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HAP Final > Heart and Neck vessels > Flashcards

Heart and Neck vessels Flashcards

1
Q

Risk Factors for Heart and Neck vessel conditions

A
  • Age
  • Male
  • A. American
  • Mexican
  • American Indian
  • Hawaiian
  • Elevated cholesterol
  • Elevated C Reactive protein
  • Elevated thyroid hormone levels
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2
Q

Hypothyroidism has been linked to…. and increases….

A

Hypothyroidism has been linked to atrial fibrillation and increases risk of cardiovascular disease and other increased morbidities

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3
Q

Drinking numbers that lead to higher BP

A

Men: More than 2 drinks/day
Women: More than 1 drink/day

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4
Q

Center of the chest

A

Precordial

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5
Q

Behind the sternum

A

Retrosternal

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6
Q

Angina

A

chest pain - assess with OLDCARTS!

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7
Q

What medication can help relieve angina?

A

Nitroglycerin

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8
Q

How would you know if pain is a MI not just an angina

A

If pain is not relieved after 1-2 tablets

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9
Q

Other subjective data of the heart

A
  • Pain
  • Fatigue
  • Fainting
  • Dizziness
  • Dyspnea on exertion
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Cyanosis
  • Nocturia
  • Edema
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10
Q

What is a characteristic specific to women for MI

A

50% of women report difficulty sleeping about 1 month before a MI

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11
Q

Subjective of peripheral

A
  • Coldness
  • Swelling of legs (time of day and activity)
  • Discoloration of hands or feet (red for inflammation? blue for cyanosis?)
  • Intermittent claudication (cramping)
  • Swollen glands
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12
Q

Other subjective data for older adults?

A
  • Does the illness interfere with ADLs?
  • Medications?
  • Does the pt know of the side effects?
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13
Q

What if you can’t feel radial or pedal pulses?

A

Get a doppler

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14
Q

In women, when might pitting edema occur?

A

With heart failure and pregnancy

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15
Q

Assessment techniques for Cardiovascular/Peripheral

A

Inspection - Palpation - Percussion - Auscultation

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16
Q

Abnormal objective findings during Inspection and Palpation

A
  • Tenderness
  • Enlargement
  • Lumps/masses
  • Edema, swelling
  • Drainage
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17
Q

Neck - Inspection

A

-Skin color and condition
(Abnormal: Hyperpigmentation, hypopigmentation, rashes, lesions, cyanosis)
-JVD (jugular venous distension)
(Abnormal: visible JVD)

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18
Q

What does a visible JVD indicate?

A

Heart failure

  • Tricuspid regurgitation
  • Fluid volume overload
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19
Q

How should the patient be positioned to check JVD?

A

Laying down in 45 degree position

-Just check to see if its visible or not

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20
Q

If ___ cm, JVD is a problem

A

Greater than 3 cm

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21
Q

Neck - Palpation

A
  • Check carotid arteries
  • Grade from 0-3
  • Check one at a time
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22
Q

What would a +1, or weak thready pulse, indicate?

3

A
  • Reduced stroke/fluid volume
  • Narrowed carotid artery due to atherosclerosis
  • Dehydration
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23
Q

What do you auscultate for at the neck?

A

Check carotid arteries for bruits

-Bruit = abnormal

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24
Q

What is a bruit?

A

Low, blowing, whooshing sound from occlusion causing turbulent flow

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25
Q

What should you use to auscultate for a bruit?

A

Bell

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26
Q

What do you inspect for at the Precordium?

A

Heaves/Lifts/Pulsations

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27
Q

Normal finding at precordium

A

Apical pulse

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28
Q

Abnormal findings at Precordium

A

Other heaves, lifts, pulsations could indicate cardiac hypertrophy

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29
Q

How does an enlarged heart displace the heart?

A

Laterally and inferiorly

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30
Q

What is PMI and where is it?

A

Point of Maximal Impulse

-4th/5th intercostal where the apex of the heart is

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31
Q

What do you palpate for at the precordium?

A
  • Thrill

- Apical pulse

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32
Q

What does thrill indicate?

A

Turbulent blood flow

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33
Q

Where do you palpate the apical pulse?

A

Midclavicular line

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34
Q

What is the most important part of the Precordium assessment?

A

Auscultation!!

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35
Q

What do you want to note upon precordium auscultation?

A
  • Rate
  • Rhythm
  • Normal heart sounds
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36
Q

Lub =

A

S1

-Beginning of systole

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37
Q

Dub =

A

S2

-End of systole, beginning of diastole

38
Q

Where is a split S1 heard?

