Health Assessment 3

All Heart sounds are described by...

(1) FREQUENCY (pitch)-high or low (need a stethoscope to hear low pitched) (2) INTENSITY (loudness)-loud of soft (3) DURATION--very short for heart sounds; silent periods are longer (4) TIMING- diastole or systole

Conditions resulting in a murmur

(1) Velocity of blood increases (flow murmur) ex. exercise, thyrotoxicosis (2) Viscosity of blood decreased ex. in anemia (3) Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitating valve) or unusual openings occur in the chambers (dilated chamber, septal defect)

Select ALL the statements that are TRUE: S1 represents the opening of the mitral and tricuspid valves. It is best to listen with the bell of the stethoscope for S3 and S4. The pulmonic valve is auscultated on the left of the sternum in 2nd intercostal space. S2 is louder than S1 at the base of the heart.

(not the first one) It is best to listen with the bell of the stethoscope for S3 and S4. The pulmonic valve is auscultated on the left of the sternum in 2nd intercostal space. S2 is louder than S1 at the base of the heart.

Heart of an infant

2/3 of blood is shunted through an opening in the atrial septum (FORAMEN OVALE) into the left side of the heart where it is pumped out of the aorta. The rest of the oxygenated blood is pumped by the right side of the heart out through the pulmonary artery, but is detoured through the DUCTUS ARTERIOSUS.

S3 is heard? After S2 Before S2 After S1 Randomly

After S2

Gas exchange in the lungs occurs in the? A. Bronchioles B. Alveolar sinus C. Alveolar sacs D. Segmental Bronchi

Alveolar sacs

The right middle lobe is auscultated with the stethoscope where? A. Posteriorly on the right at the 4th intercostal space B. Anteriorly on the right at the 4th intercostal space C. Anteriorly between C7 to T3 D. Posteriorly between T3 to T10

Anteriorly on the right at the 4th intercostal space

What part of the heart delivers richly oxygenated blood to the body? A. Superior Vena Cava B. Aorta C. Tricuspid Valve D. Pulmonary artery

Aorta

S2 represents the closure of? Aortic and Pulmonic valves Aortic and Mitral valves Mitral and Pulmonic valves Tricuspid and Aortic valves

Aortic and Pulmonic valves

Names of Semilunar Valves

Aortic, Pulmonic

The order of heart valve auscultation is the following (starting at the angle of Louis..downward): Pulmonic, aortic, tricuspid, mitral Mitral, tricuspid, pulmonic, aortic Aortic, pulmonic, tricuspid, mitral Tricuspid, pulmonic, aortic, mitral

Aortic, pulmonic, tricuspid, mitral

S1 is best heard where? A. 2nd intercostal space left of the sternal border B. 2nd right sternal border C. Apex of the heart D. Base of the heart

Apex of the Heart

Difference between atria and ventricles?

Atria: thinner walled (blood holding portion) Ventricles: lower, thicker (pumping portion)

The ____________ separate the atria and ventricles. Semilunar valves Atrioventricular valves Pulmonic valve Aortic valve

Atrioventricular valves

Select all the correct statements about educating the patient with heart failure: A. It is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week. B. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. C. Heart failure patients should limit sodium intake to 2-3 grams per day. D. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. E. Patients with heart failure should limit exercise because of the risks.

B, C, D. Option A is wrong because heart failure patients should notify their doctor if they gain 2-3 pounds in a day or 5 pounds in a week, and option E is wrong because exercise is important for heart failure patients to help strengthen the heart muscle...so they should exercise as tolerated.

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea

B, D, F. Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.

S2 is best heard where? Base of the heart 5th intercostal space right of the sternal border Apex of the heart Right lower sternal border

Base of the Heart

S4 is heard? During diastole Over the aortic valve Before S1 After S2

Before S1

When auscultating the posterior part of the chest the upper lobes are found? A. Between C9 to T10 B. Between T3 to T10 C. Between C7 to T3 D. Directly over the scapulae

Between C7 and T3

Murmur

Blood circulating through normal cardiac chambers and valves usually don't make noise. However, some conditions create TURBULENT blood flow and COLLISION currents. These result in a murmur which sounds like a noisy water flow. A murmur is a gentle, flowing, swooshing sound that can be heard on the chest wall.

