Ch 36: Cardiac Disorders

ANS: negative When the heart is at rest, the inside of the cell is negatively charged. DIF: Cognitive Level: Comprehension REF: p. 685 OBJ: 3 TOP: Polarization of Myocardium KEY: Nursing Process Step: Assessment MSC:

39. At rest, the cardiac cells in the myocardium are electrically polarized, with the inside of the cell being more _____ than the outside of the cell.

ANS: A To detect an apical-radial pulse deficit, the rates should be counted simultaneously and compared for differences. If a difference exists between the apical rate and the radial rate, then a pulse deficit is present. For example, in atrial fibrillation, a pulse deficit exists. DIF: Cognitive Level: Analysis REF: p. 687 OBJ: 8 TOP: Vital Sign Assessment: Pulse Deficit KEY: Nursing Process Step: Assessment MSC:

1. A nurse performs an apical-radial pulse evaluation, with the result of 100/88. What is the pulse deficit? a. 12 b. 24 c. 76 d. 88

ANS: B The plaque surface acts as a trap to which fibrous plaques can adhere, causing more narrowing of the vessel. The enlarging plaque can become a thrombus but not an embolus because emboli are usually considered to be traveling aggregations that lodge in a small arteriole. DIF: Cognitive Level: Comprehension REF: p. 709 OBJ: 7 TOP: Atherosclerosis KEY: Nursing Process Step: Implementation MSC:

10. What do fibrous plaques of atherosclerosis serve as when they are laid down in the vessels? a. Stent to keep the vessel open b. Trap to which other substances adhere c. Threat to the integrity of the vessel wall d. Embolus

ANS: A The code is A (chamber-paced) atria, A (sense impulse) atria only, I (inhibit) inhibit firing from the pacemaker, O (rate modification) no rate modification, and O (multichamber) no other chambers to be stimulated by the pacemaker. If the SA fires on its own, the pacemaker does nothing until it fails to sense an impulse. DIF: Cognitive Level: Application REF: p. 615 OBJ: 7 | 9 TOP: Permanent Pacemaker Care KEY: Nursing Process Step: Implementation MSC:

11. A patient with an irregular sinoatrial (SA) node conduction has a permanent pacemaker with the code AAIOO and is now going home. The patient asks, "What happens when my real SA node fires on its own?" How should the nurse respond regarding what the pacemaker should do? a. Not fire b. Fire only the ventricles c. Change the rate of firing d. Fire both the atria and the ventricles.

ANS: B A patient with angina who has pain at rest that is not relieved with one NTG pill is considered to have unstable angina, a precursor to an acute MI. DIF: Cognitive Level: Comprehension REF: p. 688 OBJ: 7 TOP: Unstable Angina KEY: Nursing Process Step: Assessment MSC:

12. A patient with angina pectoris complains of chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. Of what should the nurse assess this as a major symptom? a. Stable angina b. Unstable angina c. Full-blown acute myocardial infarction (MI) d. Pulmonary embolus

ANS: C Cardiac rehabilitation programs are supervised by a team of experts who arrange for telemetry-supervised exercise and other modalities, such as diet and medical protocol management. The focus is on the family, as well as the patient. Although some patients reject the program, they are rarely rejected by the rehabilitation center. DIF: Cognitive Level: Comprehension REF: p. 727 OBJ: 7 TOP: Cardiac Rehabilitation KEY: Nursing Process Step: Assessment MSC:

13. A nurse explains that cardiac rehabilitation lasts from the end of acute care to the return to home and beyond. What does this service include? a. One-on-one individualized care b. Focus on the patient rather than the family c. Telemetry-monitored exercise d. Rejection from the program for noncompliance

ANS: A Heart murmurs indicate turbulent blood flow and can be caused by valves that are stiff and do not shut correctly; consequently, blood flows back into the chamber. DIF: Cognitive Level: Comprehension REF: p. 688 OBJ: 7 TOP: Heart Murmur KEY: Nursing Process Step: Assessment MSC:

14. On auscultation, a nurse detects a heart murmur. What should the nurse know that a heart murmur indicates? a. Valves that do not close correctly b. Pericardium that is inflamed c. Decrease in pacemaker cells d. Loud ventricular gallop

ANS: B Patients with mitral stenosis need to balance their activity with their oxygen supply and avoid overhydration. DIF: Cognitive Level: Application REF: p. 727 OBJ: 7 TOP: Mitral Stenosis KEY: Nursing Process Step: Implementation MSC:

15. What is an important teaching point for a patient with mitral stenosis? a. Obtain a place on the heart transplant list. b. Balance activity with oxygen supply. c. Increase daily fluid intake to over 2000 mL. d. Have an annual electrocardiogram.

