heart

chapter 19

blood flow

know flow of blood &

anatomy

any questions about

flow of blood or
anatomy of heart?

cardiac cycle

what is happening during s1, s2, s3 &

s1: systole-mitral & tricuspid valves
s4?
close

s2:systole-aortic and pulmonic valves

close

s3: blood empties from atria to

ventricles; passive filling of ventriclesdiastole

s4:at end of diastole-atria contract and

push last of blood into ventricles (atrial
kick)

cardiac cycle

s1 sound is created when AV valves

close-where is this sound heard loudest?

at apex - where is this?

s2 sound is created when SL
valves close-where is this sound
heard loudest?
at base - where is this?
what is a split s1/s2?

Clear explanation of heart sounds s1/s2, where they are heard & what is happening-follow links
http://www.blaufuss.org/arrow/S1.html
http://www.blaufuss.org/arrow/S2.html

extraneous heart sounds

**s3 when do we hear this? physiologic

& pathologic reasons

physiologic: young adults, children,

pregnancy

patho:
**s4heart
whenfailure,
do weregurgitation
hear this? - V gallop

physiologic & pathologic

reasons

physiologic: 45/50s after exercise

patho: heart dz, HTN - A gallop

Clear explanation of heart sound s4, where they are heard & what is happening-follow links

http://www.blaufuss.org/arrow/S4.html

murmur

*be able to define

how do we document these sounds? p

478

timing

loudness - graded

pitch

pattern

quality

location- where heard

radiation - travel?

position - of pt

precordium

know & be able to define

heave/lift/pulsations/apical
impulse/thrill/murmur

when/how you note these & when they will

occur (during inspection, palpation,
auscultation, etc)

which part of the stethoscope will we use for

s1, s2, s3 and s4?

which set of pts will we have a difficult time

palpating the apical impulse?

auscultation heart sound

locations

**know location of each may have to draw on blank

picture & label

**read over Z pattern on pg

475

which pulse is associated

with s1? carotid

what is a pulse deficit?

other terms
angina-we ask about chest discomfort here-pain is subjectivethis occurs when the hearts own blood supply cannot keep up
with metabolic demand
DOE-dyspnea on exertion-shortness of breath-when does this
happen?
PND-paroxysmal nocturnal dyspnea-occurs with heart failurelying down increases pressure on heart workload-pt feels short
of air
nocturia-increased urinary frequency during the night-due to
fluid reabsorption when lying down occurring with heart failure
pericardial friction rub-inflammation of pericardial sac
surrounding the heart-sounds like rubber against leather-best
heard pt sitting up and learning forward breath held on expiration

Cardiovascular DZ

list modifiable vs non-modifiable risk

factors

warning signs of hypoxia

neck vessel assessment

why do we palpate carotid artery one at a

time?

what is a bruit & what does it indicate?

(*difference between bruit & murmur)

be able to describe the inspection of the

jugular vein - slide 21/pg 472 - always read
specific inspection instructions in book if on
slide r/t test questions

PVS
chapter 20

PVS

look over anatomy

this HH is VERY similar to cardiac

assessment questions except for HPI

**VTE risk assessment (select all that

apply would be applicable here) know
differences between modifiable and
non-modifiable-slide 30 & pg

occlusion of
arteries vs veins
slide 38, 40; chart on page 521
veins=towards (deoxygenated)
painful!
large veins, edema pitting/non, thick skin, warm, erythema,
thrombosis, etc
homans sign
arteries=away (oxygenated)
5 Ps - pain, pallor, pulseless, paresthesia, paralysis
loss of hair, thick nails, thin skin, cap refill, cold extremities, etc
allen test

signs

be able to describe what the test is determining, the

process, and what a positive (or negative) sign
indicates
allen test-evaluate the adequacy of collateral
ARTERIAL circulation in the hand-read over steps on
pg. 509-POSITIVE test is when the blood flow does
NOT return to the hand within 2-5 seconds
homans sign-may indicate DVT or superficial
thrombophlebitis-read over steps on slide 40POSITIVE sign means potential for DVT or
thrombophlebitis

terms
ischemia-deficient supply of oxygenated arterial blood to a
tissue caused by obstruction of a blood vessel-partial blockage
creates insufficient supply and ischemia may be apparent only
at exercise when oxygen needs increase (claudication occurs
with activity, relieved with rest)
edema-swelling-occurs in both extremities when right sided HF
is present-unilaterally when there is an obstruction
orthostatic hypotension-drop in systolic BP >20 mmHg and
diastolic of >10 mmHg-results in feeling lightheaded or
dizziness-results primarily from blood pooling in lower
extremities which results in decreased venous return and
decreased cardiac output

A patient has been diagnosed with Right-Sided

Congestive Heart Failure and is confused about return
of deoxygenated blood from the tissue. To clarify the
confusion, which chamber of the heart receives blood
from systemic circulation?