These type of breath sounds are found at the site of the bronchi and are located anteriorly at the 1st and 2nd intercostal space & posteriorly in between the scapulae? A. Crackles B. Wheezes C. Bronchovesicular D. Vesicular

Bronchovesicular

Select all of the following that are considered discontinuous breath sounds: A. High-pitched wheeze B. Stridor C. Pleural friction rub D. Fine crackles E. Low-pitched wheeze F. Coarse Crackles

C, D, F

Everything below is part of the lower respiratory system EXCEPT (select-all-that-apply)? A. Trachea B. Carina C. Pharynx D. Bronchioles E. Nasal cavities

C, E The pharynx and nasal cavities are part of the upper respiratory system.

A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? A. Encourage the patient to cough and deep breathe. B. Place the patient in Semi-Fowler's position. C. Assist the patient into High Fowler's position. D. Perform chest percussion therapy.

C. Assist the patient into High Fowler's position.

The trachea splits at the _________ to form the ____________. A. Cricoid cartilage, secondary bronchi B. Thyroid cartilage, primary bronchi C. Carina, primary bronchi D. Hilum, secondary bronchi

Carina, primary bronchi

The condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, an cerebral ischemia with syncope. This may occur in older adults with hypertension or occlusion of the carotid artery.

Carotid Sinus Hypersensitivity

The term" blue bloaters" is used to describe patients with? A. Pulmonary hypertension B. Left-sided heart failure C. Chronic Bronchitis D. Emphysema

Chronic Bronchitis

What is the best way to assess for extra heart sounds, such as S3 and S4? A. Place the patient on their right side and listen with the diaphragm of the stethoscope over the apex of the heart. B. Place the patient on their left side and listen with the bell of the stethoscope over the base of the heart. C. Place the patient forward (leaning slightly) and have them exhale while listening with the diaphragm over the aortic and pulmonic areas. D. Place the patient on their left side and listen with the bell of the stethoscope over the apex of the heart.

D. Place the patient on their left side and listen with the bell of the stethoscope over the apex of the heart.

During _______, the ventricles are relaxed and the AV valves are ________ to allow blood to flow through the atria and ventricles. Systole, closed Diastole, opened Diastole, closed Systole, closed

Diastole, opened

In which of the following conditions below do the alveolar sacs lose elasticity which can lead to "air-trapping": A. Chronic Bronchitis B. Emphysema

Emphysema

True or False: Low-pitched wheezes are polyphonic sounds that can be cleared when coughing.

FALSE. Low-pitched wheezes are MONOPHONIC (have one sound quality to them) that are not usually cleared by coughing.

True or False: The left lung has three lobes and the right lung has two lobes.

False

True or False: S1 split is due to the asynchronous closing of the aortic and pulmonic values.

False. S2 split is due to the asynchronous closing of the aortic and pulmonic values.

True or false: The semilunar valves are the tricuspid and mitral valves.

False. The semilunar valves are the AORTIC and PULMONIC valves.

Which of the following is a late sign of heart failure? A. Shortness of breath B. Orthopnea C. Edema D. Frothy-blood tinged sputum

Frothy-blood tinged sputum. Shortness of breath, orthopnea, and edema are EARLY signs and symptoms. Frothy-blood tinged sputum is a late sign.

While auscultating heart sounds you heard a blowing/swooshing noise over the apex of the heart. You note when you lift up the chest piece of the stethoscope you can still hear the sound through the ear pieces (a thrill is also present as well). You would grade this heart murmur as: Grade 4 Grade 3 Grade 6 Grade 1

Grade 6

In order to auscultate for an aortic regurgitation heart murmur, what is the best position to place the patient in? Place the patient in a supine position Turn the patient onto their left side Have the patient sitting-up, leaning forward Turn the patient onto their right ride

Have the patient sitting-up, leaning forward

Culture and genetic influences on the heart

High BP, smoking, cholesterol, obesity, type 2 diabetes, sex differences: CVD is leading cause of death in women

This lung sound is continuous, high-pitched with musical instrument sound that is polyphonic and occurs mainly during expiration but can be present with inspiration as well? A. Stridor B. Fine crackles C. High-pitched wheeze D. High-pitched crackles

High Pitched Wheeze

The right & left bronchus along with the pulmonary artery & vein enter into the lungs at the? A. Hilum B. Carina C. Alveolar ducts D. Right middle lobe

Hilum

Which of the following conditions can cause the extra heart sound S4? Fluid volume overload Fluid volume deficient Hypertrophic left ventricle Aortic regurgitation

Hypertrophic left ventricle

What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath. A. Left ventricular systolic dysfunction B. Left ventricular ride-sided dysfunction C. Right ventricular diastolic dysfunction D. Left ventricular diastolic dysfunction

Left ventricular diastolic dysfunction

While assessing a patient's lung sounds you note bronchial breath sounds in the peripheral lung fields. What could this finding represent? A. This is a normal finding. B. Pulmonary emboli C. Lung consolidation like with pneumonia D. Pleuritis

Lung consolidation like with pneumonia.

