LA#4 (Cardio) Chapters 34, 35, 36, 43 in Med Surg Flashcards Preview

Nursing Practice 3 > LA#4 (Cardio) Chapters 34, 35, 36, 43 in Med Surg > Flashcards

Flashcards in LA#4 (Cardio) Chapters 34, 35, 36, 43 in Med Surg Deck (147)
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1

While monitoring a patient’s cardiac activity, the nurse recognizes that stimulation of which of the following is a normal physiological mechanism responsible for an increase in heart rate (HR) and force of cardiac contractions?
a. The vagus nerve
b. Baroreceptors in the aortic arch and carotid sinus
c. α-Adrenergic receptors in the vascular system
d. Chemoreceptors in the aortic arch and carotid body

ANS: D
Chemoreceptors located in the aortic arch and carotid body are capable of initiating changes in HR and arterial pressure in response to decreased arterial O2 pressure, increased arterial carbon dioxide pressure, and decreased plasma pH.

2

While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. Which of the following does the nurse anticipate that the patient may require?
a. Hourly blood pressure (BP) checks
b. A coronary arteriogram
c. Electrocardiographic (ECG) monitoring
d. A two-dimensional echocardiogram

ANS: C
Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that dysrhythmias might be detected with ECG monitoring.

3

A patient has a BP of 142/84 mm Hg. The nurse will calculate and document the patient’s mean arterial pressure (MAP) as being which following amount?
a. 103 mm Hg
b. 113 mm Hg
c. 123 mm Hg
d. 131 mm Hg

ANS: A
MAP = Diastolic BP + 1/3 Pulse pressure.

4

The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. Which symptom has the most immediate implications for the patient’s care during the exercise testing?
a. BP rising from 134/68 to 150/80 mm Hg
b. HR increasing from 80 to 96 beats/min
c. Patient complaining of feeling short of breath
d. ECG indicating the presence of coronary ischemia

ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST-segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately.

5

During physical examination of a 56-year-old man, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the midclavicular line. What is the most appropriate interpretation of this finding?
a. The PMI is in the normal location.
b. The patient may have left ventricular hypertrophy.
c. The patient has age-related downward displacement of the heart.
d. The patient should be observed for signs of left atrial enlargement.

ANS: B
The PMI should be felt at the intersection of the fifth intercostal space and the midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy.

6

To auscultate for extra heart sounds in the mitral area, with what part of the stethoscope will the nurse listen?
a. The bell of the stethoscope with the patient in the left lateral position
b. The diaphragm of the stethoscope with the patient in a reclining position
c. The diaphragm of the stethoscope with the patient lying flat on the left side
d. The bell of the stethoscope with the patient sitting and leaning to the right 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.

7

The standard orders on the cardiac unit state, “Notify the physician for MAP less than 70 mm Hg.” For which patient would the nurse call the physician?
a. The patient with left ventricular failure who has a BP of 110/70 mm Hg
b. The patient with a myocardial infarction who has a BP of 114/50 mm Hg
c. The postoperative patient with a BP of 116/42 mm Hg
d. The newly admitted patient with a BP of 122/60 mm Hg

ANS: C
The MAP is calculated using the formula MAP = (Diastolic BP + 1/3 Pulse Pressure). The MAP for the postoperative patient in C is 67 mm Hg. The MAP in the other three patients is higher than 70 mm Hg.

8

During physical examination of a 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. How will the nurse interpret this finding?
a. Normal assessment data in a thin person
b. Sclerosis and inelasticity of the aorta
c. A possible abdominal aortic aneurysm
d. Evidence of elevated systemic arterial pressure

ANS: A
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals.

9

A patient is scheduled for cardiac catheterization with coronary angiography. Before the test, about which of the following should the nurse inform the patient?
a. A catheter will be inserted into a vein in the arm or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias.
c. A feeling of warmth and a fluttering sensation may be experienced as the catheter is advanced.
d. Complications of the test include breaking of the catheter, air or blood embolism, and puncture of the ventricles.