1. Left atrium

2. Right atrium

3. Right ventricle

4. Left ventricle

answer: 2 right atrium

nurse is listening to client's heartbeat & focusing on 2nd

heart sound, which heart valves produce this sound?

1. Pulmonic & Mitral

2. Aortic & Pulmonic

3. Mitral & Tricuspid

4. Tricuspid & Aortic

answer: 2. Aortic & Pulmonic

S2

a nurse is performing a cardiac assessment on a 22

year old. the first heart sound can best be heard at
which of the following locations?

1. third or fourth intercostal space

2. the apex with the stethoscope bell

3. second intercostal space, left

midclavicular line

4. fifth intercostal space, left

midclavicular line

answer: 4 fifth intercostal space,

left midclavicular line

S1 can best be heard at the fifth

intercostal space, midclavicular line.

this is just knowledge of where heart

sounds can be heard-on powerpoint

when auscultating the heart, which of the following

characteristics or statements best describes the
first heart sound?

1. heard late in diastole

2. heard early in diastole

3. closure of the mitral and tricuspid

valves

4. closure of the aortic and pulmonic

valves

answer:3. closure of the mitral

and tricuspid valves

A 12 year old client has an S3 heart

sound. The nurse knows:

1. she can document this as an

abnormal finding and continue the
assessment

2. physiologic S3 is common in children

and young adults

3. she must contact the attending

physician immediately, something is
wrong

answer:2. physiologic S3 is common in

children and young adults

An S3 heart sound, also called a

ventricular gallop, occurs early in
diastole when blood is flowing from the
atria into the ventricles and causes
vibrations. S3 is a physiologic heart
sound in children, young adults, and
pregnant females

Which of the following risk factors for

coronary artery disease cannot be corrected?
(non-modifiable)

1. Cigarette smoking

2. DM

3. Heredity

4. HTN

answer: 3 heredity

Because heredity refers to our genetic

makeup, it cant be changed. Cigarette
smoking cessation is a lifestyle change
that involves behavior modification.
Diabetes mellitus is a risk factor that
can be controlled with diet, exercise,
and medication. Altering ones diet,
exercise, and medication can correct
hypertension.

A murmur is heard at the second left intercostal

space along the left sternal border. Which valve
area is this?

1. Aortic

2. Mitral

3. Pulmonic

4. Tricuspid

answer: 3 pulmonic

Abnormalities of the pulmonic valve are

auscultated at the second left intercostal
space along the left sternal border. Aortic
valve abnormalities are heard at the second
intercostal space, to the right of the sternum.
Mitral valve abnormalities are heard at the
fifth intercostal space in the midclavicular
line. Tricuspid valve abnormalities are heard
at the third and fourth intercostal spaces
along the sternal border.

What position should the nurse place the head of the bed in to
obtain the most accurate reading (in our case, to visualize it)of
jugular vein distention?

1. High-fowlers

2. Raised 10 degrees

3. Raised 30 degrees

4. Supine position

answer: 3. Raised 30 degrees

30-45 is ideal. Inclined pressure cant

be seen when the client is supine or
when the head of the bed is raised 10
degrees because the point that marks
the pressure level is above the jaw
(therefore, not visible). In high Fowlers
position, the veins would be barely
discernible above the clavicle.

The client is diagnosed with pericarditis. When

assessing the client, the nurse is unable
to auscultate a friction rub. Which action should the
nurse implement?

1. Notify the health-care provider.

2. Document that the pericarditis has

resolved.

3. Ask the client to lean forward and

listen again.

4. Prepare to insert a unilateral chest

tube

answer: 3. Ask the client to lean forward and

listen again.

pericarditis is best heard when the

patient is sitting up and learning
forward

Two nurses are taking an apical-radial pulse and note a

difference in pulse rate of 8 beats per minute. The nurse
would document this difference as which of the following?

1. Pulse decit

2. Pulse amplitude

3. Ventricular rhythm

4. Heart arrhythmia

answer: 1. Pulse decit

when the apical heart rate and the

radial heart rate do not coincide, this is
termed pulse deficit

When evaluating a client's circulation the nurse should

include which assessments? Select all that apply.

1. Palpation of pulses

2. Skin temperature of bilateral

extremities

3. Skin color

4. Moles & freckles

5. Hair on the legs and feet

Answer: 1, 2, 3 & 5

1. Palpation of pulses

2. Skin temperature of bilateral

extremities

3. Skin color

5. Hair on the legs and feet

These are indicative of circulation to

and from the extremities

A 65-year-old patient with a history of heart failure comes to

the clinic with complaints of "being awakened from sleep with
shortness of breath." Which action by the nurse is most
appropriate?

