NSE 103 FINAL EXAM QUESTIONS
WITH CORRECT DETAILED
ANSWERS (GRADED A+)
What are the normal findings for jugular vein assessment? - Answer- Right external
jugular vein is flat with no distension. Double diffuse pulsation of right internal jugular
vein at sternal notch."
where is the external jugular vein located? - Answer- superficial to sternocleidomastoid
where is the internal jugular vein located? - Answer- deep to the sternocleidomastoid
muscle; seen in the sternal notch when supine
are distended/bulging jugular veins a critical finding? - Answer- yes
distended jugular veins may be caused by - Answer- heart failure
pulmonary hypertension
tricuspid valve stenosis/prolapse
what other cues are typically associated with distended/bulging jugular veins? - Answer-
heart palpitations
chest pain
tachycardia
perspiration
dyspnea
other signs of respiratory distress
what should you do if a patient has distended jugular veins? - Answer- determine the
cause, keep client stabilized
notify the physician
monitor vitals
,auscultate valves to determine quality of blood flow & presence of murmurs
what is the precordium? - Answer- the region on the chest wall that overlays the heart
area
how do pulsations manifest when inspecting the precordium? - Answer- as flickers
observed on the skin of the chest wall
are pulsations of the chest wall concerning? what does it suggest? - Answer- yes,
unless the client is very thin
suggests increased cardiac workload
what are heaves? - Answer- forceful movements observed on the skin over the chest
wall
what may cause heaves? - Answer- hypertension
valvular disease
septal defects
infarction
what do heaves suggest? - Answer- increased cardiac workload
enlarged heart
dissecting aorta
what are you looking for when palpating the precordium? - Answer- the presence of any
pulsations/vibrations
are pulsations/vibrations of the precordium concerning? - Answer- yes, suggests
turbulent blood flow
what are thrills? - Answer- vibrations produced by turbulent blood flow within the heart
(murmus)
thrills suggest - Answer- an incompetent valve
what should you do if you find thrills of the precordium? - Answer- conduct a full cardiac
assessment
take vitals
notify the physician
,how do you palpate for an apical pulse? - Answer- use finger pad, fifth intercostal space
at left midclavicular line
ask client to breath in & out
if you can't feel it, help them into a left lateral position
is it normal to not feel an apical pulse? - Answer- yes, in some clients
the apical pulse should be auscultated with the: - Answer- diaphragm of the stethoscope
what are you assessing when palpating the apical pulse? - Answer- bpm
rhythm
if the apical pulse has an irregular rhythm, what should you do? - Answer- check for a
pulse deficit
how do you check for a pulse deficit? - Answer- palpate the radial pulse at the same
time, note if they are unequal
if they are, count the apical pulse for one minute, then the radial
then subtract the radial from the apical
each pulse deficit represents: - Answer- a time the heart has contracted, but the blood is
not being perfused to the periphery
a pulse deficit of more than _____ should be investigated further, particularly when
associated with _______________ - Answer- 10
other symptoms
what should you do if the client has a pulse deficit? - Answer- conduct a full cardiac
assessment unless the client is showing signs of clinical deterioration
when auscultating the cardiac valves, if you have specific concerns, you should also
listen for murmurs in the _______________________ - Answer- in the left lateral
position & sitting position with the client leaning forwards slightly
when auscultating the cardiac valves, you should auscultate with: - Answer- both the
bell & diaphragm
what are heart murmurs? - Answer- abnormal heart sounds produced by abnormal
blood flow in the heart
, what health promotion is associated with the cardiac system? - Answer- smoking
diet
activity
sleep
stress
weight & BP
what is peripheral vascular disease? - Answer- group of diseases affecting arteries &
veins in the arms, legs, & abdominal area
what is atherosclerosis? - Answer- build up of plaque on arterial walls
what is venous stasis - Answer- collection or pooling of blood in the veins, typically in
the legs
what are varicose veins? - Answer- big, twisty veins near the skin's surface that are
caused by weakened valves
peripheral arterial issues are related to ______________________, while peripheral
venous issues are related to _______________ - Answer- problems with perfusion in
the arteries due to a blockage (restricted blood flow)
venous insufficiency
what are spider veins? - Answer- smaller red, purple, or blue veins that are easily seen
through the skin and a twisting in nature
venous pain manifests as ___________, while arterial pain is ___________ - Answer- a
dull, achy pain - full or heavy feeling
sharp pain relieved with rest
what is claudication? - Answer- a type of pain that happens with activity, caused by a
lack of oxygen to the tissues
typically related to arterial insufficiency
what is gangrene? - Answer- death of tissue; can occur when tissue does not receive
oxygen supply due to occlusion in the arterial vasculature
what is dependent edema? - Answer- type of edema that is worse while standing or
when the legs/feet are below the heart level. it improves when the legs/feet are
elevated.
