Chap 21: cardiovascular assessment

What causes the lub and dub sound?

AV valves (mitrial/bicuspid&tricuspic) closing causes lub and aortic&pulmonic causes dub sound.

Mnemonic for QRS

AVAV; Systole together, dystole together.

An older adult client reports a need to get up during the night to urinate. What assessment will provide the most relevant information concerning the management of patient's nocturia? "Is there a family history of this problem?" "Have you made any lifestyle changes because of this?" "Are you tired in the morning because of this?" "What do you think is causing this need to urinate so often?"

"Have you made any lifestyle changes because of this?"

Position to evaluate jugular vs. carotid

...jugular 30, 45, 90. carotid 30 degrees

During assessment, the nurse notes an irregular rhythm. What should the nurse do next? Assess for a pulse deficit. Notify the physician. Reposition the client and reassess. Document finding.

Assess for a pulse deficit.

position for inspecting jugular vein?

30,45, 60, and 90 degrees

Where is apical pulse taken?

4 or 5th ICS (tricuspid)

A nurse auscultates a client's carotid arteries, finding the strength of the pulse to be bounding. Which score should the nurse record? 3+ 2+ 1+ 4+

4+

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1.Over the second intercostal space at the left sternal border 2.Over the fourth intercostal space at the right sternal border 3.Over the second intercostal space at the right sternal border 4.Over the fifth intercostal space in the left midclavicular line

4.Over the fifth intercostal space in the left midclavicular line

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

5+. 6+ would be heard anywhere on the chest.

A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure? Grade III/VI systolic murmur Split S1 heard over the apex of the heart Auscultation of an S3 heart sound Jugular venous distention at 30 degrees

Auscultation of an S3 heart sound

Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy? Diminished Bounding Displaced Normal

Displaced because the heart is larger, therefore displacing where the apical pulse is palpated.

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:

Do you have any history of problems with your heart?"

T or F. murmurs should only be auscultated with the bell?

False. bell and diaphragm as they have high and low pitches, although the majority would be bell.

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age?

Increase in systolic blood pressure

What is known as the pacemaker of the heart?

SA node

cardiac output=

SVXHR. normal is 5-6L

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what? Increased intracranial pressure Surgical site infection Severe sepsis Cardiac dysrhythmias

Severe sepsis. low BP and ↑HR to pump what's left.

S4 heart sound (MCM cause/important assoc.)

Stiff/hypertrophic ventricle (aortic stenosis, restrictive cardiomyopathy). AKA atrial gallop

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action?

administer diuretics. also, the nurse should monitor edema, intake, and output; weigh patient daily; auscultate lung and heart sounds; administer diuretic with order; elevate head of bed for dyspnea.

differentiate cardiac pain from GI pain?

antacids relieve GI, activity exascerbates MI pain.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

aortic and pulmonic

The nurse is planning to auscultate a female adult client's carotid arteries. The nurse should plan to

ask client to hold breath

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:

inflammation of the precordium

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

inspect for edema

Best position for auscultating murmurs?

left lateral position.

The nurse is performing a cardiac examination of a client with shortness of breath and palpitations. The nurse listens to the heart with the client sitting upright, then has him change to a supine position, and finally has him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?

mitral because it is located more laterally

Variations in the presentation of S1 are due to alterations in which heart valve?

mitrial. tricuspid is also involved but obscured by louder mitrial.

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

murmur

While auscultating an adult client's heart rate and rhythm, the nurse detects an irregular pattern. The nurse should refer the client to a physician. assess the client for signs and symptoms of pulmonary disease. document this as a normal finding. schedule the client for an ECG.

refer the client to a physician.

The S3 and S4 sounds are produced by

stiff, non-elastic ventricles

How are S3 heart sounds best heard?

with bell of stethoscope@apex (bottom) with patient in left lateral position

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique?

Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client?

Low-fat, low-cholesterol meals

When learning about hereditary variability, the student would learn that what ethnic group has the highest number of premature deaths due to heart disease?

Native American, NOT AA.

What does orthoapnea indicate?

Orthopnea, which is dyspnea that occurs when lying down and improves when sitting up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

A nurse experiences difficulty differentiating S1 from S2 when auscultating a client's heart sounds. What is an appropriate action by the nurse? Palpate the carotid pulse while auscultating simultaneously Turn the client to the left side Ask the client to hold the breath Listen with the bell of the stethoscope

Palpate the carotid pulse while auscultating simultaneously

A nurse cares for a client with acute pericarditis. The nurse should monitor the client for the onset of which clinical manifestation of cardiac tamponade? Paradoxical pulse Bounding heart sounds Third heart sound Flattened jugular veins

Paradoxical pulse

A nurse detects a bruit on auscultation of the carotid arteries. What precaution should the nurse take during the remainder of the physical assessment of the carotid arteries? Perform only auscultation Avoid frequent repositioning Make the client sit upright Perform palpation lightly

Perform palpation lightly

Upon assessment of a client's pulse, a nurse notices that the amplitude of the pulse varies between beats. Which other finding should the nurse assess for in this client? Split S2 on inspiration Presence of an S3 Changes on expiration Diminished heart sounds

Presence of an S3

During a cardiovascular assessment, the nurse knows that a "thrill" is:

a vibration that is palpable

kussmaul respirations and kussmaul sign

increased deep respirations; ie hyperventilation as compensation for ketoacidosis.