ANS: B Pulse oximetry measures arterial oxygen saturation noninvasively by attaching a clip to a digit, an ear, or a nose. DIF: Cognitive Level: Comprehension REF: p. 694 OBJ: 6 TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC:

16. A physician has ordered continuous pulse oximetry. What should the nurse explain to the patient about this procedure? a. Involves a single prick b. Measures the amount of oxygen in the blood c. Is applied to the wrist d. Identifies damaged cells in the myocardium

ANS: A A stress test is a noninvasive test that consists of a patient walking on a treadmill while an electrocardiogram records the activity. A consent form is required. DIF: Cognitive Level: Application REF: p. 692 OBJ: 6 TOP: Stress Test KEY: Nursing Process Step: Implementation MSC:

17. A stress test is scheduled for a 41-year-old patient. What action should the nurse implement to prepare the patient for the examination? a. Have the patient sign a consent form. b. Give the patient a special heart diet. c. Prepare the patient for sedation. d. Remove all metal objects.

ANS: B Cardiac catheterizations are invasive procedures during which a catheter is threaded through an artery. Postprocedure care requires bedrest and monitoring the puncture site. DIF: Cognitive Level: Application REF: p. 690 OBJ: 6 TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC:

18. What action should a nurse expect to implement when a patient returns from a cardiac catheterization? a. Ambulate the patient in the hall. b. Check the puncture site. c. Monitor the gag reflex. d. Remove the gel from all sites on the skin.

ANS: C The abnormal wave form of the inverted T wave is an indicator that tissue death has occurred in part of the cardiac wall. The cardiac wall now has no ability to conduct or to contract and sends that message to the ECG via the inverted T. The tissue will take 6 weeks to regenerate. DIF: Cognitive Level: Analysis REF: p. 711 OBJ: 8 TOP: Significance of Inverted T Wave KEY: Nursing Process Step: Evaluation MSC:

19. A nurse assesses an inverted T wave on the ECG of a patient who had an acute MI two days earlier. How should the nurse interpret this finding? a. Normal recovery b. New MI c. Abnormal wave form d. Congestive heart failure

ANS: A, D, E Stroke volume is dependent on contractility, preload, and afterload. Age may affect all three, but the stroke volume, regardless of age, is dependent on these three factors. DIF: Cognitive Level: Knowledge REF: p. 685 OBJ: 2 TOP: Stroke Volume KEY: Nursing Process Step: Implementation MSC:

35. Which factors affect stroke volume? (Select all that apply.) a. Contractility b. Climate c. Age d. Preload e. Afterload

ANS: D An increase blood pressure creates an increase in afterload because the heart must work harder to push the blood out of the left ventricle into the circulating volume. DIF: Cognitive Level: Comprehension REF: p. 685-686 OBJ: 7 TOP: Hypertension Effect on Afterload KEY: Nursing Process Step: Implementation MSC:

2. What is increased in hypertension that in turn causes an increase in the work of the heart? a. Preload b. Stroke volume c. Contractility d. Afterload

ANS: D Troponin is elevated within 3 to 6 hours and is often measured in the emergency department. CPK-MB is elevated in 12 to 24 hours. Three serial samples are drawn. The LDH increases with heart damage within 3 to 6 days. The lipid profile is not elevated with heart damage. DIF: Cognitive Level: Knowledge REF: p. 690 | p. 712 OBJ: 8 TOP: Cardiac Enzymes KEY: Nursing Process Step: Implementation MSC:

20. Laboratory tests are performed to identify damage to the heart muscle. Which test is elevated the earliest with heart damage? a. Creatine phosphokinase-MB (CPK-MB) b. Lactate dehydrogenase (LDH) c. Lipid profile d. Troponin

ANS: A The dye injected during the cardiac catheterization is iodine based. An allergy to seafood is correlated with a reaction to this dye as well. DIF: Cognitive Level: Application REF: p. 693 OBJ: 5 TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC:

21. A patient is scheduled for a heart catheterization. What action should the nurse implement in preparation for this examination? a. Ask the patient about allergies to seafood or iodine. b. Remove all metal objects. c. Give the patient a special heart diet. d. Test arterial blood gases (ABGs).

