During the assessment of cardiac function, listening to the heart first is a common error. The nurse, however, should follow the proper sequence: Show A. Inspection: The nurse looks for abnormalities in the skin of the thorax, the chest, and neck. Students also viewedCorrect response: Ineffective Tissue Perfusion 1, murmur, Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium Recommended textbook solutions
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Terms in this set (128)eat low fat , low cholesterol meals The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and LDL cholesterol levels, what would be important to teach this client? Eat low-cholesterol, low-carbohydrate meals Auscultate to determine the heart rate and if the rhythm is normal Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Auscultate to determine the heart rate and if the rhythm is normal Accentuated When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe this heart sound? S2 is: Wide Split false To function adequately, the nurse knows that the heart valves need to open simultaneously. True late systole The nurse hears a murmur in a patient with a known mitral valve prolapse. The murmur most likely occurs in mid-systole Slipping forward or down. What is a prolapse? mitral A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur? Pulmonic palpable 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? Palpable Smoking increases the heart's workload and contributes to atherosclerosis. A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client? Smoking is a central component of metabolic syndrome. 1-6 What is the scale for grading murmurs, from what number to what number? grade 5 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? Grade 1 ineffective tissue perfusion 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 Health Maintenance S2 When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? S1 Dizziness Which of the following would put the client at risk for falls? Select all that apply. Confusion
hypovolemia The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? Hypovolemia ineffective tissue perfusion What nursing diagnosis would be most appropriate for a client admitted with heart failure? Risk for denial 1+pulses The client is experiencing severe sepsis. What assessment finding would the nurse expect? Heart rate 88 between the left atrium and the left ventricle The bicuspid, or mitral, valve is located between the left atrium and the left ventricle. angina An adult 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 acute
anxiety reaction. a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart. What is angina? Walk briskly 30 minutes per day. A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. Consume two to three glasses of red wine daily. pericardial friction rub What is the most important physical sign of acute pericarditis? Elevated white cell count inflammation or irritation of the pericardium, the thin sack like membrane surrounding the heart What is pericarditis shortness of breath A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? Shortness of breath Atherosclerotic stenotic carotid arteries An older adult client has come to the clinic for a routine checkup. The nurse practitioner notes that the carotid artery pulse is diminished bilaterally and a systolic bruit is auscultated bilaterally. What would the nurse practitioner want to have this client assessed for by a cardiologist? Atherosclerotic stenotic carotid arteries wide splitting A client presents at the cardiology clinic for a checkup 6 months after a myocardial infarction. The client is known to have a bundle branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds? Wide splitting Premature beats followed by compensatory pause A nurse monitors a client at risk for the onset of premature ventricular contractions. The nurse should monitor the client's cardiac rhythm for which characteristic feature? P wave preceding every QRS complex perform palpation lightly 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 palpation lightly 65- diabetes Which client is at greatest risk for the development of coronary heart disease? 45-year-old female with a total cholesterol level of 20 0mg/dL blood swooshing past a problem heart valve What is a murmur? 5-6 A nurse auscultates a murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur? Grade I/VI aortic and pulmonic When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? Pulmonic and
tricuspid Disease of the heart muscle. The heart muscle becomes enlarged, thick or rigid in cardiomyopathy, and in rare cases the muscle tissue is replaced with scar tissue. What is cardiomyopathy Aortic stenosis, with pressure overload of the left ventricle The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? Hypothyroidism It is caused by rapid deceleration of blood against the ventricular wall. Which is true of a third heart sound (S3)? It marks atrial contraction. Observe for a decrease in jugular venous pressure A nurse is assessing a client for possible dehydration. Which of the following should the nurse do? Observe for a decrease in jugular venous pressure Check for pulse inequality between right and left carotid arteries A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do? Auscultate for split S1 at the base and apex narrowing. the abnormal narrowing of a passage in the body. What is stenosis? blood pressure A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? Blood pressure assess for a pulse deficit, no repositioning is needed A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? Blood pressure Atrial depolarization The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer? Atrial depolarization precordium The anterior chest area that overlies the heart and great vessels is called the precordium. High serum level of LDL An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is high serum
