Exam 5 - Chp 27 30 52
A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" Which of the following responses by the nursing instructor would be best?
"A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made."
A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? As close to the end of the day as possible After a meal high in fat After a 12-hour fast Thirty minutes after a normal meal
12 hour fast Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast.
The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids? In the evening between 4 PM and 6 PM Prior to going to sleep at night At noon every day In the morning between 7 AM and 8 AM
7-8AM In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects.
A nurse works in a walk-in clinic. The nurse recognizes that certain patients are at higher risk for different disorders than other patients. What patient is at a greater risk for the development of hypothyroidism? A 75-year-old female patient with osteoporosis A 50-year-old male patient who is obese A 45-year-old female patient who used oral contraceptives A 25-year-old male patient who uses recreational drugs
75 yo female Even though osteoporosis is not a risk factor for hypothyroidism, the condition occurs most frequently in older women.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Right-sided heart failure Acute pulmonary edema Pneumonia Cardiogenic shock
Acute Pulmonary Edema Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
A cardiac patient's resistance to left ventricular filling has caused blood to back up into the patient's circulatory system. What health problem is likely to result? Acute pulmonary edema Right-sided HF Right ventricular hypertrophy Left-sided HF
Acute Pulmonary Edema With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.
A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patient's immediate care? Select all that apply. Administering diuretics to prevent fluid overload Administering beta blockers to reduce heart rate Administering insulin to reduce blood glucose levels Applying interventions to reduce the patient's temperature Administering corticosteroids
Admin Beta Blockers Apply interventions to reduce patients temp Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? Assess pulse of affected extremity every 15 minutes at first. Palpate the affected leg for pain during every assessment. Assess the patient for signs and symptoms of compartment syndrome every 2 hours. Perform Doppler evaluation once daily.
Assess every 15 minutes at first. The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? Pulseless electrical activity (PEA) Ventricular fibrillation Ventricular tachycardia Asystole
Asystole Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.
The nurse is providing care for an older adult patient whose current medication regimen includes levothyroxine (Synthroid). As a result, the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication? A fluoroquinalone antibiotic A loop diuretic A proton pump inhibitor (PPI) A benzodiazepine
Benzo's Oral thyroid hormones interact with many other medications. Even in small IV doses, hypnotic and sedative agents may induce profound somnolence, lasting far longer than anticipated and leading to narcosis (stupor like condition). Furthermore, they are likely to cause respiratory depression, which can easily be fatal because of decreased respiratory reserve and alveolar hypoventilation. Antibiotics, PPIs and diuretics do not cause the same risk.
The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A beta-adrenergic blocker An antiplatelet aggregator A calcium channel blocker A nonsteroidal anti-inflammatory drug (NSAID)
Beta blocker Several medications are routinely prescribed for systolic HF, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? Blood pressure Level of consciousness (LOC) Assessment for nausea Oxygen saturation
Blood Pressure Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea. .
The nurse is assessing a patient diagnosed with Graves' disease. What physical characteristics of Graves' disease would the nurse expect to find? Hair loss Moon face Bulging eyes Fatigue
Bulging Eyes Clinical manifestations of the endocrine disorder Graves' disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves' disease is not associated with hair loss, a moon face, or fatigue.
Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? Pulmonary edema Pericardiocentesis Cardiac tamponade Pericarditis
Cardiac Tamponade An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiological process.
The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the step-down unit should prioritize what assessment? Cardiac monitoring Monitoring the implanted device signal Pain assessment Monitoring the patient's level of consciousness (LOC
Cardiac monitoring Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments. Ablation does not involve the implantation of a device.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? Confusion and bradycardia Uncontrolled diuresis and tachycardia Numbness and tingling in the extremities Chest pain and shortness of breath
Confusion and bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
The nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours Administration of dexamethasone IV, followed by an x-ray of the adrenal glands Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is administered
Dexamethasone (1 mg) is administered orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning. This test can be performed on an outpatient basis and is the most widely used and sensitive screening test for diagnosis of pituitary and adrenal causes of Cushing syndrome.
A patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the patient should prioritize what question when addressing potential complications? "Do you feel any muscle twitches or spasms?" "Do you feel flushed or sweaty?" "Are you experiencing any dizziness or lightheadedness?" "Are you having any pain that seems to be radiating from your bones?"
Do you have muscle twitches or spasms As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia.
The nurse in the ED is caring for a patient recently admitted with a likely myocardial infarction. The nurse understands that the patient's heart is pumping an inadequate supply of oxygen to the tissues. For what health problem should the nurse assess? Dysrhythmias Increase in blood pressure Increase in heart rate Decrease in oxygen demands
Dysrhythmias Cardiogenic shock occurs when the heart's ability to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. Symptoms of cardiogenic shock include angina pain and dysrhythmias. Cardiogenic shock does not cause increased blood pressure, increased heart rate, or a decrease in oxygen demands.