ANS: B Atropine increases the heart rate. The nurse should watch for tachycardia, which increases the workload of the heart. This medication causes urinary retention. DIF: Cognitive Level: Application REF: p. 701 OBJ: 7 TOP: Drugs for Dysrhythmias KEY: Nursing Process Step: Assessment MSC:

22. A patient has had atropine sulfate that has been administered intravenously to treat a dysrhythmia. What should the nurse assess this patient for after administration? a. Weight gain b. Tachycardia c. Muscle twitching d. Incontinence of urine

ANS: A, B, C, D Aging thickens and stiffens the valves and reduces the cells in the SA node. Age decreases the nerve fibers in the ventricles. DIF: Cognitive Level: Knowledge REF: p. 686 OBJ: 9 TOP: Age-Related Cardiac Changes KEY: Nursing Process Step: Planning MSC:

36. Which age-related changes in the heart should a nurse take into consideration? (Select all that apply.) a. Decrease in contractility b. Thickened valves c. Stiffened valves d. Decreased SA node cells e. Increased nerve fibers in ventricles

ANS: A Dopamine has a direct effect by elevating the blood pressure. The criterion is to titrate to the target blood pressure. Urinary output should also be monitored for a decreased amount because a heightened blood pressure may slow urine filtration and reduce urine output. DIF: Cognitive Level: Application REF: p. 701 OBJ: 7 TOP: Dopamine KEY: Nursing Process Step: Assessment MSC:

23. A dopamine infusion is being administered to a patient with shock. For what should the nurse be alert? a. Sharp spike in blood pressure b. Tremor of the hands c. Increasing urinary output d. Hyperirritability of the patient

ANS: A The drug amiodarone is meant to quiet atrial activity and modify rapid pulse rate, high blood pressure, and decreased cardiac output caused by the dysrhythmia. The drug interferes with the thyroid and causes an ataxic gait and trembling of hands as adverse effects. DIF: Cognitive Level: Application REF: p. 699 OBJ: 7 TOP: Atrial Fibrillation with Amiodarone KEY: Nursing Process Step: Assessment MSC:

24. A patient with atrial fibrillation is prescribed amiodarone for the dysrhythmia. Which potential adverse reaction should the nurse report? a. Ataxia b. Decreasing pulse rate c. Decreasing blood pressure d. Increase in cardiac output

ANS: D The reading that has both an HDL level above 40 mg/dL and an LDL level below 100 mg/dL is in the therapeutic target range. DIF: Cognitive Level: Knowledge REF: p. 695 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

25. A medication, simvastatin (Zocor), is administered to lower a patient's cholesterol level. Follow-up lipid levels are reviewed by the nurse. Which level indicates the desired therapeutic range? a. High-density lipoprotein (HDL), 29 mg/dL; low-density lipoprotein (LDL), 160 mg/dL b. HDL, 38 mg/dL; LDL, 120 mg/dL c. HDL, 56 mg/dL; LDL, 106 mg/dL d. HDL, 42 mg/dL; LDL, 98 mg/dL

ANS: C The patient needs written instructions for diet, follow-up appointments, and exercise protocols. Giving detailed information about symptoms is not necessary other than to remind the patient about reporting chest pain and shortness of breath. A high-energy exercise program is not appropriate. Morphine is not part of the home care after an MI. DIF: Cognitive Level: Application REF: p. 716 OBJ: 7 TOP: Myocardial Infarction KEY: Nursing Process Step: Implementation MSC:

26. What information should a nurse include in a patient's discharge instruction after an acute myocardial infarction (MI)? a. Cautions about the use of morphine b. Detailed symptoms that indicate impending MI c. Written instructions on diet and follow-up appointments d. High-energy exercise program directions

ANS: B Fluid volume excess increases the workload of the heart and interferes with breathing. DIF: Cognitive Level: Application REF: p. 687 | p. 720 OBJ: 7 TOP: Congestive Heart Failure KEY: Nursing Process Step: Nursing Diagnosis MSC:

27. A patient with acute congestive heart failure has jugular vein distention, crackles bilaterally, and dyspnea. Which nursing diagnosis should have the highest priority? a. Activity intolerance b. Excess fluid volume c. Anxiety d. Ineffective coping

ANS: A This pattern is NSR because it has one P wave for every QRS and one T wave. DIF: Cognitive Level: Analysis REF: p. 731 OBJ: 7 TOP: Recognition of NSR KEY: Nursing Process Step: Assessment MSC:

28. A nurse is assessing the cardiac complex above. What pattern should the nurse recognize in this rhythm strip? a. NSR b. Premature ventricular contractions (PVCs) c. Ventricular tachycardia (VT) d. AF

