NSG 316 EXAM 3 HEALTH ASSESSMENT REVIEW EXAM(LATEST UPDATE |VERIFIED EXAM QUESTIONS AND CORRECT ANSWERS|ALL GRADED A+|GUARANTEED SUCCESS

NSG 316 EXAM 3 HEALTH ASSESSMENT REVIEW EXAM(LATEST UPDATE |VERIFIED EXAM QUESTIONS AND CORRECT ANSWERS|ALL GRADED A+|GUARANTEED SUCCESS Myocardium - ANSWER-heart muscle that surrounds ventricles and atrium Atria are thinner as they need to pump less strong pericardium - ANSWER-external layer that protects heart from injury/infection endocardium - ANSWER-3 layered membrane that lines heart chambers blockage of coronary arteries can lead to - ANSWER-heart attack or stroke heart failure - ANSWER-increased pressure of cardiac overload -pulm congestion -inc amount of blood in pulm capillaries Left sided heart failure - ANSWER-dyspnea/SOB, pulmonary edema right sided heart failure - ANSWER-blood back up in the periphery and will present with edema cardiomegaly - ANSWER-abnormal enlargement of the heart due to over working to compensate for decreased function frequency - ANSWER-high pitched or low pitched what should you use the diaphragm of a stethoscope for - ANSWER-high pitched, normal sounds what should you use the bell of a stethoscope for - ANSWER-low pitched, abnormal heart sounds, murmurs intensity/loudness - ANSWER-loud or soft duration - ANSWER-short heart sounds, or silent periods timing - ANSWER-systole or diastole carotid artery/pulse - ANSWER-found in the neck. feel one at a time. S1 is felt what is the most diminished pulse in the aging adult - ANSWER-pedal pulse normal heart sounds - ANSWER-S1 and S2 S1 heart sound - ANSWER--occurs with closure of mitral and tricuspid valves (AV valve) -"lub" sound -loudest at apex (5th intercostal space at midclavicular line) S2 heart sound - ANSWER--occurs with closure of aortic and pulmonic valves (semilunar valves) -"dub" sound -loudest at base of heart (2nd intercostal space) abnormal heart sounds - ANSWER-S3 and S4 sounds, murmurs, and bruits S3 heart sounds - ANSWER--not usually heard -gallop sound -indication of HF -occurs with ventricular resistance of filling S4 heart sounds - ANSWER--create vibrations -can be heard right before S1 sound -occurs at end of diastole when ventricles resist filling murmurs - ANSWER--from turbulent blood flow -heard directly over heart -gentle blowing/swooshing sound murmur loudness scale - ANSWER-1-3: no thrill 4: feel thrill 5-6: feel and hear thrill 5: hear thrill through stethoscope 6: can hear thrill without stethoscope timing of murmur - ANSWER-early, middle, late, systole/diastole (S1/S2) murmur pitch - ANSWER-high, medium, low murmur pattern - ANSWER-grows louder or softer murmur quality - ANSWER-musical, flowing, harsh murmur location - ANSWER-valve/space it is heard at murmur radiation - ANSWER-down with blood flow murmur posture - ANSWER-disappear/enhance with different pos. systolic murmur - ANSWER--heard in between S1 and S2 -Mitral/Tricuspid stenosis/regurgitation, mitral valve prolapse diastolic murmur - ANSWER--heard between S2 and S1 -Atrial/pulmonic stenosis/regurgitation bruits - ANSWER-swishing sound heard over arteries carotid artery - ANSWER-Timing closely coincides with ventricular systole. Document wave form. Should be sitting with assessment jugular veins - ANSWER-look for pulsations, distinguish between internal jugular and carotid artery as they can be easily confused heave/lift - ANSWER--sustained forceful thrusting of ventricle during systole -obvious/visible movement of chest -felt best with heal of hand at sternal border thrill - ANSWER-palpable vibratory sensation felt on aspects of 4 fingers. audible with stethoscope. exaggerated heart murmurs thrill cause - ANSWER-tin blood flow in the heart from valve disease/congenital heart failure auscultation of heart (locations) - ANSWER-Z formation -Aortic: 2nd intercostal space on right sternal border -Pulmonic: 2nd intercostal space on left sternal border -Erb's pt: tricuspid area (3rd intercostal space on left) -Tricuspid: 4th intercostal space on left side -Mitral: 5th intercostal space, midclavicular line apical pulse - ANSWER-near the apex of the heart; 5th intercostal, midclavicular line doppler ultrasonic probe - ANSWER-Use this device to detect a weak peripheral pulse (dorsalis pedis) locate pulse site by the swishing, whooshing sound how to detect skin changes in darker skinned people - ANSWER-expect feet to be darker; look at soles of feet allen test - ANSWER-evaluates patency of the radial and ulnar arteries Occlude radial /ulnar arteries and have person make fist, release, palpate to feel blood flow cardiac factors (assessment) - ANSWER--Nutrition: usual weight, changes, basic food groups, additives, calorie intake, cholesterol -Smoking -Meds: OTCs, antihypertensives, beta blockers, Ca channel blocker, digoxin, diuretics, aspirin/anticoagulant -Alcohol -Exercise -Env. -Fam hx how to document murmur - ANSWER-how it sounds, when it was heard, was it heard continuously, quality of sound, low/high pitch, intensity (how loud, use grade I-VI), where it sounds. Occurs when velocity of blood increases (exercise and thyrotoxicosis), viscosity of blood decreases (anemia) structural defects in valves - ANSWER-narrowed valve/ incomplete valve peripheral vascular system in aging adult - ANSWER--vessels become more rigid (arteriosclerosis) -DP and PT pulses may become more difficult to find -Arterial insufficiency -Loss of lymphatic tissue, fewer lymph nodes, decreased size of nodes peripheral vascular system assessment - ANSWER--examine arms, edema, DVT, injury, cap refill -compare both extremities -legs deep vein thrombosis - ANSWER-blood clot forms in a large vein, usually in a lower limb acute (14 days) with unilateral pain chronic venous stasis - ANSWER-brown discoloration. deposits of RBC degradation chronic arterial deficit causes - ANSWER-ulcers on the toes peripheral vascular system inspection - ANSWER--ask pt to stand to assess venous flow -note varicose veins, swelling, fatigue and color changes