Unit IV (Cardiovascular Assessment) Flashcards
1
Q
The heart is the ______ organ in the body.
A
Strongest
2
Q
Average heart beat for a healthy adult is ______ bpm.
A
60-100
3
Q
The heart is a ______ _________ organ.
A
hollow muscular
4
Q
The ______ of the heart is located at the lower portion.
A
apex
5
Q
The _______ of the heart is located at the upper portion.
A
base
6
Q
Cardiac Output= ______ X _______
A
Stroke Volume X Heart Rate
7
Q
What does cardiac output describe?
A
The amount of blood pumped per minute.
8
Q
What does stroke volume describe?
A
The amount of blood pumped by the Left Ventricle with each contraction.
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.
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.
11
Q
What sound is given to S1?
A
‘lub’
12
Q
What sound is given to S2?
A
‘dub’
13
Q
What is taking place in the heart during S1?
A
Closing of Tricuspid and Mitral atrioventricular valves.
14
Q
What is taking place in the heart during S2?
A
Closing of the Pulmonary and Aortic semilunar valves.
15
Q
What is taking place between S1 and S2, Diastole or Systole?
A
S1—>S2 Systole
16
Q
What is taking place between S2 and S1, Diastole or Systole?
A
S2—>S1 Diastole
17
Q
Where would the nurse place the stethoscope to auscultate the Aortic Area?
A
2nd ICS, Right of Sternum
18
Q
Where would the nurse place the stethoscope when auscultating the Pulmonic Area?
A
2nd ICS, Left of Sternum
19
Q
Where would the nurse place the stethoscope when auscultating the Tricuspid Area?
A
5th ICS, Left of Sternum.
20
Q
Where would the nurse place the stethoscope when auscultating the Mitral Area?
A
5th ICS, Midclavicular line.
21
Q
What two areas are auscultated to assess S2?
A
Aortic & Pulmonic
22
Q
What two areas are ausculated to assess S1?
A
Tricuspid & Mitral
23
Q
The Aortic and Pulmonic areas are auscultated to assess what heart sound?
A
S2
24
Q
The Tricuspid and Mitral areas are auscultated to assess what heart sound?
A
S1
25
___________ is defined as an abnormal heart rhythm.
Dysrhythmia
26
Early, late, missed or extra heart beats are all considered:
Dysrhythmia
27
S3 is also called ______ _______.
Ventricular Gallop
28
S3 occurs during _______.
| Diastole or Systole
Diastole
29
S3 is defined as ________ of ventricular _____ from _______ filling.
vibration
walls
rapid
30
Where would the nurse best hear S3?
Apex of heart/ Mitral Area
31
S3 is normal in healthy ________ and adults up to ___ years old.
children
| 40
32
When is S3 heard?
After S2.
33
S4 is also called _____ _______.
Atrial Gallop
34
S4 is cause by _________ to ______ filling as ______ are contracting.
resistance
ventricular
atria
35
When is S4 heard?
Before S1
36
S4 is normal in _______ ______ adults, but abnormal in ________ and ______ adults.
healthy older
| children young
37
After 40, S3 is indicative of ____ _______ _______.
Left Ventricular Failure.
38
Auscultation reveals swishing and blowing sounds created by turbulence of flood flow through a narrowed arterial lumen what is this sound?
Bruits
39
Name the three causes of a heart murmur?
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.
40
In general, heart murmurs are caused by a disruption of _____ ______ _____.
blood through valves.
41
Intensity of murmur sounds are related to the:
rate of blood flow.
42
Define Tissue Perfusion
Transportation of blood (that carries O2 and nutrients) to the tissues.
43
Where would the nurse palpate for a brachial pulse?
'pinky side' of antecubital area.
44
Where would the nurse palpate for a radial pulse?
'thumb side' of the wrist.
45
Where would the nurse palpate for a femoral pulse?
Interior thigh, close to groin. (Requires more pressure to palpate)
46
Where would the nurse palpate for a popliteal pulse?
Behind the knee.
47
Where would the nurse palpate for a posterior tibial pulse?
interior, posterior ankle.
48
Where would the nurse palpate for a dorsalis pedis pulse?
Top of feet, following space between the great and first toe.
49
Bradycardia is defined as a pulse rate that is ______.
<60
50
Tachycardia is defined as a pulse rate that is ________.
>100
51
Pulse rhythm can be either _____ or _____.
Regular or Irregular.
52
Patterns of pulsations and pauses between pulsations is defined as:
Rhythm.
53
What does the strength of the pulse represent?
The strength of the Left Ventricle.
54
A pulse has been given a grade of '0'. What does this mean?
Pulse is absent; NOT PALPABLE
55
A pulse has been graded '1+'. What does this mean?
