 Show
Chapter 31: Assessment of Cardiovascular System Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1.A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b.a cardiac catheterization. c.hourly blood pressure (BP) checks. d.electrocardiographic (ECG) monitoring. ANS:D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit. DIF:Cognitive Level: Apply (application)REF:668 TOP:Nursing Process: Planning MSC:NCLEX: Physiological Integrity 2.The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse? a.A right bundle-branch block.c.The QRS duration is 0.13 seconds. b. The PR interval is 0.21 seconds.d.The heart rate (HR) is 41 beats/min. ANS:D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches. DIF:Cognitive Level: Analyze (analysis)REF:662 TOP:Nursing Process: AssessmentMSC:NCLEX: Physiological Integrity 3.During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to a.ask about risk factors for atherosclerosis. b.determine family history of heart disease. c.assess for symptoms of left ventricular hypertrophy. d.auscultate carotid arteries for the presence of a bruit. ANS:C The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease. Why is this page out of focus?This is a Premium document. Become Premium to read the whole document. Why is this page out of focus?This is a Premium document. Become Premium to read the whole document. Why is this page out of focus?This is a Premium document. Become Premium to read the whole document. What is the transesophageal echocardiogram tee used for select all that apply?Transesophageal echocardiography (TEE) is an ultrasound technology that provides highly detailed images of the heart and its internal structures. Our heart experts use TEE to detect blood clots, evaluate heart valves, and guide treatment for arrhythmias (abnormal heartbeats) and many other heart conditions.
What techniques should the nurse use while assessing the heart sounds of a patient select all that apply?What techniques should the nurse use while assessing the heart sounds of a patient? Listen for friction rubs with the patient upright and leaning forward. Use the diaphragm of the stethoscope to listen to S 1 and S 2 sounds. Listen to S 3 and S 4 sounds (if present) with the bell of the stethoscope.
Which technique would the nurse use to assess for the presence of a pulse deficit?To assess for a pulse deficit, use the following steps: While auscultating the apical pulse, also palpate the radial pulse. You can usually do this at the same time and note whether they are equal. If they are unequal, count the apical pulse for one minute, and then count the radial pulse for one minute.
What position should the nurse place the patient in to Auscultate for signs of acute pericarditis?Auscultation with the diaphragm of the stethoscope over the left lower sternal edge or apex during end expiration with the patient sitting up and leaning forward (or on hands and knees) allows the best detection of the rub and increases the likelihood of observing this finding.
|
Which assessment is essential for the nurse to complete immediately following a tee?
zusammenhängende Posts
Urheberrechte © © 2024 defrojeostern Inc.