ANS: D Increased urinary output, weight loss, and thirst are all anticipated consequences of the therapy. Muscle weakness is a sign of hypokalemia. DIF: Cognitive Level: Comprehension REF: p. 696 OBJ: 7 TOP: Diuretic Therapy KEY: Nursing Process Step: Assessment MSC:

29. A diuretic medication, furosemide (Lasix), is being administered for congestive heart failure. Which assessment is not an anticipated consequence of the therapy? a. Increased urinary output b. Weight loss c. Thirst d. Muscle weakness

ANS: A, B, C, D Conditioning exercises performed daily for 30 minutes can reduce weight, improve the cardiac output of the left ventricle, decrease arterial stiffening, and decrease LDLs. Exercise does not affect dysrhythmias. DIF: Cognitive Level: Comprehension REF: p. 715-716 OBJ: 7 TOP: Effects of Conditioning Exercises KEY: Nursing Process Step: Implementation MSC:

38. A nurse urges a 50-year-old overweight executive who had a myocardial infarction (MI) 3 months earlier to take up some conditioning exercises for 30 minutes a day. What rationale supports this suggestion? (Select all that apply.) a. Lose weight. b. Improve function of the left ventricle. c. Decrease arterial stiffening. d. Decrease cholesterol levels. e. Improve cardiac dysrhythmia.

ANS: A, C, E To minimize the workload of the heart, the nurse would adjust nursing care to eliminate all unnecessary activities, assist in position changes, and give a minimal bath. Ambulation and active range-of-motion exercises are unnecessary activities at this time. DIF: Cognitive Level: Application REF: p. 720 OBJ: 7 TOP: Nursing Care of Congestive Failure KEY: Nursing Process Step: Planning MSC:

37. What actions should a nurse implement to decrease the workload of the heart in a patient with acute congestive failure? (Select all that apply.) a. Eliminate unnecessary activities. b. Direct the patient in active range-of-motion exercises. c. Help the patient change positions every 2 hours. d. Assist the patient to ambulate to the bathroom. e. Give a partial bed bath rather than full bed bath.

ANS: A Ventricular gallops are considered normal in individuals younger than 30 years of age. All other options are pathologic abnormalities. DIF: Cognitive Level: Application REF: p. 688 OBJ: 7 TOP: Heart Sound Assessment KEY: Nursing Process Step: Assessment MSC:

3. Which heart sound should the nurse record as normal? a. Ventricular gallop in a 20-year-old patient b. Atrial gallop in a 25-year-old patient c. Friction rub in a 45-year-old patient d. Medium diastolic murmur in a 50-year-old patient

ANS: B The dose should be held if the apical rate is less than 60 beats/min for 1 minute. DIF: Cognitive Level: Application REF: p. 679 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

30. A patient is receiving digoxin 0.25 mg/day. What should the nurse do prior to administering this medication? a. Count an apical pulse for 15 seconds. b. Hold the dose if the apical rate is 57 beats/min. c. Give the dose if the apical rate is 59 beats/min. d. Double the dose if the rate is 62 beats/min.

ANS: D Beta-blockers should never be stopped abruptly because they can cause angina or MI. Patients are gradually weaned off these medications. DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Implementation MSC:

31. A 46-year-old patient is receiving propranolol (Inderal), a nonselective beta-adrenergic blocker, for a heart condition. What patient teaching is most appropriate? a. Sit or lie down when taking the drug. b. Limit caffeine intake. c. Double the dose if symptoms occur. d. Never stop taking the drug abruptly.

ANS: C A temperature that goes up drastically indicates an adverse reaction to lidocaine, malignant hyperthermia. The slowed ventricular rate, even with occasional PVCs, is an expected outcome of lidocaine infusion. Nausea and vomiting are adverse effects. DIF: Cognitive Level: Application REF: p. 699 OBJ: 7 TOP: Drug Therapy KEY: Nursing Process Step: Assessment MSC:

32. Which assessment should be immediately addressed in a patient on lidocaine? a. Slowed ventricular rate b. Occasional PVCs c. Increase in temperature to 102° F d. Nausea and vomiting

ANS: B This is an arrhythmia of a PVC with an extra premature QRS complex (inverted) before the P wave. DIF: Cognitive Level: Analysis REF: p. 732 OBJ: 7 TOP: Recognition of PVC KEY: Nursing Process Step: Assessment MSC:

33. How should a nurse interpret the arrhythmia in the above strip? a. NSR b. PVC c. VT d. AF

ANS: C A "1" in a pulse evaluation indicates a thready pulse that is easily obliterated by pressure. DIF: Cognitive Level: Application REF: p. 687 OBJ: 8 TOP: Pulse Quality KEY: Nursing Process Step: Assessment MSC:

