Exam3: 31AMR2017
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alteration in function should the nurse expect? Difficulty reading Inability to recognize his family members Right hemiparesis Aphasia
Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness
Force (pressure) ventricles must overcome to eject blood
Afterload
Measurement of the pressure exerted as the blood flows through the arteries
Arterial blood pressure
Fibrous tissue replaces the elastic tissue of arteries creating a decreased ability of the arteries to contract and dilate
Atherosclerosis
Heart rate less than 60bpm in adults, infant and newborn below 80bpm, teen below 50bpm, 5-8 year old below 75bpm
Bradycardia
Cardiac output adjusted for the client's body size (body surface area)
Cardiac index
The ability of the heart to respond by adjusting cardiac output to an increase need for oxygen supply
Cardiac reserve
Ability of the cardiac muscle to contract or expand
Compliance
Ability of cardiac muscle fibers to shorten
Contractility
A nurse is providing education about heart failure to a community group. Which risk factors should the nurse include in the presentation? (select all) Coronary heart disease Hypertension Diabetes mellitus Pituitary adenoma Sleep apnea
Coronary heart disease Hypertension Diabetes mellitus Sleep apnea
The nurse is assessing a client during a routine check-up. The client is concerned that he is at risk for stroke. Which item will the nurse include in the health history to determine the client's risk? Monitor skin integrity Assess the level of consciousness Determine a history of smoking Auscultate breath sounds
Determine a history of smoking
Ventricular relaxation
Diastole
A nurse in a providers office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Asthma Aortic valve regurgitation Heart failure Aortic stenosis
Heart failure Fatigue and tachycardia are early manifestation of heart failure. Other manifestation include dyspnea and weak peripheral pulses
Proportion of the red blood cells to the blood plasma
Hematocrit
Main intracellular protein of erythrocytes
Hemoglobin
A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? Dry, hacking cough Hepatomegaly Dizziness Crackles in the lungs
Hepatomegaly Liver enlargement is a manifestation of right-sided heart failure
Above normal blood pressure reading
Hypertension
Below normal blood pressure reading
Hypotension
A nurse is providing teaching about a heart healthy diet to a group of client with HTN. Which of the following statement by one of the clients indicates a need for further teaching? I may eat my 10oz of lead protein each day Fresh fruits make a good snack option I will replace table salt with dried herbs I may thicken gravies with cornstarch as I cook
I may eat my 10oz of lead protein each day This should be 5-6oz a day
Tissues do not receive enough oxygenated blood resulting in oxygen deprivation of tissues
Ischemic
While assessing peripheral pulses in a 2-week-old infant, the nurse is unable to palpate the radial and pedal pulses. What action should the nurse take? Insert a venous access device for intravenous cardiac medications Nothing because this is a normal finding Notify the health care provider immediately Prepare the infant for emergency cardiac catheterization
Nothing because this is a normal finding
A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? Weight loss Increased urine output Bradycardia Orthopnea
Orthopnea A toddler who has heart failure has increase venous return to the heart and lungs, which leads to pulmonary congestion
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor which of the following findings? Poor impulse control Unable to discriminate works and letters Deficits in the right visual field Motor retardation
Poor impulse control A client with a right sided stroke can have personality changes
Volume of blood returning to the heart to create muscle fiber stretch and tension
Preload
The difference of the apical pulse and radial pulse resulting from weak and ineffective ventricular contractions
Pulse defecit
Difference between systolic and diastolic pressure
Pulse pressure
At the completion of a health history and physical assessment, the nurse is concerned that a middle-aged adult client is at risk for developing cardiovascular disease. What did the nurse most likely assess in this client? (select all) Smokes 1 pack per day of cigarettes Blood pressure 158/96 mmHg Body mass index 31.4 Plays racquet ball 4 times a week for 1 hour Fasting blood glucose 86 mg/dL
Smokes 1 pack per day of cigarettes Blood pressure 158/96 mmHg Body mass index 31.4
Amount of blood pumped with each heart beat
Stoke volume (stroke god)
Ventricular contraction
Systole
Heart rate above 100bpm in adults, above 180 in newborn, above 90 in teens, above 140 in infants, above 120 in children 5-8
Tachycardia
A clot that is attached to the vessel wall and is somewhat stable
Thrombus
Fraction or percentage of blood ejected from the heart during systole