A patient with a diagnosis of HF is started on a beta-blocker. What is the nurse's priority role during gradual increases in the patient's dose? Educating the patient that symptom relief may not occur for several weeks Stressing that symptom relief may take up to 4 months to occur Making adjustments to each day's dose based on the blood pressure trends Educating the patient about the potential changes in LOC that may result from the drug
Educating the patient that symptom relief may not occure for several weeks An important nursing role during titration is educating the patient about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. Facilitate the presence of friends and family whenever possible. Teach the patient about the harmful effects of anxiety on cardiac function. Provide supplemental oxygen, as needed. Provide validation of the patient's expressions of anxiety. Administer benzodiazepines two to three times daily.
Facilitate the prescence of family, Provide supplemental oxygen and validate their expression of anxiety The nurse should empathically validate the patient's sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
The nurse is caring for a patient diagnosed with hypothyroidism secondary to Hashimoto's thyroiditis. When assessing this patient, what sign or symptom would the nurse expect? Fatigue Bulging eyes Palpitations Flushed skin
Fatigue Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, dry skin, voice huskiness or hoarseness, menstrual disturbance, and numbness and tingling of the fingers. Bulging eyes, palpitations, and flushed skin would be signs and symptoms of hyperthyroidism.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. Platelet level Fluid status Cardiac rhythm Action of medications
Fluid status, cardiac rhythm and action of meds. The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.
A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patient's nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. Foods high in vitamin D Foods high in calories Foods high in protein Foods high in calcium Foods high in sodium
Foods high in Vit D, protein and calcium Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? Nervousness or paresthesia Throbbing headache or dizziness Drowsiness or blurred vision Tinnitus or diplopia
Headache and dizziness They commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? In a high Fowler's position On the left side-lying position In a flat, supine position In the Trendelenburg position
High Fowlers Position Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.
The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? Loop diuretic and antiplatelet aggregator Loop diuretic and calcium channel blocker Combination of hydralazine and isosorbide dinitrate Combination of digoxin and normal saline
Hydralazine and Isosorbide dinitrate A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed
A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal? Hyponatremia Hypophosphatemia Hypocalcemia Hypokalemia
HypoCalcemia Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? Partial thromboplastin time (PTT) within normal reference range Prothrombin time (PT) eight to ten times the control International normalized ratio (INR) between 2 and 3 Hematocrit of 32%
INR from 2-3 The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.
The nurse's assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention? Oral calcium chloride and vitamin D IV calcium gluconate STAT levothyroxine Administration of parathyroid hormone (PTH)
IV Calcium Gluconate When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? Heparin is contraindicated in the treatment of this patient. Heparin may be administered subcutaneously, but not IV. Lower doses of heparin are required for this patient. Coumadin will be substituted for heparin.
If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Improve functional status Prevent endocarditis. Extend survival. Limit physical activity. Relieve patient symptoms.
Improve Functional Status, Extend Survival and Relieve patient symptoms The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? Ineffective breathing pattern related to decreased cardiac output Anxiety related to fear of death Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Impaired skin integrity related to CAD
Ineffective Cardiopulmonary tissue perfusion related to CAD. Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.
You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? Chronic pain Ineffective tissue perfusion Impaired skin integrity Risk for injury
Ineffective tissue perfusion Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.
The nurse is caring for a patient admitted with cardiogenic shock. The patient is experiencing chest pain and there is an order for the administration of morphine. In addition to pain control, what is the main rationale for administering morphine to this patient? It promotes coping and slows catecholamine release. It stimulates the patient so he or she is more alert. It decreases gastric secretions. It dilates the blood vessels.
It dilates blood vessels for patients experiencing chest pain, morphine is the drug of choice because it dilates the blood vessels and controls the patient's anxiety. Morphine would not be ordered to promote coping or to stimulate the patient. The rationale behind using morphine would not be to decrease gastric secretions.
The nurse is providing patient education prior to a patient's discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist? Know how to recognize and prevent orthostatic hypotension. Weigh yourself weekly at a consistent time of day. Measure everything you eat and drink until otherwise instructed. Limit physical activity to only those tasks that are absolutely necessary.
Know how to recognized and prevent orthostatic hypotension Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.
The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? The possibility of precipitous weight gain The need for lifelong steroid replacement The need to match the daily steroid dose to immediate symptoms The importance of monitoring liver function
Lifelong need Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the patient and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.
The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? Lipids and fibrous tissue White blood cells Lipoproteins High-density cholesterol
Lipids and Fibrous tissue As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.