level of low-density lipoproteins. "This problem can depend on how you respond when you notice it." A client tells the nurse he is very worried that he will have a heart attack because he recently noticed he is having fluttering in his chest. The client also reports his heart feels like it sometimes "skips a beat." Which response best addresses the client's symptoms? "These are possible signs of heart disease." sinus arrhythmia The nurse notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating? premature atrial contractions Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. what is "A-fib"? quitting smoking What is the most important lifestyle changes a client can make to improve cardiovascular health? have the client hold his or her breath; if the rub persists, it is pericardial How does the nurse differentiate a pleural friction rub from a pericardial friction rub? Auscultate the base of the heart; if
a rub is present, it is pericardial 3rd left The area known as Erb's point is the third site for auscultation on the precordium. Where is it located? 4th left rib space Watch the client's respirations while listening for effect on the heart sound During auscultation of the heart, a nurse hears an extra heart sound immediately after S2 at the second left intercostal space. What should the nurse do to further assess this finding? Watch the client's respirations while listening for effect on the heart sound Early in Diastole. The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium. When does S3 happen No current medications or treatment A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system? Apical heart rate 70 beats per minute
Sinus arrhythmia A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? Premature atrial contractions inflammation of the pericardial sac
A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? Inflammation of the pericardial sac Ineffective tissue perfusion 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 III/VI systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data? Impaired Breathing Pattern 1)The murmur is only audible on listening carefully for some time. What is the Levine Scale? How do you grade a murmur? grade 2, Grade 2 murmurs are quiet but heard immediately on placing the stethoscope on the chest. The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include grade
2 Right atrium. explanation:The sinus node is a group of specialized cardiac cells located in the right atrium near the junction of the vena cava. The sinus node acts as the cardiac pacemaker and automatically discharges an impulse about 60 to 100 times a minute. In the patient with an irregular pulse, this area of the heart needs to be further assessed. The nurse assesses the apical pulse while conducting a cardiovascular exam. The nurse notes the client has an irregular pulse. Which of the following chambers of the heart should be further assessed? gender 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 constrictive pericarditis Other JVP causes include right-sided heart failure, tricuspid stenosis and superior vena cava syndrome 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? Left-sided heart failure AV node, The AV node slightly delays incoming electrical impulses from the atria, then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum. As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase? Bundle of His 6 The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal? 2 Changing pressures within the right atrium What do the oscillations in the internal jugular veins reflect? Changing pressures within the right atrium Can be heard during diastole The S4 heart sound is usually due to a heart murmur. cardiac cycle A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following? Cardiac cycle The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? The spread of depolarization in the atria Using machines to read/ monitor cardiac rhythm. Like and EKG What does telemetry mean? The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? The spread of depolarization in the atria obstructive pulmonary 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? peripheral vascular disease The serous membrane lining layer that surrounds the lungs What is the pleura? left and right coronary Which two arteries feed the heart with blood? 9 oz in women and 10.9 oz in men how much does the heart weigh? aorta, pulmonary vein, superior and inferior vena cava, pulmonary artery. What are the great vessles the left Which ventricle is thicker? The pericardium is a tough, inextensible,
loose-fitting, fibroserous sac that attaches to the great vessels and surrounds the heart. What is the pericardium? endocardium, myocardium, What are the layers of the heart in order? between the atria in the septum Where is the AV node located The AV node slightly delays incoming electrical impulses from the atria and then relays the impulse to the AV bundle (bundle of His) in the upper interventricular septum Which node delays the incoming electrical signal and where does it send it to? The electrical impulse
then travels down the right and left bundle branches and the Purkinje fibers in the myocardium of both ventricles, causing them to contract almost simultaneously. Where does the electrical impulse travel to after the bundle of his? The filling phases during diastole result in a large amount of blood in the ventricles, causing the pressure in the ventricles to be higher than in the atria. This
causes the AV valves (mitral and tricuspid) to shut. Closure of the AV valves produces the first heart sound (S1), which is the beginning of systole. What causes the first heart sound and which event marks the beginning of systole? When the ventricles contract What is the QRS complex? contraction of the atria What is the P-wave ventricular repolarization T-wave? With ventricular emptying, the ventricular pressure falls and the semilunar valves close. This closure produces the second heart sound (S2), which signals the end of systole. What makes the S2 sound? at the apex Where is S1 heard the best? When S2 is heard as two sounds because the semilunar (leading to the aorta and pulmonary) valves are closing at different times What is a splitting of S2 it correlates with the beginning of systole. What does S1 correlate with, diastole or systole? softer at the base and louder at the apex Is S1 softer or louder at the base compared to the apex? occurs when the mitral valve is wide open and closes quickly. (fever, anemia, hyperthyroidism, mitral stenosis) What is one condition where the S1 sound is going to be accentuated? (louder than the s2 sound) With increased pressure or stenosis How do you get an accentuated S2? deceased pressure and stenosis How do you get diminished heart sounds? If present, S3 can be heard early in diastole, after S2 When is S3 heard? Late in diastole, just before S1 When is S4 heard ventricular vibrations caused by rapid ventricular filling. What do the S3 and S4 sounds come from? increased blood velocity, structural valve defect, valve malfunction, abnormal chamber opening What are some conditions that can cause a murmur? the amount of blood pumped by the ventricles during a given period of time (usually 1 minute) SV X HR= cardiac output normal =5 L/min How do you measure cardiac output? The amount of blood pumped from the heart with each contraction. What is stroke volume? precordium, which is the anterior surface of the body overlying the heart and great vessels. What is the precordium? Second intercostal space at the right sternal border=the base of the heart Where do you hear the aortic sound, when you are using your stethoscope? Pulmonic
