Week #4: Heart & Neck Flashcards
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?
Right carotid bruit auscultated
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?
Orthopnea
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?
S1
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?
Pericardial friction rub
Which formula will the nurse use to calculate cardiac output?
Heart rate X stroke volume
The sternal angle at the right 2nd rib space is also known as what?
The aortic area (the angle of Louis)
The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse’s assessment technique?
Palpating carotid pulses simultaneously
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
a) Undergo regular cholesterol screening
b) Undergo regular screening for diabetes
d) Quit or do not start smoking
e) Exercise regularly
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:
Myocardial infarction
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?
Ineffective tissue perfusion
Valve that separates the right atrium and right ventricle
Tricuspid valve
Valve that lies between the right ventricle and pulmonary artery
Pulmonic valve
Valve that separates the left atrium and left ventricle
Mitral valve
Valve that lies between the left ventricle and aorta
Aortic valve
Ventricular relaxation
Diastole
Volume in the right atrium at the end of diastole
Preload
Swishing auscultatory sound that indicates turbulent blood flow or narrowing from constriction or dilation of a tortuous vessel
Bruits
Amount of blood ejected from the left ventricle each minute
Cardiac Output
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
Murmur
How much blood is ejected with each beat or stroke
Stroke Volume
Contraction of the ventricles
Systole
Common name for the extra heart sounds S3 & S4
Gallop
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
b) False
The coronary veins may develop atherosclerotic plaques that narrow them, leading to MI (heart attack) or angina.
a) True
b) False
a) True
The pulmonary artery carries deoxygenated blood to the lungs, whereas the pulmonary vein delivers oxygenated blood to the left atrium.
a) True
b) False
a) True
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
a) True
African American men are 40% more likely to have high blood pressure than Caucasians.
a) True
b) False
a) True
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.
Mediastinum
The parts of the heart that pump blood to the lungs and out to the body are called ___________________.
Ventricles
The cells in the SA node are unique because they possess ______________ (property that enables the heart to generate its own pulses).
Automaticity
__________________ are abnormal heart rhythms with early (premature), delayed, or irregular beats.
Arrhythmias
If a patient is experiencing chest pain, dyspnea, cyanosis, diaphoresis, or dizziness, focus assessment on data to ______________ the discomfort while simultaneously providing treatments.
Resolve
Heart rate X stroke volume = ____________________.
Cardiac Output
_________________ is one cause of reduced cardiac output. It is a medical diagnosis that reduces contractility, causing preload to increase.
Heart Failure
What is the term used to describe the area where apical pulsation can be seen or palpated?
Point of Maximal Impulse
Where would you located (on the body) the Point of Maximal Impulse?
the left 5th intercostal space on the midclavicular line
List the grading of Pulse Scale (include # & description):
0 - Absent
1 - Weak/diminished
2 - Normal (can palpate with normal pressure)
3 - Bounding
found on the thumb side of the forearm and wrist
radial pulse
found approximately at the inner third of the antecubital fossa when the palm is held upward
brachial pulse
found halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament
femoral pulse
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)
popliteal pulse
found in the groove between the medial malleolus and Achilles tendon
posterior tibial pulse
found approximately halfway up the foot immediately lateral to the extensor tendon of the great toe
dorsalis pedis pulse
2nd right intercostal space
aortic area
2nd left intercostal space
pulmonic area
3rd left intercostal space
Erb’s point
4th left intercostal space
tricuspid area
5th left intercostal space
mitral area
