Sherpath: Chapter 20, Heart and Neck Vessels: Assessing the Heart

Question 1 of 16

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While inspecting the chest, the nurse observes unusual chest movements. Which assessment technique should the nurse perform next?

• • AuscultationAuscultation involves listening to the chest with a stethoscope and would be the final step in the physical examination process, after percussion.
• • InspectionThe nurse would inspect the chest as the initial step in the physical examination process.
• Correct
  • PalpationPalpation of the chest for lifts and heaves would follow the observation of unusual chest movements.
• • PercussionPercussion is an optional technique and usually follows palpation when it is performed.

Question 2 of 16

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Identify the area of the body where the nurse observes for lifts and heaves.

• Correct
  • PrecordiumThe precordium is the area of the body the nurse would observe for lifts and heaves.
• • Right internal jugular veinPulsations are observed when measuring the jugular veins for pressure, but they are not identified as lifts or heaves.
• • Epigastric regionPulsations will be observed in the epigastric area from the aorta, but this is not the area in which to identify lifts and heaves.
• • Carotid arteryThe carotid arteries can be palpated, and bruits may be heard using a stethoscope, but lifts and heaves are not identified in this area.

Question 3 of 16

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Put the steps the nurse uses to locate the point of maximal impulse (PMI) in the correct order.

1. Place patient in supine position.
2. Stand on patient’s right side.
3. Gently place palmar surface of fingers at the apex of the heart.
4. Have patient turn slightly to left side if unable to locate pulsation with patient in supine position.
5. Have a female patient displace her left breast to the side.

The supine position is the best position for observing the chest. The point of maximal impulse (PMI) is located at the apex of the heart, which is at the fifth intercostal space at the midclavicular line, best accessed from the right side of the patient. Gentle placement of the palmar surface of the fingers on the chest allows small pulsations to be felt. If the pulsation cannot be felt, the patient should be asked to turn slightly to the left side because this brings the heart closer to the chest wall. It will be helpful to have a female patient displace her left breast to make palpating the PMI easier.

Question 4 of 16

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Describe how the nurse uses palpation to ensure the identification of the first heart sound (S₁).

• • Using two fingers over the popliteal arteryThe cardiac pulsations can be felt by palpating the popliteal artery, but it is the not the location for palpating the first heart sound.
• • Using two fingers over the aortic and pulmonic valvesThe aortic and pulmonic areas are anatomical landmarks to auscultate, but the valves cannot be palpated from these areas.
• • Counting the beats from the popliteal artery and radial arteryCounting the beats from both the popliteal and radial arteries provides information about the heart rate, but it is difficult to identify the first heart sound from these arteries.
• Correct
  • Placing the hand over the carotid artery and point of maximal impulse (PMI)By simultaneously placing fingers of one hand over the carotid artery and fingers of the other hand over the PMI, the nurse can identify when the first heart sound (S₁) occurs. The beat of S₁ and pulsation of the carotid artery occur synchronously.

Question 5 of 16

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Describe how the nurse uses palpation to identify dextrocardia.

• Correct
  • Locate the point of maximal impulse (PMI)In a healthy, normal heart, the PMI is located to the left of the sternum, but in patients with dextrocardia, the apical pulsation is located to the right of the sternum.
• • Observe for presence of cyanosisCyanosis may be a minor sign of dextrocardia but is not identified by palpation.
• • Locate the borders of the heartIn patients with dextrocardia, the borders of the heart will be located to the right of the sternum instead of to the left, as in a normal heart. However, the heart borders are identified through percussion, not through palpation.
• • Identify the direction of the thrillAlthough a thrill may be noted in a patient with dextrocardia, it is not noted by its direction.

Question 6 of 16

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The nurse is palpating the base of the heart and identifies a fine rushing vibration. The nurse correctly documents this symptom as what?

• • Pericardial friction rubA pericardial friction rub results from inflammation of the pericardium and produces a scratchy or grating sound.
• Correct
  • MurmurA murmur result from turbulent blood flow through the heart and large vessels and is felt as a vibration.
• • GallopA gallop is an extra heart sound that is not felt but can be heard with the stethoscope.
• • Opening snapAn opening snap occurs when rigid heart valves pop open, producing a characteristic snapping sound.

Question 7 of 16

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Describe the technique for percussing the heart by placing the steps in the correct order.

1. Identify the third, fourth, and fifth intercostal spaces.
2. Place the middle finger of the nondominant hand on the surface to be percussed.
3. Curve the middle finger of the dominant hand.
4. Starting on the left, use a quick, sharp motion of the wrist and strike the middle finger of the nondominant hand.
5. Strike in one or two areas, then move on.
6. Listen for resonance to dullness.

First, the area to be percussed should be identified. The technique of percussion requires use of both hands. The nondominant hand is placed on the surface to be percussed. The middle finger of the dominant hand should be curved and used to gently strike the middle finger of the nondominant hand, starting from the left and using a quick motion of the wrist. A shift from resonance to dullness indicates the borders of the heart.

Question 8 of 16

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Which statement describes the limitations of using the percussion technique in physical examination?

