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NSG 1100 > Unit IV (Cardiovascular Assessment) > Flashcards

Unit IV (Cardiovascular Assessment) Flashcards

1
Q

The heart is the ______ organ in the body.

A

Strongest

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2
Q

Average heart beat for a healthy adult is ______ bpm.

A

60-100

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3
Q

The heart is a ______ _________ organ.

A

hollow muscular

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4
Q

The ______ of the heart is located at the lower portion.

A

apex

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5
Q

The _______ of the heart is located at the upper portion.

A

base

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6
Q

Cardiac Output= ______ X _______

A

Stroke Volume X Heart Rate

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7
Q

What does cardiac output describe?

A

The amount of blood pumped per minute.

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8
Q

What does stroke volume describe?

A

The amount of blood pumped by the Left Ventricle with each contraction.

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9
Q

Where would a nurse place the stethoscope when listening for the apical pulse?

A

Left of the midline, between the 4th and 5th intercostal spaces.

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10
Q

The nurse is listening for the PMI, or point of maximal impulse. Where is this located? (General)

A

Over the apex of the heart.

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11
Q

What sound is given to S1?

A

‘lub’

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12
Q

What sound is given to S2?

A

‘dub’

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13
Q

What is taking place in the heart during S1?

A

Closing of Tricuspid and Mitral atrioventricular valves.

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14
Q

What is taking place in the heart during S2?

A

Closing of the Pulmonary and Aortic semilunar valves.

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15
Q

What is taking place between S1 and S2, Diastole or Systole?

A

S1—>S2 Systole

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16
Q

What is taking place between S2 and S1, Diastole or Systole?

A

S2—>S1 Diastole

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17
Q

Where would the nurse place the stethoscope to auscultate the Aortic Area?

A

2nd ICS, Right of Sternum

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18
Q

Where would the nurse place the stethoscope when auscultating the Pulmonic Area?

A

2nd ICS, Left of Sternum

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19
Q

Where would the nurse place the stethoscope when auscultating the Tricuspid Area?

A

5th ICS, Left of Sternum.

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20
Q

Where would the nurse place the stethoscope when auscultating the Mitral Area?

A

5th ICS, Midclavicular line.

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21
Q

What two areas are auscultated to assess S2?

A

Aortic & Pulmonic

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22
Q

What two areas are ausculated to assess S1?

A

Tricuspid & Mitral

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23
Q

The Aortic and Pulmonic areas are auscultated to assess what heart sound?

A

S2

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24
Q

The Tricuspid and Mitral areas are auscultated to assess what heart sound?

A

S1

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25
Q

___________ is defined as an abnormal heart rhythm.

A

Dysrhythmia

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26
Q

Early, late, missed or extra heart beats are all considered:

A

Dysrhythmia

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27
Q

S3 is also called ______ _______.

A

Ventricular Gallop

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28
Q

S3 occurs during _______.

Diastole or Systole

A

Diastole

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29
Q

S3 is defined as ________ of ventricular _____ from _______ filling.

A

vibration
walls
rapid

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30
Q

Where would the nurse best hear S3?

A

Apex of heart/ Mitral Area

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31
Q

S3 is normal in healthy ________ and adults up to ___ years old.

A

children

40

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32
Q

When is S3 heard?

A

After S2.

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33
Q

S4 is also called _____ _______.

A

Atrial Gallop

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34
Q

S4 is cause by _________ to ______ filling as ______ are contracting.

A

resistance
ventricular
atria

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35
Q

When is S4 heard?

A

Before S1

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36
Q

S4 is normal in _______ ______ adults, but abnormal in ________ and ______ adults.

A

healthy older

children young

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37
Q

After 40, S3 is indicative of ____ _______ _______.

A

Left Ventricular Failure.

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38
Q

Auscultation reveals swishing and blowing sounds created by turbulence of flood flow through a narrowed arterial lumen what is this sound?

A

Bruits

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39
Q

Name the three causes of a heart murmur?

A

1) Increased blood flow across a normal valve.
2) Flow across an irregular valve/ into an enlarged heart chamber
3) Back-flow through an insufficient valve that fails to close.

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40
Q

In general, heart murmurs are caused by a disruption of _____ ______ _____.

A

blood through valves.

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41
Q

Intensity of murmur sounds are related to the:

A

rate of blood flow.

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42
Q

Define Tissue Perfusion

A

Transportation of blood (that carries O2 and nutrients) to the tissues.

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43
Q

Where would the nurse palpate for a brachial pulse?

A

‘pinky side’ of antecubital area.

44
Q

Where would the nurse palpate for a radial pulse?

A

‘thumb side’ of the wrist.

45
Q

Where would the nurse palpate for a femoral pulse?

A

Interior thigh, close to groin. (Requires more pressure to palpate)

46
Q

Where would the nurse palpate for a popliteal pulse?

A

Behind the knee.

47
Q

Where would the nurse palpate for a posterior tibial pulse?

A

interior, posterior ankle.

48
Q

Where would the nurse palpate for a dorsalis pedis pulse?

A

Top of feet, following space between the great and first toe.

49
Q

Bradycardia is defined as a pulse rate that is ______.

A

<60

50
Q

Tachycardia is defined as a pulse rate that is ________.

A

> 100

51
Q

Pulse rhythm can be either _____ or _____.

A

Regular or Irregular.

52
Q

Patterns of pulsations and pauses between pulsations is defined as:

A

Rhythm.

53
Q

What does the strength of the pulse represent?

A

The strength of the Left Ventricle.

54
Q

A pulse has been given a grade of ‘0’. What does this mean?

A

Pulse is absent; NOT PALPABLE

55
Q

A pulse has been graded ‘1+’. What does this mean?

