Patient Assessment & Documentation Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
During a cardiovascular physical exam, which position best enhances auscultation of a mitral stenosis murmur?
Answer: Left lateral decubitus position
The left lateral decubitus position brings the cardiac apex closer to the chest wall, enhancing the low-pitched mid-diastolic rumble of mitral stenosis.
A patient's chart documents 'JVD at 45 degrees.' What does this assessment finding suggest?
Answer: Elevated central venous pressure indicating right heart failure
Jugular venous distension visible at 45 degrees indicates elevated CVP (above ~8 cmH2O), a sign of right heart failure or volume overload.
When documenting a murmur's intensity, a grade III/VI murmur is best described as:
Answer: Moderately loud without a palpable thrill
A Grade III murmur is moderately loud and easily heard but does not produce a palpable thrill (which begins at Grade IV).
Which finding on a 12-lead ECG is the most specific indicator of acute ST-elevation myocardial infarction requiring immediate documentation and action?
Answer: ST elevation ≥1 mm in two or more contiguous leads
ST elevation ≥1 mm in two or more contiguous leads is the diagnostic criterion for STEMI, triggering immediate reperfusion protocols.
A patient's cardiac catheterization report documents 'LVEDP of 28 mmHg.' How should this finding be interpreted and documented in the nursing assessment?
Answer: Elevated left ventricular end-diastolic pressure indicating diastolic dysfunction or heart failure
Normal LVEDP is 5–12 mmHg; a value of 28 mmHg indicates significantly elevated filling pressure consistent with diastolic dysfunction or heart failure.
When completing a functional assessment, a patient states they can walk one block but must stop due to chest pain. Which Canadian Cardiovascular Society (CCS) angina class applies?
Answer: Class III
CCS Class III angina is marked limitation of ordinary activity, including inability to walk more than one to two blocks on the level at normal pace.
Which documentation element is required by The Joint Commission to ensure safe handoff communication during a cardiovascular patient transfer?
Answer: Standardized SBAR or I-PASS handoff including current status, anticipated changes, and contingency plans
TJC requires structured handoff communication (SBAR/I-PASS) that includes patient status, background, assessment, and contingency planning to prevent information gaps.