A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this?

increased distance between apex and precordium

The nurse hears a murmur in a patient with a known mitral valve prolapse. The murmur most likely occurs in early diastole middiastole late systole mid-systole

late systole

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

listen with the bell of the stethoscope to assess for bruits.

Suzanne is a 20-year-old college student who complains of chest pain. The pain is intermittent and located to the left of her sternum. There are no associated symptoms. Examination reveals a short, high-pitched sound in systole, followed by a murmur that increases in intensity until S2. It is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis?

mitrial valve prolapse

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of obstructive lung disease. aortic stenosis. premature ventricular contractions. left-sided heart failure

obstructive lung disease

The nurse assesses a client who has ventricular enlargement. The nurse palpates the left parasternal area but cannot feel the ventricle. Which underlying condition does this client likely have? obstructive pulmonary disease peripheral vascular disease ischemic heart disease arrhythmia

obstructive pulmonary disease

A patient with prehypertension is in the clinic for counseling. All lifestyle modifications are important in preventing or managing hypertension. Which modification would be the best to implement first for this patient? smoking cessation regular exercise for at least 30 minutes a day elimination of alcohol consumption weight loss to BMI under 25 kg/m2

regular exercise for at least 30 minutes a day

distended jugular is caused by

right sided CHF,

Which heart sound lasts longer?

s2 or the dub

bed position for cardio exam

semi fowler; left lateral, and leaning forward

While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?

shortness of breath. Shortness of breath, also called orthopnea, is dyspnea that occurs while the client is lying flat and improves when the client sits up. The client would not experience relief from chest pain, palpitations or edema by sitting upright. For this reason, these options are incorrect.

s1:____::s2:____

systolic; diastolic

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?

S2

What causes orthoapnea?

fluid that accumulates when supine.

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs?1. Roll toward the left side2. Roll toward the right side3. Trendelenburg position4. Recumbent position

1. Roll toward the left side

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? 1.Pulsatile abdominal mass 2.Hyperactive bowel sounds in the area 3.Systolic bruit over the area of the mass 4.Subjective sensation of "heart beating" in the abdomen

2.Hyperactive bowel sounds in the area

A patient reports pain and discomfort in the chest. After assessing the patient, the nurse determines that the pain is of pulmonary origin. Which characteristics in the patient enabled the nurse to make this conclusion?1Squeezing burning pain, dyspnea on exertion, and an intolerance to exercise2Sharp pain that does not radiate, dyspnea on exertion, along with diaphoresis3Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis4Sharp pleuritic pain that worsens with deep breathing along with tightness in the chest

3 Sharp stabbing pain that worsens with deep breathing and a cough with hemoptysis

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1.Lub-dub sounds 2.Scratchy, leathery heart noise 3.A blowing or swooshing noise 4.Abrupt, high-pitched snapping noise

3.A blowing or swooshing noise

The nurse would perform which action to assess for a pulse deficit? 1.Count the carotid pulsations for 1 full minute. 2.Measure the blood pressure in both the arm and leg. 3.Auscultate the apical heartbeat while palpating the radial artery. 4.Place the diaphragm of the stethoscope directly over the skin at the mitral area.

3.Auscultate the apical heartbeat while palpating the radial artery.

Erb's point

3rd ICS

A nurse auscultates the heart of a client with hypertension for the past ten (10) years. With the client in the left lateral position, the nurse hears a heart sound that occurs just before S1. The nurse recognizes this sound as what pathological process? Atrial contractions heard as vibrations against stiff walled ventricles Abnormal contraction of the ventricles due to a conduction delay Splitting of S2 that does not disappear with expiration Turbulence within the ventricles caused by rapid filling

Atrial contractions heard as vibrations against stiff walled ventriclesLong-standing hypertension causes stiffening of the ventricles. This produces an S4 heart sound, heard best with the bell of the stethoscope over the apical area with the client in a supine or left lateral position. The sound is produced as the atria contract and produce vibrations from blood flow into stiff walled ventricles. Abnormal contraction of the ventricles due to a conduction delay would produce a split S1. Turbulence within the ventricles caused by rapid filling is an acute finding and most often the result of acute heart failure. Splitting of S2 that does not disappear with expiration is suggestive of heart disease.

A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nause and diaphoresis. The nurse should prepare for which treatment? Open heart surgery Nitroglycerin with no restrictions on activity Balloon angioplasty Morphine and observation

Balloon angioplasty done for diagnosis and then perhaps open heart surgery.