ANS: C
A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can produce anxiety unless it has been discussed with the patient.

10

Which of the following is a normal cardiac index (CI) assessment finding?
a. 2 L/min
b. 3 L/min/m2
c. 6 L/min
d. 8 L/min/m2

ANS: B
The normal range for a CI reading is 2.8 to 4.2 L/min/m2.

11

What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter monitor to do?
a. Remove the electrodes to shower or bathe.
b. Exercise as much as possible while his monitor is in place.
c. Keep a diary of his activities as long as he wears the monitor.
d. Attach the recorder, and call the assigned number if an episode of irregular heartbeats occurs.

ANS: C
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities.

12

When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. How will the nurse document this finding?
a. Bruit
b. Thrill
c. Heave
d. Arterial obstruction

ANS: A
A bruit is the sound created by turbulent blood flow in an artery.

13

The physician orders serum troponin levels in a patient with a possible myocardial infarction. What will the nurse explain to the patient about this test?
a. It is the most specific indicator for myocardial damage available.
b. It measures the amount of myoglobin released from damaged myocardial cells.
c. It can provide evidence of myocardial damage more quickly than can enzyme tests.
d. It is diagnostic for myocardial damage only when used in combination with creatinine kinase-MB isoenzymes.

ANS: C
Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium.

14

Which of the following is a normal age-related change in the heart?
a. Increased elastin
b. Decreased collagen
c. Decreased cardiac output
d. Increased stroke volume

ANS: C
A normal age-related change in the heart is a decrease in cardiac output. Elastin and stroke volume are decreased, and collagen is increased.

15

The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. What is the best way to record this information?
a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”

ANS: A
The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur.

16

What should the nurse expect as a possible etiology in a patient who exhibits a positive Homans sign?
a. Thyrotoxicosis
b. Thrombophlebitis
c. Incompetent valves
d. Intermittent claudication

ANS: B
The nurse should suspect thrombophlebitis in a patient who exhibits a positive Homans sign.

17

Upon auscultation, the nurse identifies an arterial bruit. What is a possible cause?
a. Cardiac dysrhythmias
b. Aneurysm
c. Pericarditis
d. Cardiac valve disorder

ANS: B
An arterial bruit is suggestive of wither an aneurysm or an arterial obstruction.

18

The registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student does which of the following?
a. Presses on the skin over the tibia for 10 seconds to check for edema
b. Palpates both carotid arteries simultaneously to compare pulse quality
c. Places the patient in the left lateral position to check for the PMI
d. Uses the palm of the hand to assess extremity skin temperature

ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not dangerous to the patient.

19

A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse explains that Holter monitoring provides information about which of the following?
a. Ventricular ejection fraction during usual daily activities
b. Cardiovascular response to high-intensity exercise
c. Changes in cardiac output when the patient is resting
d. HR and rhythm during normal patient activities

ANS: D
Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level.

20

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?
a. Make the patient nothing by mouth (NPO) status.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.

ANS: A
The patient will need to be NPO status for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received.

21

Which one of the following central venous pressure (CVP) readings would the nurse report to the physician as being abnormal?
a. 3 mm Hg
b. 6 mm Hg
c. 9 mm Hg
d. 12 mm Hg

ANS: D
The normal CVP reading is 2 to 9 mm Hg.

22

A new patient is seen at an outpatient clinic for a routine health examination. During the patient’s initial visit, which technique would the nurse use to assess the patient’s blood pressure (BP)?
a. Have the patient sit with the arm supported at heart level, and measure the BP in each arm first.
b. Average all the BP readings obtained in both arms to establish a baseline BP for the patient.
c. Measure the first BP with the patient lying supine, and repeat the measurement in 5 minutes in the opposite arm.
d. Take additional measurements if there is a difference of more than 10 mm Hg between the first and second BP readings.

ANS: A
To obtain the baseline BP, the patient’s arm should be at the level of the heart. The BP is obtained in both arms; if there is a difference, the arm with the higher pressure should be used to monitor BP.

