Week #4: Heart & Neck

Question 1

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

Answer 1

Right carotid bruit auscultated

Question 2

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Answer 2

Orthopnea

Question 3

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

Answer 3

S1

Question 4

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

Answer 4

Pericardial friction rub

Question 5

Which formula will the nurse use to calculate cardiac output?

Answer 5

Heart rate X stroke volume

Question 6

The sternal angle at the right 2nd rib space is also known as what?

Answer 6

The aortic area (the angle of Louis)

Question 7

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse’s assessment technique?

Answer 7

Palpating carotid pulses simultaneously

Question 8

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following [select all that apply]?
a) Undergo regular cholesterol screening
b) Undergo regular screening for diabetes
c) Stay at home as often as possible
d) Quit or do not start smoking
e) Exercise regularly

Answer 8

a) Undergo regular cholesterol screening
b) Undergo regular screening for diabetes
d) Quit or do not start smoking
e) Exercise regularly

Question 9

A 62-year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible:

Answer 9

Myocardial infarction

Question 10

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?

Answer 10

Ineffective tissue perfusion

Question 11

Valve that separates the right atrium and right ventricle

Answer 11

Tricuspid valve

Question 12

Valve that lies between the right ventricle and pulmonary artery

Answer 12

Pulmonic valve

Question 13

Valve that separates the left atrium and left ventricle

Answer 13

Mitral valve

Question 14

Valve that lies between the left ventricle and aorta

Answer 14

Aortic valve

Question 15

Ventricular relaxation

Answer 15

Diastole

Question 16

Volume in the right atrium at the end of diastole

Answer 16

Preload

Question 17

Swishing auscultatory sound that indicates turbulent blood flow or narrowing from constriction or dilation of a tortuous vessel

Answer 17

Bruits

Question 18

Amount of blood ejected from the left ventricle each minute

Answer 18

Cardiac Output

Question 19

Abnormal heart sound that may result from intrinsic cardiovascular disease or circulatory disturbance; usually indicates disease of the heart valves either from stenosis or regurgitation

Answer 19

Murmur

Question 20

How much blood is ejected with each beat or stroke

Answer 20

Stroke Volume

Question 21

Contraction of the ventricles

Answer 21

Systole

Question 22

Common name for the extra heart sounds S3 & S4

Answer 22

Gallop

Question 23

The top of the heart is referred to as the apex because it is broad; the bottom of the heart is referred to as the base.
a) True
b) False

Answer 23

b) False

Question 24

The coronary veins may develop atherosclerotic plaques that narrow them, leading to MI (heart attack) or angina.
a) True
b) False

Answer 24

a) True

Question 25

The pulmonary artery carries deoxygenated blood to the lungs, whereas the pulmonary vein delivers oxygenated blood to the left atrium.
a) True
b) False

Answer 25

a) True

Question 26

S1, or “lub”, the beginning of systole, results from the closure of the aortic and pulmonic valves, and S2, or “dub”, the end of systole and beginning of diastole, results from closure of the mitral & tricuspid valves.
a) True
b) False

Answer 26

a) True

Question 27

African American men are 40% more likely to have high blood pressure than Caucasians.
a) True
b) False

Answer 27

a) True

Question 28

The heart and great vessels are located in the ______________ between the lungs and above the diaphragm from the center to the left of the thorax.

Answer 28

Mediastinum

Question 29

The parts of the heart that pump blood to the lungs and out to the body are called ___________________.

Answer 29

Ventricles

Question 30

The cells in the SA node are unique because they possess ______________ (property that enables the heart to generate its own pulses).

Answer 30

Automaticity

Question 31

__________________ are abnormal heart rhythms with early (premature), delayed, or irregular beats.

Answer 31

Arrhythmias

Question 32

If a patient is experiencing chest pain, dyspnea, cyanosis, diaphoresis, or dizziness, focus assessment on data to ______________ the discomfort while simultaneously providing treatments.

Answer 32

Resolve

Question 33

Heart rate X stroke volume = ____________________.

Answer 33

Cardiac Output

Question 34

_________________ is one cause of reduced cardiac output. It is a medical diagnosis that reduces contractility, causing preload to increase.

Answer 34

Heart Failure

Question 35

What is the term used to describe the area where apical pulsation can be seen or palpated?

Answer 35

Point of Maximal Impulse

Question 36

Where would you located (on the body) the Point of Maximal Impulse?

Answer 36

the left 5th intercostal space on the midclavicular line

Question 37

List the grading of Pulse Scale (include # & description):

Answer 37

0 - Absent
1 - Weak/diminished
2 - Normal (can palpate with normal pressure)
3 - Bounding

Question 38

found on the thumb side of the forearm and wrist

Answer 38

radial pulse

Question 39

found approximately at the inner third of the antecubital fossa when the palm is held upward

Answer 39

brachial pulse

Question 40

found halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament

Answer 40

femoral pulse

Question 41

best palpated with your fingers braced on the knee, curling your hands around the back of the knee and pressing against the lower edge of the femur; might be felt immediately lateral to the medial tendon (often difficult to locate)

Answer 41

popliteal pulse

Question 42

found in the groove between the medial malleolus and Achilles tendon

Answer 42

posterior tibial pulse

Question 43

found approximately halfway up the foot immediately lateral to the extensor tendon of the great toe

Answer 43

dorsalis pedis pulse

Question 44

2nd right intercostal space

Answer 44

aortic area

Question 45

2nd left intercostal space

Answer 45

pulmonic area

Question 46

3rd left intercostal space

Answer 46

Erb’s point

Question 47

4th left intercostal space

Answer 47

tricuspid area

Question 48

5th left intercostal space

Answer 48

mitral area