardiovascular Flashcards
- After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require
a.
emergent cardioversion.
b.
a cardiac catheterization.
c.
hourly blood pressure (BP) checks.
d.
electrocardiographic (ECG) monitoring.
ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
- When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse?
a.
The PR interval is 0.21 seconds.
b.
The QRS duration is 0.13 seconds.
c.
There is a right bundle-branch block.
d.
The heart rate (HR) is 42 beats/minute.
ANS: D
The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.
- During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to
a.
ask the patient about risk factors for atherosclerosis.
b.
document that the PMI is in the normal anatomic location.
c.
auscultate both the carotid arteries for the presence of a bruit.
d.
assess the patient for symptoms of left ventricular hypertrophy.
ANS: D
The PMI should be felt at the intersection of the fifth intercostal space and the left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
- To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a.
bell of the stethoscope with the patient in the left lateral position.
b.
diaphragm of the stethoscope with the patient in a supine position.
c.
bell of the stethoscope with the patient sitting and leaning forward.
d.
diaphragm of the stethoscope with the patient lying flat on the left side.
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2.
- To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?
a.
Troponin
b.
Homocysteine (Hcy)
c.
Low-density lipoprotein (LDL)
d.
B-type natriuretic peptide (BNP)
ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
- While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
a.
Teach the patient about aneurysms.
b.
Notify the hospital rapid response team.
c.
Instruct the patient to remain on bed rest.
d.
Document the finding in the patient chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
- A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
a.
it will be important to lie completely still during the procedure.
b.
a flushed feeling may be noted when the contrast dye is injected.
c.
monitored anesthesia care will be provided during the procedure.
d.
arterial pressure monitoring will be required for 24 hours after the test.
ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.
- While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
a.
Document this finding in the patients record.
b.
Obtain vital signs, including oxygen saturation.
c.
Have the patient perform the Valsalva maneuver.
d.
Observe for JVD with the patient upright at 45 degrees.
ANS: D
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.
- The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a.
connect the recorder to a computer once daily.
b.
exercise more than usual while the monitor is in place.
c.
remove the electrodes when taking a shower or tub bath.
d.
keep a diary of daily activities while the monitor is worn.
ANS: D
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patients rhythm until the end of the testing, when it is removed and the data are analyzed.
- When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a
a.
thrill.
b.
bruit.
c.
murmur.
d.
normal finding.
ANS: B
A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.
- The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be
a.
myoglobin.
b.
low-density lipoprotein (LDL) cholesterol.
c.
troponins T and I.
d.
creatine kinase-MB (CK-MB).
ANS: C
Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. LDL cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels.
- When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next?
a.
Find the point of maximal impulse.
b.
Determine the timing of the murmur.
c.
Compare the apical and radial pulse rates.
d.
Palpate the quality of the peripheral pulses.
ANS: B
Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is also important in the cardiac assessment but will not provide information that is relevant to the murmur.
- The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth intercostal space and midclavicular line. How will the nurse record this information?
a.
Systolic murmur heard at mitral area
b.
Systolic murmur heard at Erbs point
c.
Diastolic murmur heard at aortic area
d.
Diastolic murmur heard at the point of maximal impulse
ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.
- A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse
a.
presses on the skin over the tibia for 10 seconds to check for edema.
b.
palpates both carotid arteries simultaneously to compare pulse quality.
c.
documents a murmur heard along the right sternal border as a pulmonic murmur.
d.
places the patient in the left lateral position to check for the point of maximal impulse.
ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.
- Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
a.
Insert an IV catheter.
b.
Administer oral sedative medications.
c.
Teach the patient about the procedure.
d.
Confirm that the patient has been fasting.
ANS: C
The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.
