HEART N NECK VESSELS ASSESSMENT

Question 1

A major purpose of this examination is

Answer 1

to identify any sign of heart disease and initiate early referral and treatment.

Question 2

Assessment of the heart and neck vessels is an

Answer 2

essential part of the total cardiovascular examination

Question 3

[…] are useful to the nurse in all types of health care settings, including acute, clinical, and home health care.

Answer 3

Heart and neck vessel assessment skills

Question 4

Preparing the Client

Explain to the client..

Answer 4

that it is necessary to assume several different
positions for this examination

Question 5

Preparing the Client

Explain that you will need to place the client in the ______ ________ with the head elevated to about 30 degrees during auscultation and palpation of the neck vessels and inspection, palpation and auscultation of the precordium.

Answer 5

supine position

Question 6

Preparing the Client

Tell the client that it will be necessary to assume a _____ _______ ________ for palpation of the apical
impulse if you are having trouble locating the pulse with the client in the supine position.

Answer 6

left lateral position

Question 7

Preparing the Client

Explain to the client the necessity to
assume a left lateral and _______ __ and _______ _______ ________ so that you can auscultate for the presence of any abnormal heart sounds.

Answer 7

sitting up and leaning forward position

Question 8

Preparing the Client

Make sure you explain to the client
that you will be [..]

Answer 8

listening to the heart in a number of places and that this does not necessarily mean that anything is wrong.

Question 9

Preparing the Client

Clinical Tip

In women with large breasts, it may
be helpful to ask the client to […]

Answer 9

pull her breast upward and to her side when you are auscultating for heart sounds.

Question 10

Equipment:

Answer 10

Stethoscope with a bell and diaphragm
Small pillow
Penlight or movable examination light
Watch with second hand
Centimeter rulers (two)

Question 11

Inspection (Neck Vessels) - Observe the Jugular Venous Pulse

Ask the client to turn the head slightly to the _____

Answer 11

left

Question 12

Inspect the jugular venous pulse by standing on the

Answer 12

right side of the client

Question 13

The client should be in a

Answer 13

supine position with the torso elevated 30-40 degrees.

Question 14

Observe the Jugular Venous Pulse

Normal Findings:

Answer 14

The jugular venous pulse is not normally visible with the client sitting upright.

Question 15

Be careful not to confuse

Answer 15

pulsations of the carotid arteries with pulsations of the internal jugular veins.

Question 17

This position fully distends the vein, and pulsations may or may not be discernible.

Answer 17

Observe the Jugular Venous Pulse

Normal Findings:

Question 18

Fully distended jugular veins with the client’s torso elevated more than 45 degrees indicate increased central venous pressure that may be the result of right ventricular failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade.

Answer 18

Observe the Jugular Venous Pulse

Abnormal Findings:

Question 19

To evaluate jugular vein distention, position the client in a supine position with the head of the bed elevated

Answer 19

30, 45, 60 and 90 degrees.

Question 20

The jugular vein should not be distended, bulging,or protruding at 45 degrees or greater.

Answer 20

Evaluate Jugular Venous Pressure

Normal Findings:

Question 21

Distension, bulging, or protrusion at 45, 60 or
90 degrees may indicate right sided heart failure
document at which positions (45, 60 and or
90 degrees) you observe distension.

Answer 21

Evaluate Jugular Venous Pressure

Abnormal Findings:

Question 22

Clients with obstructive pulmonary disease
may have elevated venous pressure only
during

Answer 22

expiration

Question 23

An inspiratory increase in venous pressure called ________ ____ may occur in clients with severe constrictive pericarditis.

Answer 23

Kussmaul’s sign

Question 24

Auscultate the carotid arteries if the client is …

Answer 24

middle aged or
older or
if you suspect cardiovascular disease.

Question 25

Place the bell of the stethoscope over the carotid artery and ask the client to […]

Answer 25

hold his or her breath for a moment so that breath sounds do not conceal any vascular sounds.

Question 26

No blowing or swishing or other sounds are heard.

Answer 26

Auscultate the Carotid Arteries Normal Findings:

Question 27

A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is indicative of occlusive arterial disease. If the artery is more than two thirds occluded a bruit may not be heard.

Answer 27

Auscultate the Carotid Arteries Abnormal Findings:

Question 28

Auscultate the Carotid Arteries Clinical Tip Always auscultate the carotid arteries before _________ because ________ may increase or slow the HR, changing the strength of the carotid impulse heard.

Answer 28

palpation

Question 29

Palpate each carotid artery _____________

Answer 29

alternatively

Question 30

Palpate each carotid artery alternately by placing the […] medial to the _________________ muscle on the neck

Answer 30

pads of the index and middle fingers medial to the sternocleidomastoid muscle on the neck.

Question 31

What do you note in palpating the carotid arteries it’s pulse

Answer 31

Note amplitude and contour of the pulse, elasticity of the artery, and any thrills (which feel like similar to a purring cat).

Question 32

Pulses are equally strong; a 2+ or normal with no variation in strength from beat to beat. Contour is normally smooth and rapid on the upstroke and slower and less abrupt on the downstroke.

Answer 32

Palpate the Carotid Arteries Normal Findings:

Question 33

Pulse inequality may indicate arterial constriction or occlusion in one carotid.

