D443 Health Assessment - Set 4 - Part 2

Correct Answer: Aortic area

The aortic area is auscultated at the second intercostal space at the right sternal border. The pulmonic area is directly across at the second intercostal space at the left sternal border. Erb's point is at the third left intercostal space, the tricuspid area is at the fourth or fifth left intercostal space near the sternum, and the mitral (apical) area is at the fifth intercostal space at the midclavicular line.

Correct Answer: Third intercostal space, left sternal border

Erb's point is located at the third intercostal space at the left sternal border. It is a useful listening post where both S1 and S2 are often heard equally well, and murmurs of both aortic and pulmonic origin may radiate to this area. The third left intercostal space defines Erb's point.

Correct Answer: Closure of the mitral and tricuspid (atrioventricular) valves

The first heart sound, S1, is produced by the closure of the atrioventricular valves, the mitral and tricuspid valves, at the beginning of ventricular systole. It marks the start of systole and is loudest at the apex. The second heart sound, S2, results from closure of the semilunar (aortic and pulmonic) valves at the end of systole.

Correct Answer: The bell of the stethoscope at the apex with the patient in the left lateral position

An S3 is a low-pitched sound occurring in early diastole just after S2, produced by rapid ventricular filling into a noncompliant or volume-overloaded ventricle, as in heart failure. Because it is low-pitched, it is best detected with the bell of the stethoscope applied lightly at the apex with the patient turned to the left lateral decubitus position, which brings the ventricle closer to the chest wall.

Correct Answer: Fifth intercostal space at the left midclavicular line

The point of maximal impulse, also called the apical impulse, is normally palpated at the fifth intercostal space at the left midclavicular line, where the apex of the left ventricle contacts the chest wall. Displacement of the PMI laterally and downward suggests left ventricular enlargement or cardiomegaly.

Correct Answer: A noncompliant, stiff ventricle as in ventricular hypertrophy

An S4, or atrial gallop, occurs late in diastole just before S1 and is produced when the atria contract to force blood into a stiff, noncompliant ventricle. It is commonly associated with conditions that reduce ventricular compliance, such as long-standing hypertension causing left ventricular hypertrophy, aortic stenosis, and coronary artery disease. An S4 is generally considered abnormal in adults.

Correct Answer: A murmur

A murmur is a prolonged, blowing or swishing sound caused by turbulent blood flow within the heart, typically across a diseased, incompetent, or stenotic valve, or through an abnormal opening. Murmurs are graded on intensity from 1 to 6. A pericardial friction rub is a grating sound from inflamed pericardial surfaces, and a bruit is heard over a peripheral artery.

Correct Answer: Normal pulse

On the common 0 to 4+ pulse grading scale, 0 indicates an absent pulse, 1+ indicates a weak or thready pulse, 2+ indicates a normal pulse, 3+ indicates an increased or full pulse, and 4+ indicates a bounding pulse. Documenting a pulse as 2+ therefore communicates a normal, expected amplitude.

Correct Answer: This prolonged refill suggests decreased peripheral perfusion

Normal capillary refill time is generally 2 seconds or less; the return of color reflects adequate peripheral arterial perfusion. A refill time greater than about 2 to 3 seconds, as in this patient with a 5-second refill, is prolonged and suggests decreased perfusion from causes such as hypovolemia, shock, hypothermia, or peripheral arterial disease.

Correct Answer: Arterial (peripheral) insufficiency

Arterial insufficiency results from inadequate arterial blood supply to the tissues. Characteristic findings include cool, pale, shiny, hairless skin; thickened brittle nails; diminished or absent pulses; and pain (intermittent claudication) that worsens with activity and with leg elevation, and improves with dependency. Venous insufficiency instead causes warm, brownish skin, edema, and aching that improves with elevation.