Names of AV Valves

Mitral, Tricuspid open during SYSTOLE (filling phase) closed during DIASTOLE (pumping phase)

S3

Normally diastole is a silent event. However, in some conditions ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3. S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole). Occurs immediately after S2 when the AV valves open and atrial blood first pours into the ventricles.

S4

Occurs at the end of diastole, at pre systole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. This creates vibrations that are heard as S4, which occurs just before S1.

______________ delivers unoxygenated blood to the lungs. A. Pulmonary vein B. Aorta C. Left ventricle D. Pulmonary artery

Pulmonary Artery

What part of the heart delivers unoxygenated blood to the lungs? A. Pulmonary artery B. Pulmonary vein C. Aorta D. Left Ventricle

Pulmonary artery

What part of the heart delivers oxygenated blood to the heart? A. Pulmonary artery B. Pulmonary vein C. Aorta D. Tricuspid Valve

Pulmonary vein

The blood enters on the left side of the heart through the ______________ and enters the left atrium. It then passes through the _____________to enter the left ventricle. A. pulmonary vein, bicuspid valve B. pulmonary artery, mitral valve C. pulmonary vein, tricuspid valve D. pulmonary artery, aortic valve

Pulmonary vein, bicuspid valve

S1 split can be caused by which of the following: Right bundle branch block Left bundle branch block Ventricular tachycardia Asystole

Right bundle branch block

First Heart Sound

S1- Apex- Closure of AV valves (systole)

Second Heart Sound

S2- Base- closure of semilunar valves (diastole)

When auscultating the anterior part of the chest, specifically the apex of the lungs, it is best to auscultate where with the stethoscope? A. Slightly above the clavicle B. 2nd intercostal space mid-clavicular C. 4th intercostal space mid-clavicular D. 6th intercostal space mid-axillary line

Slightly above the clavicle

On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as: A. Stridor B. Vesicular C. Rales D. Rhonchi

Stridor

The contraction phrase of the heart so blood can be pumped through the body's system and lungs is known as? Diastole Systole Pericardial closure Repolarization

Systole

Which of the following is most commonly found in a patient with emphysema? A. Barrel chest B. Cyanosis C. V/Q mismatch D. Excessive productive cough

The answer is A. Cyanosis, V/Q mismatch, and excessive productive cough are found in chronic bronchitis.

In which of the following conditions below is there a matched V/Q defect? A. Chronic Bronchitis B. Emphysema

The answer is B. Emphysema patients have a matched V/Q defect mainly due to a damaged capillary bed where there is poor ventilation (V) and poor perfusion (Q)...hence there is matched ventilation and perfusion.

A patient is newly diagnosed with COPD due to chronic bronchitis. You're providing education to the patient about this disease process. Which statement by the patient indicates they understood your teaching about this condition? A. "If I stop smoking, it will cure my condition." B. "Complications from this condition can lead to pulmonary hypertension and right-sided heart failure." C. "I'm at risk for low levels of red blood cells due to hypoxia and may require blood transfusions during acute illnesses." D. "My respiratory system is stimulated to breathe due to high carbon dioxide levels rather than low oxygen levels.

The answer is B. This is the only correct statement. Option A is wrong because smoking cessation will NOT cure the condition but it may slow down the progress of it. Option C is wrong because the patient may develop HIGH LEVELS of red blood cells due to the body trying to compensate for hypoxia. Option D is wrong because patients with COPD are stimulated to breathe due to LOW OXYGEN LEVELS rather than high carbon dioxide levels.

You are auscultating a patient's lung sounds. During your assessment, you note there is a low-pitched harsh, grating sound that sounds like a pleural friction rub. However, you're not sure if this is a pleural friction rub or pericardial friction rub. What do you do next to determine the difference? A. Have the patient cough and see if the sound clears B. Assess the posterior lower lobe only C. Have the patient hold their breath and note if the sound is still present D. Place the patient in supine position and reassess for the sound

The answer is C. A pleural friction rub can sound similar to a pericardial friction rub. If you are unsure about what you are hearing, have the patient hold their breath which will cause the lungs to stop inflating and deflating. If you still hear the sound, it is possible the patient has a pericardial friction rub rather than pleural friction rub. All the other options are incorrect.