A

At the tricuspid

39
Q

Each lub dub is…

A

Each lub dub is one pulse

40
Q

How long should you assess for if there is an irregular heart rate

A

1 min

41
Q

What is regular irregular rhythm?

A

A pattern that is abnormal (but is still a pattern)

42
Q

On inspiration rate ____, on expiration rate ______

A

On inspiration: heart rate increases

On expiration: heart rate decreases

43
Q

CO =

A

CO = HR x SV

44
Q

Murmur indicates

A

Congenital defects or valvular defects

45
Q

Murmur characteristics to note

A
  • Timing
  • Loudness (1-6)
  • Pitch (low, medium, high)
  • Quality
  • Location
  • Radiation
46
Q

S3

A 
Ventricular gallop (lub, dub, dub)
-Ken-tuck-y
47
Q

S4

A 
Atrial gallop (Ten-nes-see) 
-Results from a noncompliant ventricle as a consequence from hypertension
48
Q

6P’s for peripheral vascular inspection

A 
Pain
Pallor
Poikilothermic (cool to touch) 
Pulselessness
Paresthesia
Paralysis
49
Q

Other things to note with peripheral vascular inspection

A

Hair distribution, varicosities, DVT (pain, edema, swollen)

50
Q

Grading range for pulses

A

0 - not palpable
1 - weak, thready
2 - normal
3 - strong, bounding

51
Q

Edema grading

A

1+ disappears rapidly (2mm)
2+ disappears in 10-15 seconds (4mm)
3+ lasts more than 1 min (6mm)
4+ lasts 2-5 min (8mm)

52
Q

Abnormal upper-extremity findings (peripheral vascular)

A
  • Edema / lymphatic obstruction
  • Sluggish capillary refill
  • Weak radial pulse (PVD)
  • Strong, bounding pulse (exercise, anxiety, fever, anemia, hyperthyroidism)
53
Q

Abnormal lower-extremity findings (peripheral vascular)

A
  • Pallor (vasoconstriction)
  • Erythema (vasodilation)
  • Thin, shiny skin, hair loss (malnutrition and arterial insufficiency)
  • Doppler assessment of pedal pulses
54
Q

What does the lymphatic system do? (2)

A
  • Maintain fluid and protein balance

- Filtering

55
Q

Lymphedema

A

Inflamed lymphs, inflamed and infected lymphatic vessels

56
Q

Is labored breathing normal for children?

A

No - indicates a cardiovascular issue

57
Q

What is the “normal” abnormal heart sounds for older adults?

A

S4 - normal due to decreased left ventricle compliance

58
Q

Cardio nursing diagnoses

A
  • Activity intolerance
  • Decreased cardiac output
  • Fatigue sedentary lifestyle
  • Risk for decreased cardiac tissue perfusion
  • Acute pain
59
Q

Peripheral Vascular nursing diagnoses

A
  • Ineffective peripheral tissue perfusion
  • Activity intolerance
  • Chronic pain: intermittent claudication (cramping)
  • Risk for falls
  • Risk for impaired skin integrity
60
Q

Health promotion for heart and peripheral vascular system

A
  • maintenance of ideal body weight (exercise and diet)
  • smoking cessation
  • regular check ups (esp. elderly)
  • disease management (ex: HTN, HF, CAD, DM), medication regimen (side effects, drug-drug interactions), dietary restrictions, activity restrictions, signs and symptoms of exacerbation
61
Q

When assessing the HR of a patient, the nurse identifies a change in rate from 86 to 56 beats per minute. What should the nurse do first?

A) wait 30 min to retake the pulse
B) obtain other vitals
C) ask about recent activity
D) tell the nurse in charge

A

B) obtain other vitals

62
Q

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would

A) palpate the artery to determine occlusion pressure
B) listen with the bell of the stethoscope to assess for bruits
C) palpate both arteries simultaneously
D) instruct patient to take slow deep breaths during auscultation

A

B) listen with the bell of the stethoscope to assess for bruits

63
Q

The function of which part of anatomy is primarily being assessed when a nurse obtains a patient’s pedal pulse?

A) veins
B) heart
C) blood
D) arteries

A

D) arteries

64
Q

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) ___ pulse?

A) normal
B) absent
C) bounding
D) weak, thready

A

C) bounding

65
Q

The top of the hart is known as the…

A

base

66
Q

The bottom of the heart

A

Apex

67
Q

The carotid arteries are located between

A

The trachea and sternomastoid muscle

68
Q

Ventricular contraction

A

Systole

69
Q

Ventricular relaxation

A

Diastole

70
Q

Closure of the mitral and tricuspid valves

A

S1

71
Q

Closure of the aortic and pulmonic valves

A

S2

72
Q

A split heart sound is audible when…

A

the valves close at slightly different times

73
Q

Which of the following statements describes the cardiovascular system most accurately?