Correct Answer: Venous insufficiency

Chronic venous insufficiency results from impaired venous return, leading to blood pooling in the lower extremities. Typical findings include dependent edema; warm skin; brownish hyperpigmentation from hemosiderin deposition; and irregularly shaped ulcers located near the medial malleolus. Arterial ulcers, by contrast, are pale, dry, and painful, with well-defined edges typically over toes or pressure points.

Correct Answer: To evaluate the patency of the ulnar artery and collateral circulation to the hand

The Allen test assesses the adequacy of collateral circulation to the hand, specifically confirming that the ulnar artery can supply the hand if the radial artery is compromised. The examiner compresses both the radial and ulnar arteries, has the patient clench and open the hand to blanch it, then releases the ulnar artery and observes for return of color within several seconds. Adequate refill confirms ulnar patency and makes radial artery puncture safer.

Correct Answer: 3+ pitting edema

Pitting edema is commonly graded on a 1+ to 4+ scale based on the depth of the indentation and how quickly it rebounds. Approximate depths are 1+ (about 2 mm), 2+ (about 4 mm), 3+ (about 6 mm, deeper with a slower rebound), and 4+ (about 8 mm, very deep and persistent). A 6-millimeter depression that is slow to rebound corresponds to 3+ pitting edema.

Correct Answer: Increased work of breathing and respiratory distress

During normal quiet breathing, the diaphragm and external intercostal muscles perform most of the work, and accessory muscles are not visibly active. Recruitment of accessory muscles such as the sternocleidomastoid and scalenes, along with retractions, signals increased work of breathing and respiratory distress, seen in conditions such as asthma exacerbation, COPD, and severe pneumonia.

Correct Answer: Cheyne-Stokes respirations

Cheyne-Stokes respiration is a cyclic pattern in which breaths gradually increase in depth and then gradually decrease, followed by a period of apnea before the cycle repeats. It is associated with severe heart failure, brain injury, and the dying process. Kussmaul respirations are deep and rapid, seen in metabolic acidosis, and Biot respirations are irregular with unpredictable pauses.

Correct Answer: Pleural friction rub

A pleural friction rub is a superficial, grating or creaking sound produced when inflamed, roughened parietal and visceral pleural surfaces rub together during breathing. It is heard during both inspiration and expiration, is loudest over the lower anterolateral chest, does not clear with coughing, and is often accompanied by sharp, localized pleuritic pain.

Correct Answer: Turbulent blood flow, often from arterial narrowing

A bruit is a blowing or swishing sound heard with the stethoscope over a peripheral artery, such as the carotid, and it reflects turbulent blood flow. Turbulence commonly results from narrowing of the artery due to atherosclerotic plaque, which disrupts the normally smooth laminar flow. Detecting a carotid bruit warrants further evaluation for stenosis and stroke risk.

Correct Answer: An exaggerated drop in systolic blood pressure of more than 10 mmHg during inspiration

Pulsus paradoxus is an exaggerated fall in systolic blood pressure of more than 10 mmHg during inspiration. Normally systolic pressure drops slightly with inspiration, but conditions such as cardiac tamponade, severe asthma, and constrictive pericarditis exaggerate this decline. A pulse alternating strong and weak is pulsus alternans, a different finding.

Correct Answer: Whispered pectoriloquy, suggesting consolidation

Whispered pectoriloquy is the clear, distinct transmission of whispered words heard through the stethoscope over the chest. Normally whispered sounds are faint and muffled because air-filled lung dampens them, but consolidated lung, as in pneumonia, transmits high-frequency whispered sounds clearly. Clearly audible whispered speech indicates dense, consolidated tissue.

Correct Answer: An underlying problem such as atelectasis or pneumonia on the lagging side

To assess thoracic expansion, the nurse places the thumbs along the spine at about the tenth rib and watches them move apart symmetrically as the patient inhales deeply. Symmetric movement is normal. Asymmetric or delayed expansion, where one side lags, indicates a localized problem on the affected side such as atelectasis, pneumonia, pleural effusion, or splinting from pain.