"Thready", not easily found and faint. Can be obliterated with light pressure.
56
A pulse has been graded '2+'. What does this mean?
Normal, easily felt; requires great amount of pressure to obliterate.
57
A pulse has been graded '3+'. What does this mean?
Strong. does not obliterate with pressure.
58
(1+) Thready pulse indicates:
decreased cardiac output.
59
(3+) Bounding pulse indicates:
hypertension or circulatory overload
60
The nurse notes that the patients pulses are (3+) on the left side, and (1+) on the right side. Is this normal?
No, pulses should be equal on both sides of the body.
61
Skin color is influence by ______
oxygen content
62
Cyanosis is indicative of _____ or _______ disease, or ______ temperatures.
cardiac
pulmonary
cold
63
Define Pallor
paleness of skin
64
Pallor can be caused by:
Decreased HGB or Blood Volume
65
How can a nurse assess pallor in dark skinned patients?
Conjunctiva of eyelid
-or-
palm surface of hands (appears ashen gray)
66
Rubor is also defined as
Erythema/Redness
67
Rubor is caused by:
Inflammation, blushing, alcohol intake, fever, and injury/infection.
68
Yellowish color of the skin is defined as:
jaundice
69
Jaundice is first noticed in the ______
sclera
70
Jaundice is often caused by:
liver disease
71
Dark skinned patients can be assess for jaundice by assessing:
Sclera, Oral Mucous Membranes, palms, soles of feet.
72
When assessing for temperature/warmth, the nurse should use what part of their hand?
Dorsal surface- most sensitive to temperature.
73
Capillary Refill is used to monitor ____ ____.
Tissue Perfusion.
74
The nurse notes that capillary refill in a patients hand takes 6 seconds. Is this a normal capillary refill value?
No, normal capillary refill takes 2-3 seconds.
75
What factor needs to be assessed when testing capillary refill?
Temperature: cold temperatures delays capillary refill.
76
Jugular Vein Distention provides information about ___ ______ _______ __________.
the hearts pumping efficiency.
77
How is Jugular Vein Distention Assessed?
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
Where is a bruit heard?
Arteries
79
What are the causes of a bruit?
Blocked/Narrowing Artery
80
How does the nurse assess for a bruit?
1) Check Carotid Artery
2) Have pt turn head away.
3) Have pt hold breath while auscultating.
81
Why is it important to the patient to hold their breath while auscultating for a bruit?
Holding the breath prevents the sound of air passing through the trachea being heard.
82
Edema is caused by excess fluid accumulation in the __________ ______.
intercellular spaces
83
The nurse should assess what areas for edema?
Hands, feet, ankles, sacral area.
84
When pressing on the skin, the nurse notes that the skin remains depressed. This is called ______.
Pitting
85
Edema that allows for 2mm depression is rated:
1+
86
Edema that allows for 4mm depression is rated:
2+
87
Edema that allows for 6mm depression is rated:
3+
88
Edema that allow for 8mm depression is rated:
4+
89
Hands and feet should be assessed in what position
Sitting, hanging against gravity.
90
Thick and rigid nails suggest ______ ______
arterial Insufficiency.
91
Spongy nails suggest ____ of _____
lack of O2
92
Patchy distributions of light colored skin indicates:
Mottling
93
Patchy distribution of hair on the legs may indicate:
circulation problems
94
What are the signs of arterial insufficiency on the hands/feet?
swelling, skin lesion, ulcers.
95
HOMAN's sign is used to detect __________
thrombophlebitis
96
How is the patient assessed for HOMAN's sign?
Patient supine, with legs extended.
| Nurse dorsiflexes the patients feet.
97
What indicates a positive (+) HOMAN's sign?
Sharp pain in calf during passive dorsiflexion.
98
A nurse cannot palpate pedal pulses, and charts: Pedal pulses absent. What should the nurse have charted?
R & L Pedal pulse non palpable.
99
Fluid imbalance is easly assessed through:
Mucous Membranes and Skin Turgor
100
Tenacious Mucous Membranes are described as:
the presence of thick white mucous that is difficult to remove.
101
Skin turgor evaluate the ______ of the _____.
elasticity of the skin.
102
The pt chart reads: "Skin turgor rapid". Is this normal?
Yes, skin should quickly return to its normal position.
103
When assessing skin turgor, the skin remains raise for an extended period of time. How would this be documented, and what does this indicate?
"Tenting noted."
| Indicates decreased fluid volume.
104
True -or- False
| It is normal for older adults to have thickened vessel walls and narrowed vessels.
True
105
What effect will thickened vessel walls and narrowed vessels have?
Increased blood pressure.
106
Normal changes for aging adults includes ______ _______ & _____________ of heart valves.
decreased elasticity & calcification
107
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?
Murmurs