Answer 33

Palpate the Carotid Arteries Abnormal Findings:

Question 34

The strength of the PULSE IS EVALUATED ON A SCALE FROM 0 TO 4 AS FOLLOWS: � 0 = � 1+ = � 2+ = � 3+ = � 4+ =

Answer 34

� 0 = Absent � 1+ =Weak � 2+ = Normal � 3+ = Increased � 4+ = Bounding

Question 35

Weak pulses may indicate …

Answer 35

hypovolemia, shock, or decreased cardiac output.

Question 36

A bounding, firm pulse may indicate …

Answer 36

hypervolemia or increased cardiac output.

Question 37

Variations in strength from beat to beat or with respiration are ________ and may indicate a variety of problems.

Answer 37

abnormal

Question 38

A delayed upstroke may indicate

Answer 38

aortic stenosis.

Question 39

Loss of elasticity may indicate

Answer 39

arteriosclerosis

Question 40

Thrills may indicate

Answer 40

a narrowing of the artery

Question 41

Palpate the carotid arteries individually because bilateral palpation could result in

Answer 41

reduced cerebral blood flow.

Question 42

If you detect occlusion during auscultation, palpate lightly to avoid […]

Answer 42

blocking circulation or triggering vagal stimulation and bradycardia, hypotension, or even cardiac arrest.

Question 43

Inspection (Heart, Anterior Chest) Inspect Pulsations on Anterior Chest over Heart With the client in supine position with the head of the bed elevated between ___ and ___ degrees

Answer 43

30 and 45 degrees.

Question 44

Inspection (Heart, Anterior Chest) Inspect Pulsations on Anterior Chest over Heart Stand on the client’s right side and look for the

Answer 44

apical impulse and any abnormal pulsations.

Question 45

The apical impulse was originally called the …

Answer 45

point of maximal impulse (PMI).

Question 46

The term point of maximal impulse (PMI) is no longer used because a maximal impulse may occur in other areas of the …

Answer 46

precordium as a result of abnormal conditions.

Question 47

The apical impulse may or may not be visible. If apparent, it would be in the mitral area (Left MCL, 4th or 5th ICS) The apical impulse is a result of the left ventricle moving outward during systole.

Answer 47

Inspect Pulsations on Anterior Chest over Heart. Normal Findings:

Question 48

Pulsations, which may also be called heaves or lifts, other than the apical pulsation are considered abnormal and should be evaluated.

Answer 48

Inspect Pulsations on Anterior Chest for over Heart. Abnormal Findings:

Question 49

A heave or lift may occur as the result of an

Answer 49

enlarged ventricle from an overload of work.

Question 50

If this apical pulsation cannot be palpated, have the client assume a …

Answer 50

left lateral position.

Question 51

left lateral position is used since it

Answer 51

displaces the heart toward the left chest wall and relocates the apical impulse farther to the left.

Question 52

The apical impulse is palpated in the mitral area and maybe the size of a nickle (1-2cm). Amplitude is usually small ˆ like a gentle tap. The duration is brief, lasting through the first two thirds of systole and often less

Answer 52

Palpate the Apical Impulse Normal Findings:

Question 53

the apical impulse may not be palpable with clients that are….

Answer 53

obese or clients with large breasts

Question 54

The apical impulse may be impossible to palpate in clients with …

Answer 54

pulmonary emphysema.

Question 55

If the apical impulse is larger than 1-2 cm displaced, more forceful, or of longer duration, suspect …

Answer 55

cardiac enlargement.

Question 56

Use your ______ surfaces to palpate the apex, left sternal border, and base.

Answer 56

palmar

Question 57

No pulsations or vibrations are palpated in the areas of the apex, left sternal border, or base.

Answer 57

Palpate for Abnormal Pulsations Normal Findings:

Question 58

Palpate for Abnormal Pulsations - Abnormal Findings: A thrill or a pulsation is usually associated with

Answer 58

a grade IV or higher murmur

Question 59

Auscultate Heart Rate and Rhythm Place the diaphragm of the stethoscope at the ____ and listen closely to the r___ and r_____ of the apical impulse.

Answer 59

apex, rate, rhythm

Question 60

Auscultate Heart Rate and Rhythm - Normal Findings: Rate should be __ - ___ beats per minute, with regular rhythm.

Answer 60

60-100

Question 62

A regularly irregular rhythm, such as ____ ________ when the heart rate increases with inspiration and decreases with expiration, may be normal in young adults.

Answer 62

sinus arrhythmia

Question 63

Adult ______ RPRs are a few beats faster than ____ RPRs.

Answer 63

female, male

Question 64

Auscultate Heart Rate and Rhythm - Abnormal Findings: __________ less than 60 beats per min or ___________ more than 100 beats per min may result in decreased cardiac output.

Answer 64

Bradycardia, Tachycardia

Question 65

Refer clients with irregular rhythms (i.e, premature atrial contraction or premature ventricular contractions) And irregular rhythms (i.e, atrial fibrillation and atrial flutter with varying block) for further evaluate.

Answer 65

Auscultate Heart Rate and Rhythm Abnormal Findings:

Question 66

If you detect an irregular rhythm […]

Answer 66

auscultate for a pulse rate deficit.

Question 67

How