1. Obtain a detailed history of the patient's

allergies and history of asthma.

2. Tell the patient to sleep on his or her

right side to facilitate ease of respirations.

3. Assess for other signs and symptoms of

paroxysmal nocturnal dyspnea.

4. Assure the patient that this is normal

and will probably resolve within the next
week.

answer: 3. Assess for other signs and symptoms of

paroxysmal nocturnal dyspnea.

The patient is experiencing paroxysmal

nocturnal dyspnea: being awakened
from sleep with shortness of breath and
the need to be upright to achieve
comfort.

During an assessment of a 68-year-old man with a recent onset of

right-sided weakness, the nurse hears a blowing, swishing sound
with the bell of the stethoscope over the left carotid artery. This
finding would indicate:

1. a valvular disorder.

2. blood flow turbulence.

3. fluid volume overload.

4. ventricular hypertrophy

answer:2. blood flow turbulence.

A bruit is a blowing, swishing sound

indicating blood flow turbulence;
normally none is present.

The nurse is preparing to auscultate for heart

sounds. Which technique is correct?

1. Listen to the sounds at the aortic,

tricuspid, pulmonic, and mitral areas.

2. Listen by inching the stethoscope in a

rough Z pattern, from the base of the heart
across and down, then over to the apex.

3. Listen to the sounds only at the site

where the apical pulse is felt to be the
strongest.

4. Listen for all possible sounds at a time at

each specified area.

answer:B) Listen by inching the stethoscope in a rough Z

pattern, from the base of the heart across and down, then
over to the apex.

Do not limit auscultation of breath

sounds to only four locations. Sounds
produced by the valves may be heard
all over the precordium. Inch the
stethoscope in a rough Z pattern from
the base of the heart across and down,
then over to the apex. Or, start at the
apex and work your way up.

When performing a peripheral vascular assessment on a patient,

the nurse is unable to palpate the ulnar pulses. The patient's skin
is warm and capillary refill time is normal. The nurse should next:

1. check for the presence of claudication.

2. refer the individual for further evaluation.

3. consider this a normal finding and

proceed with the peripheral vascular
evaluation.

4. ask the patient if he or she has

experienced any unusual cramping or
tingling in the arm.

answer:3. consider this a normal finding and proceed with

the peripheral vascular evaluation.

It is not usually necessary to palpate

the ulnar pulses. The ulnar pulses are
often not palpable in the normal
person. The other responses are not
correct.

When using a Doppler ultrasonic stethoscope, the nurse

recognizes arterial flow when which sound is heard?

1. Low humming sound

2. Regular "lub, dub" pattern

3. Swishing, whooshing sound

4. Steady, even, flowing sound

answer:3. Swishing, whooshing sound

When using the Doppler ultrasonic

stethoscope, the pulse site is found
when one hears a swishing, whooshing
sound.

During an assessment of an older adult, the nurse should expect

to notice which finding as a normal physiologic change associated
with the aging process?

1. Hormonal changes causing vasodilation and a

resulting drop in blood pressure

2. Progressive atrophy of the intramuscular calf

veins, causing venous insufficiency

3. Peripheral blood vessels growing more rigid with

age, producing a rise in systolic blood pressure

4. Narrowing of the inferior vena cava, causing low

blood flow and increases in venous pressure
resulting in varicosities

answer: 3. Peripheral blood vessels growing more rigid with

age, producing a rise in systolic blood pressure

Peripheral blood vessels grow more

rigid with age, resulting in a rise in
systolic blood pressure. Aging
produces progressive enlargement of
the intramuscular calf veins, not
atrophy. The other options are not
correct.

during a cardiovascular assessment the nurse finds a bluish

tinge on the clients lips, fingers, and toes. what is the
appropriate documentation for this finding?

1. blue tinged extremities

2. central and peripheral cyanosis

3. bad circulation

4. central and peripheral pallor

ANSWER: 2. central and peripheral cyanosis

inadequate blood flow to the periphery

may be due to several different things
but will result in central & peripheral
cyanosis

A Nurse assesses the client for the presence of homan's

sign- which one indicates that this sign is positive?

1. no pain

2. pain on dorsiflexion of the foot

3. pain on plantar flexion of the foot

4. pain when bringing knee to chest

answer: 2.pain on dorsiflexion

of foot

Homans sign has to do with pain in the

calf area indicating possible DVT/VTE

A client has a 1+/0-4+ dorsalis pedis pulse on the right. The

lower leg is cool, pale, and painful. This description is most
consistent with:

1. venous insufficiency

2. arterial insufficiency

3. normal finding

answer: arterial insufficiency

Arterial insufficiency is inadequate

circulation in the arterial system, which
results in diminished pulses; cool, shiny
skin; deep muscle pain; absence of hair
on the toes; pallor on elevation; and a
red color when dependent.