A

“Thready”, not easily found and faint. Can be obliterated with light pressure.

56
Q

A pulse has been graded ‘2+’. What does this mean?

A

Normal, easily felt; requires great amount of pressure to obliterate.

57
Q

A pulse has been graded ‘3+’. What does this mean?

A

Strong. does not obliterate with pressure.

58
Q

(1+) Thready pulse indicates:

A

decreased cardiac output.

59
Q

(3+) Bounding pulse indicates:

A

hypertension or circulatory overload

60
Q

The nurse notes that the patients pulses are (3+) on the left side, and (1+) on the right side. Is this normal?

A

No, pulses should be equal on both sides of the body.

61
Q

Skin color is influence by ______

A

oxygen content

62
Q

Cyanosis is indicative of _____ or _______ disease, or ______ temperatures.

A

cardiac
pulmonary
cold

63
Q

Define Pallor

A

paleness of skin

64
Q

Pallor can be caused by:

A

Decreased HGB or Blood Volume

65
Q

How can a nurse assess pallor in dark skinned patients?

A

Conjunctiva of eyelid
-or-
palm surface of hands (appears ashen gray)

66
Q

Rubor is also defined as

A

Erythema/Redness

67
Q

Rubor is caused by:

A

Inflammation, blushing, alcohol intake, fever, and injury/infection.

68
Q

Yellowish color of the skin is defined as:

A

jaundice

69
Q

Jaundice is first noticed in the ______

A

sclera

70
Q

Jaundice is often caused by:

A

liver disease

71
Q

Dark skinned patients can be assess for jaundice by assessing:

A

Sclera, Oral Mucous Membranes, palms, soles of feet.

72
Q

When assessing for temperature/warmth, the nurse should use what part of their hand?

A

Dorsal surface- most sensitive to temperature.

73
Q

Capillary Refill is used to monitor ____ ____.

A

Tissue Perfusion.

74
Q

The nurse notes that capillary refill in a patients hand takes 6 seconds. Is this a normal capillary refill value?

A

No, normal capillary refill takes 2-3 seconds.

75
Q

What factor needs to be assessed when testing capillary refill?

A

Temperature: cold temperatures delays capillary refill.

76
Q

Jugular Vein Distention provides information about ___ ______ _______ __________.

A

the hearts pumping efficiency.

77
Q

How is Jugular Vein Distention Assessed?

A

Pt put into sitting position (from laying positing) at 45 degrees. Head is turned to the side away from the nurse. Side of neck closest to the nurse is observed.

78
Q

Where is a bruit heard?

A

Arteries

79
Q

What are the causes of a bruit?

A

Blocked/Narrowing Artery

80
Q

How does the nurse assess for a bruit?

A

1) Check Carotid Artery
2) Have pt turn head away.
3) Have pt hold breath while auscultating.

81
Q

Why is it important to the patient to hold their breath while auscultating for a bruit?

A

Holding the breath prevents the sound of air passing through the trachea being heard.

82
Q

Edema is caused by excess fluid accumulation in the __________ ______.

A

intercellular spaces

83
Q

The nurse should assess what areas for edema?

A

Hands, feet, ankles, sacral area.

84
Q

When pressing on the skin, the nurse notes that the skin remains depressed. This is called ______.

A

Pitting

85
Q

Edema that allows for 2mm depression is rated:

A

1+

86
Q

Edema that allows for 4mm depression is rated:

A

2+

87
Q

Edema that allows for 6mm depression is rated:

A

3+

88
Q

Edema that allow for 8mm depression is rated:

A

4+

89
Q

Hands and feet should be assessed in what position

A

Sitting, hanging against gravity.

90
Q

Thick and rigid nails suggest ______ ______

A

arterial Insufficiency.

91
Q

Spongy nails suggest ____ of _____

A

lack of O2

92
Q

Patchy distributions of light colored skin indicates:

A

Mottling

93
Q

Patchy distribution of hair on the legs may indicate:

A

circulation problems

94
Q

What are the signs of arterial insufficiency on the hands/feet?

A

swelling, skin lesion, ulcers.

95
Q

HOMAN’s sign is used to detect __________

A

thrombophlebitis

96
Q

How is the patient assessed for HOMAN’s sign?

A

Patient supine, with legs extended.

Nurse dorsiflexes the patients feet.

97
Q

What indicates a positive (+) HOMAN’s sign?

A

Sharp pain in calf during passive dorsiflexion.

98
Q

A nurse cannot palpate pedal pulses, and charts: Pedal pulses absent. What should the nurse have charted?

A

R & L Pedal pulse non palpable.

99
Q

Fluid imbalance is easly assessed through:

A

Mucous Membranes and Skin Turgor

100
Q

Tenacious Mucous Membranes are described as:

A

the presence of thick white mucous that is difficult to remove.

101
Q

Skin turgor evaluate the ______ of the _____.

A

elasticity of the skin.

102
Q

The pt chart reads: “Skin turgor rapid”. Is this normal?

A

Yes, skin should quickly return to its normal position.

103
Q

When assessing skin turgor, the skin remains raise for an extended period of time. How would this be documented, and what does this indicate?

A

“Tenting noted.”

Indicates decreased fluid volume.

104
Q

True -or- False

It is normal for older adults to have thickened vessel walls and narrowed vessels.

A

True

105
Q

What effect will thickened vessel walls and narrowed vessels have?

A

Increased blood pressure.

106
Q

Normal changes for aging adults includes ______ _______ & _____________ of heart valves.

A

decreased elasticity & calcification

107
Q

What sound is turbulent blood flow across a partial obstruction increased flow thru normal structures flows into a dilated chamber backward flow across incompetent valves?

A

Murmurs

NSG 1100 (22 decks)

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