Ejection fraction
A clot or foreign body that is circulating in the blood stream and can cause an occlusion
Embolus
Why are pregnant clients prone to developing supine hypotension? Pooling of blood in the lower extremities Insufficient red blood cells in proportion to volume of plasma Enlarging uterus pressing on the vena cava Increase in blood flow to the developing fetus
Enlarging uterus pressing on the vena cava
A nurse at a rehabilitation center is planning care for a client who has a left hemisphere CVA 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation? Establish the ability to communicate effectively Compensate for loss of depth perception Learn to control impulsive behavior Improve left-side motor function
Establish the ability to communicate effectively The left side is associated with language and may cause the client to need speech therapy
A nurse is providing discharge teaching to a client who has a new diagnosis of hearth failure. Which of the following instructions should the nurse include in the teaching? Exercise at least three time per week Take diuretics early in the morning and before bedtime Notify the provider of a weight game of 1lb in a week Take naproxen for generalized discomfort
Exercise at least three times per week The nurse should encourage the client to stay as active as possible and to develop a regular exercise regimen
Opening between the atria in the fetal heart allowing blood to flow from the right atrium to the left atrium and into the ventricle
Foramen ovale
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum Dependent edema Nocturnal polyuria Jugular distension
Frothy sputum Fluid backs up into the lungs with left-sided heart failure
An increase in the size of muscle cells of the myocardium
Myocardial atrophy
A 30-year-old female client is seen in the clinic for a wellness checkup. The client states that her mother had a stroke recently. The client asks the nurse about risk factors for stroke. Which risk factors would the nurse consider pertinent for this particular client? (select all) Menopause Sedentary lifestyle Family history of stroke Insomnia Oral contraceptive use
Sedentary lifestyle Family history of stroke Oral contraceptive use
A nurse is describing the pathophysiology of heart failure to a client. Which changes caused by compensatory mechanisms in the development of heart failure should the nurse describe? (select all) The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume. Increased cardiac output causes the aortic baroreceptors to stimulate the sympathetic nervous system. Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. This is the correct answer. The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output.
The ventricles in the heart remodel and develop hypertrophy because of the chronic increase in fluid volume. Atrial natriuretic peptide is released by the cardiac cells to help delay cardiac decompensation. Hypertension causes the cardiac muscles to overstretch and cause temporarily increased cardiac output. The kidneys release renin to retain sodium and water in an attempt to maintain cardiac output.
A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? Vertigo Uremia Blurred vision Dyspnea
Vertigo Findings such as vertigo, HA, facial flushing, and fainting are common in essential hypertension
After reviewing data collected during a cardiovascular assessment, the nurse determines that an older client is demonstrating normal signs of aging. Which did the nurse assess to come to this conclusion? (select all) Weak popliteal pulses bilaterally Dependent edema of both feet when sitting for several hours Blood pressure dropping from a sitting to a standing position Heart murmur heard in early diastole Elevated systolic blood pressure
Weak popliteal pulses bilaterally Dependent edema of both feet when sitting for several hours Blood pressure dropping from a sitting to a standing position Elevated systolic blood pressure
A 58-year-old client who has a strong family history of coronary artery disease asks the nurse, "How can I decrease my chances of developing problems with my arteries?" Which response by the nurse is appropriate? (select all) "As long as your cholesterol is normal, your arteries will remain clear." "Keeping your blood pressure within normal levels will decrease the risk of injury to your arteries." "Diets high in fruits, vegetables and unsaturated fatty acids appear to have a protective effect on the arteries." "You can reduce your risk by making some changes in your lifestyle such as moderate exercise." "With your age and family history, there is little you can do besides take medication to prevent coronary artery disease."
"Keeping your blood pressure within normal levels will decrease the risk of injury to your arteries." "Diets high in fruits, vegetables and unsaturated fatty acids appear to have a protective effect on the arteries." "You can reduce your risk by making some changes in your lifestyle such as moderate exercise."
