Health Assessment HESI/FINAL EXAM Verified Q&A

Health Assessment HESI/FINAL EXAM aneurysm - visible, prominent pulsation or dialation diastole - ventricular relaxation, ventricular filling from atria. erythema - redness of skin murmur - harsh, blowing sounds caused by disruption of blood flow myocardial ischemia - oxygen needs heightened so heart has to work harder systole - ventricular contraction, blood leaves the ventricles to go to the lungs or body. what is the pacemaker of the heart - sinoatrial node (SA node) how many times is the sinoatrial node set to discharge per minute - 60-100 if the heart rate is initiated in the atrioventricular node, how fast would the heart beat per minute - 60 if the heart rate is initiated in the bundle branches, how fast would the heart beat per minute - 30 what is the term used to describe a sudden droop in blood pressure that may occur when an older client changes position from lying or sitting to standing - orthostatic hypotension what two cultural groups are at the highest risk for hypertension - african americans, spanish (mexicans/cuban/filipino) dullness when percussing over the heart is - an abnormal finding that could indicate an enlarged heart. the third heart sound (S3) is heard - immediately after S2. S3= kentucky the fourth heart sound (S4) is heard - immediately before S1 S4= there are 4 e's in tenessee what is happening when S1 is heard? - tricuspid and mitral (AV) valves are closing. begins systole what is happening when S2 is heard? - aortic and pulmonic (semilunar) valves are closing. end of systole and beginning of diastole. when would the nurse hear S3 - when AV (tricuspid & mitral) valves open, blood flow into ventricles may vibrate during mid-diastole, termed ventricular gallop. when would the nurse hear S4 - before S1, termed atrial gallop. what is the significance of S3 - may indicate heart failure or fluid overload. what is the significance of S4 - may indicate hypertension or ventricular hypertrophy at erb's point you can hear - S1 and S2 equally at the aortic and pulmonic valves you can hear - S2 at the mitral valve you can hear - S1 (PMI) aortic stenosis - murmur at aortic area. narrowing of the aortic valve. may be congenital or caused by atherosclerosis mitral stenosis - murmur heard at the apical area with the client in the left lateral position. possible causes is rheumatic fever or cardiac infection. ventricular hypertrophy - occurs due to pumping against high pressures myocardial ishcemia - oxygen needs of the myocardium are not met as the heart works harder. may be caused by plaque or blood clot. need to assess client for type of pain and associated factors including nausea, epigastric pain, jaw or left shoulder pain. pulmonary stenosis - narrowing of the opening between the pulmonary artery and the right ventricle. may have murmur at pulmonic area and a thrill in the left second and third intercostal space. congestive heart failure - caused by hearts inability to pump effectively infective endocarditis - may see splinter hemorrhage of nail beds. caused by a bacterial infection to the lining of the heart chanbers. tricuspid stenosis - narrowing of the tricuspid valve. murmur over the tricuspid area aortic regurgitation - back flow of blood from the aorta into the left ventricle. murmur with the client leaning forward. may result in shortness of breath and fatigue. left sided heart failure - results in pulmonary congestion, shortness of breath, and orthopnea. crackles may be heard on auscultation. cor pulmonale - complication of untreated heart failure. results in JVD, peripheral edema, fluid retention and weight gain. may have clubbing. mitral regurgitation - back flow of blood from left ventricle into left atrium. murmur at apex transmitted to left axillae. pulmonary edema - fluid accumulation can cause severe shortness of breath, pink frothy sputum, coarse crackles that do not clear with cough, sense of doom. myocardia infarction - complete disruption of blood flow and oxygen to the myocardial tissue. may lead to death of cardiac tissue. symptoms include chest pressure, tightness, squeezing and shortness of breath. may radiate or have referred pain to the left neck, jaw or shoulder. pericardial friction rub - occurs due to inflammation of pericardial sac. ask client to hold breath to assess as compared to pleural issues. blood flow pathway - vena cava, right atrium, tricuspid valve, right ventricle, pulmonic valve, pulmonic artery, lungs for oxygenation. pulmonic veins, left atrium, mitral valve, left ventricle, aortic valve, aorta and to the body. preload - (stretch) end diastolic filling pressure afterload - (squeeze) amount of resistance the ventricles have to overcome to eject blood in systole blood pressure is - cardiac output times peripheral vascular resistance. during a physical assessment the patient should - start in upright position then proceed to supine with HOB at 45 when inspecting the precordium (anterior chest), abdomen, legs and skeletal structure: - note color, temperature of skin and presence of hair. observe precordium for any abnormal pulsation, pull, lifts or heaves. the jugular vein may be visible - when lying flat, should disappear when sitting. jugular vein distention (JVD) presents in - cor pulmonale (right heart failure) where should you palpate for PMI - mitral valve over apex myocardial ischemia or acute coronary syndrome - chest pain (angina), shortness of breath, diaphoresis. pain may be heavy, tight, squeezing, pressure. pain may be referred or radiate to jaw, shoulder, epigastric region. will result in myocardial infarction if not treated. heart failure - progressive weakening of heart as a pump. usually begins on left side. results in pulmonary congestion and shortness of breath. may progress to cor pulmonale, which results in JVD, peripheral edema, fluid retention and weight gain. effects of right sided heart failure (cor pulmonale) - JVD and peripheral edema. long term heart failure may have clubbing. need low sodium diet, daily weights. effects of left sided failure - pulmonary congestion and shortness of breath. stenotic valves do not: - fully open (narrowing) regurgant valves do not: - fully close what are septal defects - openings between the right and left atria or right and left ventricles. pleuritis - chest pain worse with breathing, shallow respirations, pleural rub. can have patient hold breath to rule out cardiac cause. apnea - absence of breathing eupnea - normal, good, unlabored ventilation dyspnea - difficulty breathing egophony - patient says "E" during auscultation. normal sounds like E. consolidation sounds like A. bronchophony - patient repeats "99" during auscultation. normal= muffled. consolidation= clear, loud. whispered pectoriloquy - patient whispers "1,2,3" normal = muffled. consolidation= clear. fremitus - a vibration felt by palpitation crackles - brief, discontinuous, popping lung sounds that are high-pitched, intermittent, nonmusical due to fluid. fine= crackling. coarse= bubbling.