34. A nurse records a "1" for the pulse quality of the pedal pulse. What interpretation is correct regarding the pulse? a. Absent b. Normal c. Thready d. Forceful

ANS: C Smoking, a high-fat diet, hypertension, sedentary lifestyle, and stress are considered modifiable risk factors. DIF: Cognitive Level: Comprehension REF: p. 708 OBJ: 7 TOP: Coronary Artery Disease Risk Factors KEY: Nursing Process Step: Assessment MSC:

4. A 49-year-old patient has multiple risk factors for coronary artery disease. Which risk factor is considered modifiable? a. Family history b. Age c. Smoking d. Male gender

ANS: C TEE evaluates the efficiency of the valves. DIF: Cognitive Level: Application REF: p. 689 OBJ: 6 TOP: TEE KEY: Nursing Process Step: Implementation MSC:

5. A patient asks what a transesophageal echocardiogram (TEE) is and what it is expected to do? What is the best explanation by the nurse? a. Measures conductivity b. Records the force of contraction c. Evaluates the efficiency of the valves d. Checks the volume of the preload

ANS: A NSR requires the presence of P, Q, R, S, and T waves, in that order, and all pointing in the same direction, with a rate of 60 to 100 seconds. Normal intervals are a PR interval of 0.12 to 0.20 seconds and a QRS complex less than 0.10 second. DIF: Cognitive Level: Application REF: p. 730-731 OBJ: 5 TOP: Normal Sinus Rhythm KEY: Nursing Process Step: Assessment MSC:

6. A nurse records the finding of a normal sinus rhythm (NSR) when the P, Q, R, S, and T are all present in the electrocardiographic complex. What additional information should the nurse document? a. Rate of 82 seconds b. PR interval of 0.36 second c. QRS complex of 0.16 second d. Inverted T

ANS: B ACE inhibitors suppress the excretion of angiotensin, which lowers the blood pressure, reduces fluid retention, and leads to increased urine output. DIF: Cognitive Level: Application REF: p. 696 OBJ: 6 TOP: ACE Inhibitors KEY: Nursing Process Step: Planning MSC:

7. A nurse should anticipate that a patient taking Vasotec, an angiotensin-converting enzyme (ACE) inhibitor, should have which positive outcome to this drug? a. Increased fluid retention b. Decreased blood pressure c. Decreased urine output d. Increased appetite

ANS: A A cardioversion has risks, such as ventricular fibrillation. Emergency equipment should be available. The digoxin dose is held before a cardioversion, and the patient is given a short-acting sedative such as Versed or Valium, which will require recovery. The electrocardiogram R wave is synchronized via the computer, and no pacemaker is involved. DIF: Cognitive Level: Comprehension REF: p. 705 OBJ: 6 | 7 TOP: Cardioversion KEY: Nursing Process Step: Implementation MSC:

8. A 29-year-old patient is to receive cardioversion for a dysrhythmia. What should the nurse instruct the patient to expect? a. Administration of a short-acting sedative b. Digoxin dose to be taken as scheduled c. Procedure to be completely safe d. Pacemaker spikes to be carefully monitored

ANS: C Therapeutic implementations identify and acknowledge feelings. Do not assume that you know how the patient feels and do not give false assurances. DIF: Cognitive Level: Application REF: p. 707 OBJ: 7 | 9 TOP: Open Heart Surgery KEY: Nursing Process Step: Implementation MSC:

9. A 68-year-old patient is scheduled for open heart surgery in the morning and is crying. What is the most appropriate response by the nurse? a. "Everything will go great! Dr. C. is the best!" b. "I know how you feel, so do not cry." c. "Tell me what concerns you the most." d. "I will call the physician for a sedative. You are too upset."

ANS: E, A, C, B, D, F The conduction pathway begins in the SA node, travels down the atrial wall, depolarizing the atria, to the AV node, bundle branches, and Purkinje fibers, contracting the ventricles. DIF: Cognitive Level: Comprehension REF: p. 684-685 OBJ: 4 TOP: Conduction Pathway for Cardiac Contraction KEY: Nursing Process Step: Assessment MSC:

OTHER 40. A nurse uses a picture to demonstrate the conduction pathway through the chambers of the heart. (Arrange the following options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. The atria contract. B. Conduction occurs through the bundle branches. C. The AV node fires. D. The Purkinje fibers conduct. E. The SA node fires. F. The ventricles contract.