• • Percussion is difficult to learn.Percussion is a skill that all nurses should learn for occasions when chest x-rays are not available. The difficulty of the technique should not preclude its use.
• • The percussion technique is not sensitive enough to detect changes in heart size.The percussion technique, when executed correctly, can identify the heart borders accurately enough to determine changes in heart size.
• Correct
  • The heart conforms to the chest’s shape, making it difficult to assess heart size.The heart is moldable and conforms to the chest’s shape, which makes identification of true heart size difficult to assess.
• Correct
  • Fluid or air can distort findings.Fluid and air in the lungs can distort the resonant and dull sounds necessary to identify the borders of the heart.
• • Enlargement of the right ventricle occurs laterally.Enlargement of the right ventricle does not occur laterally, which would help to define the borders better. The enlargement occurs in the anteroposterior position.

Question 9 of 16

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Using percussion, the nurse identifies the cardiac border by a change from a _____ to a _____ note.

• • Flat; dullA flat note has a very dull quality and sound and is typically produced over a muscle. A dull note has a thud-like quality similar to the sound produced over the liver.
• Correct
  • Resonant; dullThe heart borders are identified by a shift from a resonant to a dull sound. Percussion should begin with a resonant sound (loud and hollow, as over normal, healthy lung tissue) because it is easier to identify. A dull note has a thud-like quality similar to the sound produced over the liver.
• • Hyperresonant; tympanicHyperresonant and tympanic are not the normal notes heard over the cardiac borders.
• • Split; fixedSplit fixed is a heart sound that is heard as a complication of the heart valve opening, not at the border of the heart.

Question 10 of 16

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Match the auscultatory landmark with its anatomic location.

• Tricuspid area
• Second pulmonic area
• Pulmonic
• Aortic

Question 11 of 16

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The nurse is having trouble auscultating the apical impulse of an obese patient. Which action by the nurse would improve this assessment?

• • Have the patient lie supine.Lying supine will cause the heart to fall farther away from the chest wall and make auscultation more difficult.
• Correct
  • Have the patient lean forward.Leaning forward during auscultation brings the apex of the heart closer to the chest wall, improving the ability to auscultate heart sounds.
• • Tell the patient to take a deep breath and hold it.Having the patient to hold his or her breath will not improve the quality of heart sounds during auscultation.
• • Place the stethoscope over the epigastrum.The mitral area is the apex of the heart, which is the same location as the apical impulse. The area over the epigastrum is the incorrect location for ausculation of the apical impulse.

Question 12 of 16

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Identify the area where the mitral valve should be auscultated.

• • Second intercostal space to the left of the sternumThe second intercostal space to the left of the sternum is for auscultation of location for auscultation of the pulmonic area.
• • Second intercostal space to the right of the sternumThe second intercostal space to the right of the sternum is the location for auscultation of the aortic area.
• • Fourth intercostal space along the lower left sternumThe fourth intercostal space along the lower left sternum is the area for auscultation of the tricuspid area.
• Correct
  • Fifth intercostal space at the midclavicular lineThe mitral valve is located between the left atria and left ventricle. The mitral valve is located at the apex of the heart. The point of maximal impulse can be identified at the apex.

Question 13 of 16

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The nurse is auscultating heart sounds of a patient with heart-related symptoms. The nurse understands that the bell of the stethoscope is best used for auscultating what heart sounds?

• • High-pitched heart soundsBreath sounds are high-pitched and best heard with the diaphragm.
• Correct
  • Low-pitched heart soundsHeart sounds are usually low-pitched and best heard with the bell of the stethoscope.
• • High-pitched heart murmursHigh-pitched murmurs are best heard with the diaphragm of the stethoscope.
• • Closure of the tricuspid and mitral valvesClosure of the tricuspid and mitral valves is usually higher pitched and best heard with the diaphragm of the stethoscope.

Question 14 of 16

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The nurse assesses a patient with abnormal heart sounds. This symptom is correctly documented as the third heart sound (S₃) because it is low-pitched and located at which area of the heart?

• Correct
  • ApexS₃ is a low-pitched sound and is heard at the apex of the heart.
• • Entire pericardiumThe first heart sound is high-pitched and can be auscultated over the entire pericardium.
• • Second right intercostal spaceThe second heart sound is high-pitched and is heard at the second right intercostal space or aortic area.
• • Second left intercostal spaceThe second heart sound is high-pitched and can also be heard in the second left intercostal space.

Question 15 of 16

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When auscultating the heart sounds, the nurse makes note of what qualities of the auscultated sounds?

• Correct
  • PitchThe pitch is noted as high or low and depends on the pressure and rate of blood flow.
• Correct
  • RhythmThe rhythm may be regular or irregular.
• Correct
  • LocationLocation of the sound relates to the anatomical landmarks, or the areas where valve closure can be heard.
• Correct
  • TimingThe timing of murmurs should be noted, including whether the murmur is heard during early systole or early diastole.
• • FrequencyAlthough frequency may relate to timing and duration of the heart sounds, it is not a quality of heart sounds that is noted.

Question 16 of 16

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Why is it vital to identify the baseline rate and rhythm of the heart?

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  • To identify tachycardia or bradycardiaSome patients will have a normally irregular rhythm. Identifying the baseline rate and rhythm will allow changes to be more accurately identified. A change in the rate will identify tachycardia or bradycardia.
• • To measure cardiac outputIdentification of the baseline rate and rhythm may indicate how well the heart is beating but will not determine cardiac output.
• • To identify the first heart sound (S₁)The first heart sound can be auscultated over the mitral and tricuspid areas. Identification of the baseline rate and rhythm is not necessary to identify this sound.
• Correct
  • To identify dysrhythmiasSome patients will have a normally irregular rhythm. Identifying the baseline rate and rhythm will allow changes to be more accurately identified. An irregular rhythm may signal an arrhythmia.