What causes paroxysmal nocturnal dyspnea?

CHF

What could be a false positive for right sided HF when auscultating the jugular

COPD; would be noted on expiration

A 68-year-old mechanic presents to the emergency room for shortness of breath. The examiner is concerned about a cardiac cause and measures the client's jugular venous pressure (JVP). It is elevated. Which of the following conditions is a potential cause of elevated JVP? Aortic aneurysm Mitral stenosis Constrictive pericarditis Left-sided heart failure

Constrictive pericarditis; also could be right sided HF

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

Do you have any pain or discomfort in your chest

The nurse is participating in a health fair and performing cholesterol screens. One person has hypercholesterolemia. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? Asthma Ethnicity Gender Alcohol intake

Gender is more significant than ethnicity, though this does contribute.

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have client hold breath.

Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client admitted with left ventricular failure? Paradoxical pulse Pulsus alternans Bigeminal pulse Bisferiens pulse

Pulsus alternans; left sided HF=pulmonary edema

The nurse assesses the apical pulse while conducting a cardiovascular exam. The nurse notes the client has an irregular (ie arrythmia) pulse. Which of the following chambers of the heart should be further assessed? Left ventricle Right ventricle Left atrium Right atrium

Right atrium because this is where the SA node, the pacemaker of the heart, is located.

The nurse is auscultating heart tones. To auscultate the aortic area, the nurse would place the stethoscope where? Second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line Right second intercostal space to apex of heart Second to fifth intercostal spaces, centered over the sternum Second and third left intercostal spaces close to sternum

Right second intercostal space to apex of heart

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? Right sternal border, 2nd ICS Right sternal border 4th ICS Left mid-clavicular line, 5th ICS Left sternal border , 3rd ICS

Right sternal border, 2nd ICS

The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output? Tachycardia; hypertension Tachycardia; hypotension Bradycardia; hypertension Bradycardia; hypotension

Tachycardia; hypotension

Which of the following statements most accurately describes preload? The blood volume in the atria that must be overcome by the ventricles The amount of blood in the ventricles at the end of diastole The amount of muscle contractility possessed by the myocardium The amount of resistance that must be overcome prior to systole

The amount of blood in the ventricles at the end of diastole

Which of the following assessment findings would signal a pathophysiological finding to the nurse? S2 is split when the nurse asks the client to inhale deeply but is not split on exhalation. Auscultation at the client's apex reveals that S1 is louder than S2. S1 is softer than S2 when the nurse listens at the base of the client's heart. The intensity of the client's S1 varies between beats

The intensity of the client's S1 varies between beats

A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse?

ask to assume left lateral position

P=____ depolarization; QRS=____ depolorization, T=_____ _______

atrial; ventricular, ventricular depolarization. AV(A)V

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

bell at the apex with the patient in the left lateral position

A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse? Tachycardia Bradycardia Decreased Normal

brady?

How does CHF affect urination?

brain and kidney are high o2 demand and are affected first by o2 depletion. therefore, low perfusion to kidney, results depleted urination during the day, but at night when less o2 is needed for function, the kidney filtration rate increases, causing nocturia

The nurse is conducting a workshop on the measurement of jugular venous pulsation. As part of instruction, the nurse tells the students to make sure that they can distinguish between the jugular venous pulsation and carotid pulse. Which of the following characteristics is typical of the carotid pulse?

carotid is palpable, jugular vein is not.

S3 sounds are normal for who?

children and young adults and 3rd trimester pregnant.

s1 sound is caused by __ while s2 is caused by ___

closure of mitrial valve/bicuspid; closure of aortic. remember that the left side is bigger because it has to eject blood for the whole body. therefore, the bigger side of the heart makes more noise.

When listening to heart sounds, the nurse knows that S1:

coincides with the carotid artery pulse

s3 and s4 are heard after ___

diastole or s2

After conducting a physical examination of a client, the nurse suspects hypertrophy of the left ventricle. What is a characteristic of the apical impulse that is useful in confirming this suspicion?

duration

S3 heart sounds in adults indicates?

early sign of HF

The nurse assesses a female client who smokes cigarettes and has hypertension. Which factor would increase the likelihood that the client will develop metabolic syndrome? waist circumference of 30 inches family history fasting blood glucose of 110mg/dL high HDL cholesterol

fasting blood glucose of 110mg/dL. Fasting blood glucose levels of 110mg/dL indicates the client is developing diabetes, which is associated with metabolic syndrome. The risk for metabolic syndrome increases in women with a waist circumference greater than 35 inches. High HDL cholesterol would be considered a protective factor against metabolic syndrome. Family history is a nonmodifiable risk factor for coronary artery disease but not metabolic syndrome.

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

females have a lower resting heart rate and a smaller heart.

S3 heart sound aka

↑ventricular filling pressure (e.g., mitral regurgitation, HF). AKA ventricular gallop.