Nursing Assessment: Cardiovascular System Case Study

3242 Words 13 Pages
Register to read the introduction… A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
DIF: Cognitive Level: Apply (application)
REF:
697
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. bell of the stethoscope with the patient in the left lateral position.
b. diaphragm of the stethoscope with the patient in a supine position.
c. bell of the stethoscope with the patient sitting and leaning forward.
d. diaphragm of the stethoscope with the patient lying flat on the left side.
ANS: A

Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2.
DIF: Cognitive Level: Apply (application)
REF:
697
TOP: Nursing Process:
…show more content…
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal

border. To document more information about the murmur, which action will the nurse take next? a. Find the point of maximal impulse.
b. Determine the timing of the murmur.

USTESTBANK.COM

c. Compare the apical and radial pulse rates.
d. Palpate the quality of the peripheral pulses.
ANS: B

Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best
(e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle
(e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is also important in the cardiac assessment but will not provide information that is relevant to the murmur.
DIF: Cognitive Level: Apply (application)
REF:
697
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
13. The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth

intercostal space and midclavicular line. How will the nurse record this information?
a. Systolic murmur heard at mitral

Related Documents