A) it is double pump with pulmonary and systemic elements
B) it has a heart with six chambers and valves
C) it includes concepts of pre contractility, after contractility, and load
D) it functions with a conduction system that starts in the ventricles

A

A) It is a double pump with pulmonary and systemic elements

74
Q

In a healthy patient, the myocardial cells in the ventricle depolarize and contract during

A) prediastole
B) diastole
C) systole
D) postsystole

A

C) Systole

75
Q

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is

A) S1 is greater than S2
B) S1 is equal to S2
C) S2 greater than S1
D) No S1 is heard

A

A) S1 is greater than S2

-closure of the mitral and tricuspid valves at the beginning of systole = produces the S1

76
Q

The nurse assess the neck vessels in the patient with heart failure to determine which of the following?

A) The strength of the carotid pulse
B) the presence of bruits
C) the highest level of jugular venous pulsation
D) the strength of the jugular veins

A

C) the highest level of jugular venous pulsation

77
Q

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?

A) Auscultate heart sounds
B) Inspect the precordium
C) Percuss the left border
D) Obtain a blood pressure reading

A

D) obtain the BP

Highest priority is identifying the consequences of chest pain and cardiac ischemia

78
Q

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when performing patient teaching?

A) Teach the patient the most serious information
B) Give the patient brochures to review before the next visit
C) Discuss risk factors that the patient is interested in modifying
D) Describe consequences of risk factors to motivate the patient

A

C) Discuss the risk factors that the patient is interested in modifying

79
Q

Which of the following clusters of symptoms are common in women preceding an MI?

A) chest pain, nausea, diaphoresis
B) weight gain, edema, nocturne
C) dizziness, palpitations, low pulse
D) fatigue, difficulty sleeping, dyspnea

A

D) Fatigue, difficulty sleeping, dyspnea

80
Q

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following?

A) Grade 3 decrescendo systolic murmur
B) Grade 4 crescendo systolic murmur
C) Grade 2 crescendo diastolic murmur
d) Grade 1 decrescendo diastolic murmur

A

A) Grade 3 decrescendo systolic murmur

  • softens: decrescendo
  • medium-loud: grade 3
81
Q

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heard best at the apex. Which of the following does the nurse suspect?

A) S3 gallop
B) S4 gallop
C) Systolic ejection click
D) Split S2

A

S3 gallop

82
Q

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis?

A) Ineffective cardiac tissue perfusion
B) Decreased cardiac output
C) Impaired gas exchange
D) Excess fluid volume

A

D) Excess fluid volume

83
Q

The first heart sound (S1) is produced by the

A) closure of semilunar valves
B) closure of the AV valves
C) opening of the semilunar valves
D) opening of the AV valves

A

B)

84
Q

The semilunar valves separates the

A) right atria from left atria
B) atria from the veins
C) ventricles from the arteries
D) atria from the ventricles

A

C)

85
Q

The component of the conduction system referred to as the pace make of the heart is

A

SA node

86
Q

During an assessment of a healthy adult, where would the nurse expect to palpate the apical pulse?

A

Fifth left intercostal space at the midclavicular line

87
Q

The nurse knows that a “thrill” is

A) palpated in the right epigastric area
B) murmur auscultated at the 3rd intercostal space
C) associated with ventricular atrophy
D) vibration that is palpable

A

D) vibration that is palpable

88
Q

Claudication is caused by

A) varicose veins
B) stasis ulcerations
C) venous insufficiency
D) arterial insufficiency

A

D) arterial insufficiency

89
Q

Nurse is reviewing the blood supply to the arm - the major supplying the arm is the _____ artery

A

Brachial artery

90
Q

When auscultating over a patient’s carotid arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

A) bruits occur with turbulent blood flow, indicating partial occlusion
B) bruits occur in the presence of lymphadenopathy
C) bruits are often associated with venous disease
D) hyper metabolic states will cause bruits in the femoral arteries

A

A) bruits occur with turbulent blood flow, indicating partial occlusion

91
Q

How should the nurse document, slight pitting edema present at the ankles of a pregnant patient?

A) 1+
B) 3+
C) 4+
D) Brawny edema

A

A) 1+

92
Q

The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are 2+ – this reading indicates what type of pulse?

A) normal
B) bouding
C) weak
D) absent

A

A) normal

HAP Final (5 decks)

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