is rapid weight gain in 24 hours concerning? why? - Answer- yes - requires immediate
attention
WITH CORRECT DETAILED
ANSWERS (GRADED A+)
What are the normal findings for jugular vein assessment? - Answer- Right external
jugular vein is flat with no distension. Double diffuse pulsation of right internal jugular
vein at sternal notch."
where is the external jugular vein located? - Answer- superficial to sternocleidomastoid
where is the internal jugular vein located? - Answer- deep to the sternocleidomastoid
muscle; seen in the sternal notch when supine
are distended/bulging jugular veins a critical finding? - Answer- yes
distended jugular veins may be caused by - Answer- heart failure
pulmonary hypertension
tricuspid valve stenosis/prolapse
what other cues are typically associated with distended/bulging jugular veins? - Answer-
heart palpitations
chest pain
tachycardia
perspiration
dyspnea
other signs of respiratory distress
what should you do if a patient has distended jugular veins? - Answer- determine the
cause, keep client stabilized
notify the physician
monitor vitals
,auscultate valves to determine quality of blood flow & presence of murmurs
what is the precordium? - Answer- the region on the chest wall that overlays the heart
area
how do pulsations manifest when inspecting the precordium? - Answer- as flickers
observed on the skin of the chest wall
are pulsations of the chest wall concerning? what does it suggest? - Answer- yes,
unless the client is very thin
suggests increased cardiac workload
what are heaves? - Answer- forceful movements observed on the skin over the chest
wall
what may cause heaves? - Answer- hypertension
valvular disease
septal defects
infarction
what do heaves suggest? - Answer- increased cardiac workload
enlarged heart
dissecting aorta
what are you looking for when palpating the precordium? - Answer- the presence of any
pulsations/vibrations
are pulsations/vibrations of the precordium concerning? - Answer- yes, suggests
turbulent blood flow
what are thrills? - Answer- vibrations produced by turbulent blood flow within the heart
(murmus)
thrills suggest - Answer- an incompetent valve
what should you do if you find thrills of the precordium? - Answer- conduct a full cardiac
assessment
take vitals
notify the physician
,how do you palpate for an apical pulse? - Answer- use finger pad, fifth intercostal space
at left midclavicular line
ask client to breath in & out
if you can't feel it, help them into a left lateral position
is it normal to not feel an apical pulse? - Answer- yes, in some clients
the apical pulse should be auscultated with the: - Answer- diaphragm of the stethoscope
what are you assessing when palpating the apical pulse? - Answer- bpm
rhythm
if the apical pulse has an irregular rhythm, what should you do? - Answer- check for a
pulse deficit
how do you check for a pulse deficit? - Answer- palpate the radial pulse at the same
time, note if they are unequal
if they are, count the apical pulse for one minute, then the radial
then subtract the radial from the apical
each pulse deficit represents: - Answer- a time the heart has contracted, but the blood is
not being perfused to the periphery
a pulse deficit of more than _____ should be investigated further, particularly when
associated with _______________ - Answer- 10
other symptoms
what should you do if the client has a pulse deficit? - Answer- conduct a full cardiac
assessment unless the client is showing signs of clinical deterioration
when auscultating the cardiac valves, if you have specific concerns, you should also
listen for murmurs in the _______________________ - Answer- in the left lateral
position & sitting position with the client leaning forwards slightly
when auscultating the cardiac valves, you should auscultate with: - Answer- both the
bell & diaphragm
what are heart murmurs? - Answer- abnormal heart sounds produced by abnormal
blood flow in the heart
, what health promotion is associated with the cardiac system? - Answer- smoking
diet
activity
sleep
stress
weight & BP
what is peripheral vascular disease? - Answer- group of diseases affecting arteries &
veins in the arms, legs, & abdominal area
what is atherosclerosis? - Answer- build up of plaque on arterial walls
what is venous stasis - Answer- collection or pooling of blood in the veins, typically in
the legs
what are varicose veins? - Answer- big, twisty veins near the skin's surface that are
caused by weakened valves
peripheral arterial issues are related to ______________________, while peripheral
venous issues are related to _______________ - Answer- problems with perfusion in
the arteries due to a blockage (restricted blood flow)
venous insufficiency
what are spider veins? - Answer- smaller red, purple, or blue veins that are easily seen
through the skin and a twisting in nature
venous pain manifests as ___________, while arterial pain is ___________ - Answer- a
dull, achy pain - full or heavy feeling
sharp pain relieved with rest
what is claudication? - Answer- a type of pain that happens with activity, caused by a
lack of oxygen to the tissues
typically related to arterial insufficiency
what is gangrene? - Answer- death of tissue; can occur when tissue does not receive
oxygen supply due to occlusion in the arterial vasculature
what is dependent edema? - Answer- type of edema that is worse while standing or
when the legs/feet are below the heart level. it improves when the legs/feet are
elevated.
is rapid weight gain in 24 hours concerning? why? - Answer- yes - requires immediate
attention