The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? High HDL values and high triglyceride values Absence of detectable total cholesterol levels Elevated blood lipids, fasting glucose less than 100 Low LDL values and high HDL values
Lower LDL - "bad one" Increase HDL "good one" The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) Need for careful monitoring for cardiac symptoms Need for carefully regulated exercise Need for dietary modifications Need for early resumption of prediagnosis activity Need for increased fluid intake
Monitor Cardiac symptoms, exercise and diet Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? Monitor liver function studies Monitor for hypotension Assess the patient's vitamin D intake Assess the patient for hyperkalemia
Monitor for hypotension Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem? Truncal obesity Hypertension Muscle weakness Moon face
Muscle Weakness Patients with Addison's disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Patients with Cushing syndrome demonstrate truncal obesity, "moon" face, acne, abdominal striae, and hypertension.
The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? Development of an atrial-septal defect Myocardial ischemia Formation of a pulmonary embolism Release of potassium ions from cardiac cells
Myocardial Ischemia Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. Shortness of breath Chest pain Anxiety Numbness Weakness
Numbness and Weakness Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.
A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? The pain is worse when the resident inhales deeply. The pain occurs immediately following physical exertion. The pain is worse when the resident coughs. The pain is most severe when the resident moves his upper body.
Pain occurs immediately following physcial exertion Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.
The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. Epistaxis Pallor Rapid respiratory rate Bounding pulse Hypotension
Pallor, Rapid Resp Rate, Hypotension The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? The patient admitted with acute renal failure The patient admitted following an MI The patient admitted with malignant hypertension The patient admitted following a stroke
Patient admitted following an MI Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? Skin turgor Potassium level White blood cell count Peripheral pulses
Potassium Level The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. Pupillary response Creatinine and BUN levels Potassium level Peripheral pulses BP
Potassium level and BP Patients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.
During an adult patient's last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient's BP be categorized? Normal Prehypertensive Stage 1 hypertensive Stage 2 hypertensive
Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg. 140- Stage 1 160- Stage 2
The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? Pericarditis Cardiomyopathy Pulmonary edema Right ventricular hypertrophy
Pulmonary edema As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patient's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following? Reducing the heart's workload by decreasing heart rate and myocardial contraction Preventing platelet aggregation and subsequent thrombosis Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain
Reducing the hearts workload by decreasing heart reate and myocardial contraction. Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize?
Rising slowly from sitting or lying position
An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patient's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified? Risk for ineffective tissue perfusion related to dysrhythmia Risk for fluid volume excess related to medication regimen Risk for ineffective breathing pattern related to hypoxia Risk for falls related to hypotension
Risk for falls related to hypotension The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? An S3 heart sound Pleural friction rub Faint breath sounds A heart murmur
S3 Heart Sound The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.
The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? Warfarin (Coumadin) Furosemide (Lasix) Sodium nitroprusside (Nitropress) Ramipril (Altace)
Sodium Nitroprusside, Nitropress The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patient's immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? Lay the patient flat. Notify the family of the patient's critical state. Stay with the patient. Update the physician.
Stay with patient. Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to relieve dyspnea. The family should be informed, but this is not the priority action.
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? Sudden increase in blood pressure and a decrease in heart rate Cessation of pulsating in an aneurysm that has previously been pulsating visibly Sudden onset of severe back or abdominal pain New onset of hemoptysis
Sudden onset of severe back or abdominal pain Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? P wave inversion T wave inversion Q wave changes with no change in ST or T wave P wave enlargement
T Wave T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? Eggs Shellfish Table salt Red meat
Table Salt The major use of iodine in the body is by the thyroid. Iodized table salt is the best source of iodine.
The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? Avoid drinking fluids for 2 hours after taking the diuretic. Take the diuretic in the morning to avoid interfering with sleep. Avoid taking the medication within 2 hours consuming dairy products. Take the diuretic only on days when experiencing shortness of breath
Take the diuretic in the morning to avoid interfering with sleep Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient's nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? The patient's diet should be low protein with ample fat. The patient may experience short-term changes in cognition. The patient is at an increased risk for developing infection. The patient is at a decreased risk for development of thrombophlebitis and thromboembolism
The patient is at risk for developing infection he patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? The symptoms indicate angina and should be treated as such. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. The symptoms indicate an acute coronary episode and should be treated as such. Treatment should be determined pending the results of an exercise stress test.
The symptoms indicate an acute coronary episode and should be treated as such Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patient's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem? Therapeutic use of corticosteroids Pheochromocytoma Inadequate secretion of ACTH Adrenal tumor
Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency. The other options also cause adrenocortical insufficiency, but they are not the most common causes
The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. This is an accurate indicator of myocardial injury. This result indicates muscle injury, but does not specify the source.
This is an accurate indicator of myocaridal injury Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?To prevent the formation of infarcts of emboli To limit stroke volume and cardiac output To prevent pulmonary and peripheral edema To maintain adequate mean arterial pressure
To maintain adequate mean arterial pressure Vasoactive medications can be administered in all forms of shock to improve the patient's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.
A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks' duration can suppress the adrenal cortex for how long? Up to 4 weeks Up to 3 months Up to 9 months Up to 1 year
Up to 1 year Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks' duration.