area: Second or third intercostal space at the left sternal border Where do you hear the pulmonic area? Erb's point: Third to fifth intercostal space at the left sternal border Where do you hear Erb's point? Mitral (apical): Fifth intercostal space near the left mid-clavicular line—the apex of the
heart Where do you hear the mitral? Tricuspid area: Fourth or fifth intercostal space at the left lower sternal border Where do you hear the tricuspid? true (p423) Can you hear the gallops with the bell? Assessment of the jugular venous pulse is important for determining the hemodynamics of the right side of the heart. What information can we get from assessing the JVP? It reflects right atrial pressure (aka central venous pressure) What information can we get from bringing out the ruler and measuring the level of the JVP? left ventricle What is the most common chamber for heart failure? BP= cardiac output x arterial resistance How do you measure BP? abnormality of the heart's conduction system. which can cause irregular heart beats What is an arrhythmia? It could mean decreased cardiac output.. Fatigue can be what kind of sign concerning the heart? may indicate decreased blood flow to the brain due to myocardial damage. What does dizziness often mean, concerning the heart? true, reduction of blood flow out of the heart causes a back flow to the organs. true or false, edema is associated with heart failure? the inability to breathe while supine What does orthopnea mean? including diseases of blood vessels, such as coronary artery disease; heart rhythm problems (arrhythmias); heart infections; and congenital heart defects 'Heart disease is a broad category, what does it encompass? it is a wooshing sound and you should tell the patient to hold their breath while you listen. Bruit suggests arterial narrowing. Bell. What does a bruit sound like and what should you tell the patient to do? Do you use the bell or diaphram? 30 degrees HOB At what degree angle do you put the bed when you are assessing the heart? Stethoscope with a bell and diaphragm What equipment do you need for a heart assessment? Pulse Amplitude Scale 0 = Absent 1+ = Weak 2+ = Normal 3+ = Increased 4+ = Bounding (Weber 432) What is the pulse amplitude scale? it may indicate arterial constriction or occlusion in one carotid. What does pulse inequality of the carotid arteries potentially mean? potentially hypovolemia, shock, or decreased cardiac output What does a weak carotid pule mean? potentially hyper volemia, or increased cardiac output What does a bounding pulse mean when you palpate the carotid? auscultate for a pulse rate deficit. This is done by palpating the radial pulse while you auscultate the apical pulse. Count for a full minute. If you detect and irregular rhythm what should you do? atrial fibrilation (when the atriums quiver) , atrial flutter, premature ventricular contractions, and varying degree of heart block. What does a pulse deficit possibly indicate? A pathologic S3 (ventricular gallop) may be heard with ischemic heart disease, hyperkinetic states (e.g., anemia), or restrictive myocardial disease. What can an S3 potentially mean? A pathologic S4 (atrial gallop) toward the left side of the precordium may be heard with coronary artery disease, hypertensive heart disease, cardiomyopathy, and aortic stenosis. A pathologic S4 toward the right side of the precordium may be heard with pulmonary hypertension and pulmonic stenosis. What can an S4 potentially mean? when you hear an s3 and and s4 What is a summation gallop? turbulent blood flow through the heart valve, or great vessel. What causes a murmur? Sinus arrhythmia: The normal increase in heart rate that occurs during inspiration What is a sinus arrhythmia? Students also viewedChapter 17: Heart and Neck Vessels18 terms Neeru20 Peripheral Vascular Prep U13 terms brittany_dickerson16 Health Assessment Exam 391 terms sidney_gail_eubanks Health Assessment Ch 17190 terms juanibarra96 Sets found in the same folderChapter 21: assessing the heart and neck vessels42 terms meghan_kennedy6 PrepU: Ch.21-Heart & Neck Vessels22 terms ztfang Chapter 18- Assessing mouth throat nose and sinuses82 terms stephanieee753 PrepU - Chapter 15 - Health Assessment50 terms Dyer_Melissa_G Other sets by this creatorPharmacology exam #3257 terms Alanderos15 Week 3 Pharmacology70 terms Alanderos15 Older Adults GAE #164 terms Alanderos15 Homeless, LGBTQ and Dying34 terms Alanderos15 Verified questions
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What is the sound we hear when listening to the heart?When you listen to your heart really closely, you can usually hear two different sounds. Most people describe these sounds as “lub” and “dub”. Every time you hear “lub dub” when listening to your heart, you are actually hearing one full heartbeat!
What would be an expected finding on auscultation of the heart quizlet?While performing a cardiovascular assessment, you palpate a thrill at the Tricuspid area.. Considering this finding, what might you expect to hear upon cardiac auscultation? During cardiac auscultation, you hear a high-pitched, early diastolic sound at the apex.
When auscultating the heart the nurse is most likely to hear?When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? Explanation: Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed.
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What auscultation sound would the nurse expect when listening to heart sounds quizlet?
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