A patient with emphysema may present with all of the following symptoms EXCEPT? A. Barrel chest B. Hyperinflation of the lungs C. Hypoventilation D. Hypercapnia

The answer is C. Patients with emphysema present with HYPERventilation. The body will try to compensate for the low oxygen blood levels and will cause the patient to hyperventilate. Remember emphysema patients are sometimes called "pink puffers". They will have a barrel chest (due to the use of accessory muscles for breathing), hyperinflation of the lungs (due to damage of the alveoli sacs and creation of air sacs), and hypercapnia (high carbon dioxide levels).

A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD? A. Emphysema B. Pneumonia C. Chronic bronchitis D. Pneumothorax

The answer is C. The key words to let you know the patient is experiencing chronic bronchitis are: cyanosis and edema in the abdomen and legs. Remember chronic bronchitis is sometimes referred to as "blue bloaters".

Which of the following is NOT a sign and symptom of chronic bronchitis? A. Productive cough B. Shortness of breath C. Cyanosis D. Barrel chest

The answer is D. Barrel chest is most commonly found in patients with emphysema.

Patients with chronic bronchitis and emphysema can MOST COMMONLY experience what type of acid-base imbalance? A. High oxygen level and high carbon dioxide level B. Low oxygen level and low carbon dioxide level C. High oxygen level and low carbon dioxide level D. Low oxygen level and high carbon dioxide level

The answer is D. Low oxygen levels and high carbon dioxide levels (respiratory acidosis) are found in patients with chronic bronchitis and emphyesma.

Which of the following is NOT a treatment for chronic bronchitis or emphysema? A. Albuterol B. Spirvia C. Theophylline D. Metoprolol

The answer is D. Metoprolol is a beta blocker used to treat heart conditions. Albuterol, Spirvia, and Theophylline are types of bronchodilators which are used to treat chronic bronchitis & emphysema.

True or False: COPD is reversible and tends to happens gradually.

The answer is FALSE. COPD IRREVERSIBLE and tends to happens gradually.

True or False: During inhalation, the diaphragm contracts upward to create positive pressure in the chest which allows the body to inhale oxygen.

The answer is FALSE. During inhalation, the diaphragm contracts DOWNWARD to create NEGATIVE pressure in the chest which allows the body to inhale oxygen.

True or False: Inhaled oxygen travels down through the trachea, into the right and left bronchus, then into the segmental bronchi which branches even further into the lobar bronchi.

The answer is FALSE. Inhaled oxygen travels down through the trachea, into the right and left bronchus, then into the LOBAR BRONCHI which branches even further into the SEGMENTAL BRONCHI.

True or False: Patients with emphysema experience hypoventilation as a compensatory mechanism to help increase oxygen levels and decrease carbon dioxide levels in the body.

The answer is FALSE. Patients with emphysema experience HYPERventilation as a compensatory mechanism to help increase oxygen levels and decrease carbon dioxide levels in the body.

True or False: The left lung has 3 lobes: left upper lobe, left middle lobe, and left lower lobe.

The answer is FALSE. The right lung has THREE lobes and the left lung has TWO lobes.

True or False: V/Q mismatch is found in chronic bronchitis.

The answer is TRUE. Patients with chronic bronchitis have a mismatched V/Q because the capillary bed works properly (this is not the case in emphysema) however ventilation is poor due to obstruction from mucous and inflammed bronchioles. So, there is poor ventilation but sufficient perfusion.....hence it is mismatched.

Select ALL the options that are TRUE about chronic bronchitis and emphysema: A. Patients with chronic bronchitis have the ability to fully exhale but have limited airflow. B. Emphysema and chronic bronchitis are irreversible. C. An incentive spirometer is used to diagnose both chronic bronchitis and emphysema. D. Patients with chronic bronchitis are sometimes referred to as "blue bloaters, while patients with emphysema are sometimes referred to as "pink puffers".

The answers are B and D. Option A is wrong because patients with chronic bronchitis DON'T have the ability to fully exhale AND have limited airflow as well. Option C is wrong because SPRIOMETRY is used to diagnose chronic bronchitis and emphysema.

Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea

The answers are B, C, E, and G. These are typical signs and symptoms of pneumonia. Stridor is not very common. A PRODUCTIVE cough that can be nagging is very typical, and there is usually a HIGH PCO2 of 45 or greater due to the lungs retaining carbon dioxide

Where does the right side of the heart pump blood to?

The lungs. This side of the heart is weaker and thinner since the lungs are compliant.

Preload

The venous return that builds up during diastole. It is the length to which the ventricle muscle is stretched at the end of diastole right before contraction. When the volume is increased (exercise) the muscle bundles are stretched to accommodate. This force of stretch is the preload. Frank-Starling Law: the greater the stretch, the stronger the contraction of the heart (increased SV)

Where does the left side of the heart pump blood to?

Through the systemic portion of the body. This side is thicker since it needs to pump more forcefully.

Bronchial breath sounds can be auscultated where? A. Peripheral lung fields B. Sternal area C. Mid-scapulae area D. Tracheal area

Tracheal area

True or False: Blood flows in the following sequence in the heart: Superior vena cava/Inferior vena cava, right atrium, tricuspid valve, right ventricle, pulmonic valve, pulmonary artery, lungs, pulmonary veins, left atrium, bicuspid valve, left ventricle, aortic valve, aorta

True

True or False: During auscultation, the anterior part of the chest mainly provides an assessment of the upper lobes of the right and left lungs, while the posterior part of the chest provides mainly provides an assessment of the lower lobes of the right and left lungs.

True

True or False: During gas exchange, carbon dioxide is transported across the capillary membrane to be exhaled while oxygen is transported across the capillary membrane to attach to the red blood cells.

True

What does a bruit indicate?

Turbulence from a local vascular cause and is a marker for atherosclerotic diseased. this increased the risk of transient ischemic attack and stroke.

JVD: full vs unilateral distention

Unilateral: local cause (kinking or anuerism) Full distention: above 45 degrees signify increased CVP (central venous pressure) as with heart failure.

What is a cause of the extra heart sounds known as S3? Atrial "kick" due to resistant ventricles caused by hypertrophic left ventricle Valves defects Mitral Stenosis Ventricle filling due to fluid volume overload or heart failure

Ventricle filling due to fluid volume overload or heart failure

These breath sounds are found anteriorly and posteriorly throughout the peripheral lung fields? A. High-pitched wheezes B. Vesicular C. Discontinuous D. Bronchial

Vesicular

The inner layer that surrounds the lung itself is called the? A. Parietal Pleura B. Visceral Pleura C. Pleuracardium D. Lobar Bronchi

Visceral Pleura

Normal pulse: smooth with brisk upstroke and slower downstroke, moderate strength, equal bilaterally. What is abnormal?

Weak, diminished pulse: decreaed stroke volume as in cardiogenic shock increased pulse: strong and full like in hyperkinetic states

Jugular veins

empty unoxygenated blood directly into the superior vena cava. Since no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give info about activity on the right side of the heart. (reflect filling pressure and volume changes)

what does S4 mean?

end of diastole, pre systole. "atrial gallop" "Tennessee" normal in adult over 40/50 bc your heart gets stiffer as you age. better heard in L lateral position in apex of the heart. pathological: in patients that are younger.-->cardiovascular disease, cardiomyopathy, hypertension, fluid volume overload, stenosis of valve.

What happens to blood volume in a pregnant woman?

it increased by 30-40%. This creates an increase in stroke volume and cardiac output and and increased pulse rate of 10-15 BPM. However, BP DECREASES as a result of peripheral vasodilation.

cardiac output

normal: 4-6 L of blood/min cardiac output= vol. of blood in each systole (stroke volume) times the number of BPM (rate) CO= SV x R

What influences the heart in an aging adult?

smoking, diet, alcohol use, exercise patterns, stress, lifestyle

Afterload

the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure. It is the resistance against which the ventricles must pump its blood. Ventricle muscle tenses to make up the difference in pressure (isovolumic contraction)

what happens if there's a backup of blood from LA and it flows back into your pulmonary veins into your vascular bed?

venous congestion in pulmonary bed which causes difficulty breathing and a change in lung sounds

what does S3 mean?

when ventricles are full and there's a resistance to filling. "ventricular gallop" "kentucky" can be normal in children pathologic: in adults over 40 and goes away when they sit up. This means there is extra congestion in the heart, fluid volume overload, heart failure, or a valve that isn't closing all the way (regurgitation)

What is an "arterial kick" ?

when you lose 1/4 of the blood available to be pumped through your body, and this can affect BP.