23

The nurse assesses the risk factors for hypertension in a patient with high normal BP. Which risk factor would the nurse identify from the health history and advise the patient to change, in order to prevent hypertension?
a. Little or no regular exercise
b. No use of relaxation techniques
c. High dietary intake of simple sugars
d. Drinking wine with dinner once a week

ANS: A
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week.

24

The nurse measures the BP of a 78-year-old patient and finds it to be 168/86 mm Hg in both arms. What will the nurse include in the teaching plan for this patient?
a. Increased BP is a normal finding in older adults.
b. Prehypertension indicates the need for lifestyle changes.
c. It is important to address the increased BP.
d. A high probability of kidney and heart disease exists.

ANS: C
Although an increase in systolic BP (SBP) is a common finding in older adults, the recommendations for treating elevated BP are unchanged. An SBP of >140 mm Hg is a more important cardiovascular risk factor than diastolic BP (DBP) in individuals older than 50. The diagnosis of prehypertension indicates a systolic BP between 120 and 139 mm Hg and a DBP between 80 and 89 mm Hg.

25

Why should the nurse teach a patient who is taking labetalol (Normodyne) for treatment of hypertension to change position slowly?
a. The medication blocks the vasoconstrictive and sodium-retaining properties initiated by the presence of angiotensin.
b. The medication paralyzes the smooth muscle of blood vessels, and they cannot constrict in response to sympathetic stimulation.
c. The medication blocks the normal sympathetic nervous system response to position changes in vasoconstriction and increased heart rate.
d. The medication blocks the movement of calcium into the cardiac cells, and cardiac output cannot increase in response to decreased BP.

ANS: C
Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which lower BP.

26

A patient with hypertension asks the nurse why lifestyle changes are needed when the patient has no symptoms from the high BP. Which response is most likely to improve patient’s compliance with therapy?
a. “High BP damages the blood vessels, leading to risk for heart attack, stroke, and kidney failure.”
b. “High BP increases blood flow to the kidneys, leading to increased workload for the renal system.”
c. “High BP may not cause any problems for some people but does cause symptoms in many others.”
d. High BP is probably causing the damage, but the patient does not recognize that they are occurring.

ANS: A
Teaching the patient that hypertension can damage blood vessels and eventually causes severe health problems is most likely to improve patient compliance with needed lifestyle changes.

27

During assessment of a patient who has stage 2 hypertension, the nurse recognizes that it is common for the patient to experience which of the following?
a. Nosebleeds
b. No symptoms
c. Blurred vision
d. Dyspnea on exertion

ANS: B
Hypertension is largely asymptomatic until damage to target organs has occurred.

28

The nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented to manage BP. Which diet choice indicates that the teaching has been effective?
a. The patient has a glass of low-fat milk with each meal.
b. The patient has only one cup of coffee in the morning.
c. The patient restricts intake of dietary protein.
d. The patient has tomato juice and bacon for breakfast.

ANS: A
The DASH (Dietary Approaches to Stop Hypertension) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods.

29

The nurse is planning patient teaching for a patient who has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which of the following information is important to include when teaching the patient?
a. Increase fluid intake if dryness of the mouth is a problem.
b. Check BP daily before taking the medication.
c. Include high-potassium foods such as citrus fruits in the diet.
d. Change position slowly to help prevent dizziness and falls.

ANS: D
Angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change.

30

During assessment of a 50-year-old patient who has newly diagnosed stage 1 hypertension, the patient admits he uses a lot of salt on his foods and has not been able to lose the 13.6 kg he has gained in the last 10 years. He does not understand why he has hypertension because he is not an anxious person. What is an appropriate nursing diagnosis for the nurse to document for the patient?
a. Noncompliance related to lack of motivation
b. Disturbed self-esteem related to diagnosis of hypertension
c. Ineffective health maintenance related to lack of knowledge of disease process and management
d. Anxiety related to complexity of management regimen and lifestyle changes associated with hypertension

ANS: C
This patient’s subjective and objective assessment data indicate that lack of knowledge about hypertension will need to be addressed to allow the patient to improve the BP.