MedSurg Exam 2 PrepU Questions

Which term refers to the shifting of brain tissue form an area of high pressure to an area of low pressure?

Herniation

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?"

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

Which of the following is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

"You must avoid stress and extreme fatigue, because these can trigger a relapse."

A patient suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

- Change in LOC

A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?

15 mg

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80 Expl: 20/15 × 60 = 80 mL/hr

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?

Autonomic dysreflexia Expl: Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion. 2057

A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge instructions. Which statement by the client would indicate the need for further teaching by the nurse? A. "I should expect bruising at the catheter site for up to 3 weeks." B. "I should expect a low-grade fever and swelling at the site for the next week." C. "I should avoid prolonged sitting." D. "I should avoid taking a tub bath until my catheter site heals."

B. "I should expect a low-grade fever and swelling at the site for the next week." Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is common and may take from 1 to 3 weeks to resolve.

A client has a blockage in the proximal portion of a coronary artery and decides to undergo percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse expect to administer during the procedure? A. metoprolol B. hydrochlorothiazide C. ticagrelor D. ceftriaxone

C. ticagrelor During PTCA, the client receives heparin, an anticoagulant (ticagrelor), as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses do not routinely give antibiotics such as ceftriaxone during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive like metoprolol and a diuretic like hydrochlorothiazide may cause hypotension, which should be avoided during the procedure.

The nurse is administering oral metoprolol. Where are the receptor sites mainly located? A. Blood vessels B. Bronchi C. Uterus D. Heart

D. Heart Metoprolol works at beta 1 -receptor sites. Most beta1-receptor sites are located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.

A client's lipid profile reveals an LDL level of 122 mg/dL. This is considered a: A. low LDL level. B. normal LDL level. C. fasting LDL level. D. high LDL level.

D. high LDL level. LDL levels above 100 mg/dL are considered high. The goal is to decrease the LDL level below 100 mg/dL.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Epidural

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?

Epidural

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?

Equipment to maintain infection control precautions

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and Change in Urine Clarity Expl: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency. Pg. 2060

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation Expl: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others. 2036

Which of the following is the most common cause of acute encephalitis in the United States?

Herpes simplex virus (HSV)

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is

Motor Vehicle Accidents (MVA) Expl: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.Pg. 2048

Which of the following is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

Which of the following is inconsistent as a cardinal sign of brain death?

No brain waves

The most common cause of cholinergic crisis includes which of the following?

Overmedication

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Paresthesia Expl: When a client reports numbness and tingling in an area, he is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis. Pg. 1134

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

16. Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?

The client with a basilar fracture Expl: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly. 2035

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

chewing

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma Expl: The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive. 2042

slow bounding pulse and respiratory irregularities changes in blood pressure, pulse, and respiration

early signs of icp

ICP levels

usually measured in the lateral ventricles normal pressure being 0 to 10 mm Hg 15 mm Hg being the upper limit of normal

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5 Expl:(50 mg/80 mg) X 0.8 mL = 0.5 mL

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

1.6 Expl: (100 mg/125 mg) x 2 mL = 1.6 mL. Pg. 2051

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? A. calcium-channel blocker B. beta-blocker C. nitrate D. thrombolytic

A. calcium-channel blocker

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?

An area of bruising over the mastoid bone Expl: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull fractures are suspected when cerebrospinal fluis (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak. 2035

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for

An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding. pg 2037

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma Expl: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura. Pg. 2037

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?

Antibodies are removed from the plasma.

Which of the following nursing interventions is appropriate for a patient with double vision in the right eye due to MS?

Apply an eye patch to the right eye.

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolytic stockings prior to elevation of the head. Expl: Anti-embolytic stockings will improve venous return from the legs. An abdominal binder will also encourage venous return. The nurse should allow time for a slow progression from laying to sitting. Vasopressor drugs may be used to treat the profound vasodilation.2057

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client?

Apply warm or cool cloths to the forehead or back of the neck

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Aspiration of a brain abscess

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and then regains consciousness immediately. The first initial action by the nurse should be:

Assess the patient for a possible head injury

Which of the following is the priority nursing intervention for a patient in myasthenic crisis?

Assessing respiratory effort

Which drug should be available to counteract the effect of Tensilon?

Atropine

Which phase of a migraine headache usually lasts less than an hour?

Aura

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction?

B

Which of the following types of skull fractures may be evident by Battle's sign?

Basilar

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar Expl: Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).Pg. 2035

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician. Expl: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate. Providing information on that suggestion is appropriate. Pg. 2058

If a client were to develop rheumatic carditis, which cardiac structure would most likely be affected? A. coronary arteries B. inferior vena cava C. septum D. mitral valve

D. mitral valve In rheumatic carditis, cardiac structures that usually are affected include the heart valves (particularly the mitral valve), endocardium, myocardium, and pericardium.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

Ecchymosis over the mastoid Expl: With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose. Pg. 2035

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

Epidural Hematoma Expl: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.2036

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?

Headache and nuchal rigidity

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure?

Hydralazine hydrochloride (Apresoline) IV administered slowly Expl: If measures to identify and address a trigger do not relieve the hypertension and excruciating headache, a ganglionic blocking agent (hydralazine hydrochloride [Apresoline]) is prescribed and administered slowly by the IV route. 2057

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury Expl: Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintinence of the airway. 2040

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event. Expl: The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure. Pg. 2034

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?

Notify the physician of a possible cerebrospinal fluid leak.

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Osteoporosis

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Phenobarbital

Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?

Prevention of joint contractures

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

Subdural

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

Subdural hematoma

Which of the following is NOT a manifestation of Cushing's Triad?

Tachycardia Expl: Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad. Pg. 2042

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following?

Vasopressin therapy

A client with a neurologic impairment reports to his home care nurse that he has been having problems with constipation. Which of the following foods might the nurse recommend?

Vegetables

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

8. Which of the following is the most common cause of spinal cord injury (SCI)?

a. Motor vehicle crashes

What is one of the earliest signs of increased ICP?

decreased level of consciousness (LOC)

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

increase the frequency of the catheterizations.

The primary North American vector transmitting arthropod-borne virus encephalitis is the

mosquito

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

shivering in hypothermia can increase ICP.

25. A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

small amount of yellow drainage at the left pin insertion site

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

The Monro-Kellie hypothesis explains

the dynamic equilibrium of cranial contents.

Monro-Kellie hypothesis

theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents— brain tissue, blood, or cerebrospinal fluid— causes a change in the volume of the others;

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

unequal response

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

vomits

A mother brings her 6-year-old to the emergency department (ED) after the child fell off a bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain." Expl: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. Options A, B, and C are incorrect as they give incorrect information to the mother. Pg. 2037

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating." Expl: Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. 2056

Increase ICP causes

-tumor -hydrocephalis -encophalitis/meningitis -injury -hematoma -bleeding -high csf

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site Expl: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective. pg 2056

The nurse has completed a teaching session on self-administration of sublingual nitroglycerin. Which client statement indicates that the teaching has been effective? A. "I can take nitroglycerin before sex so I won't develop chest pain". B. "I can put the nitroglycerin tablets in my daily pill dispenser with my other medications". C. "Side effects of nitroglycerin include flushing, throbbing headache, and hypertension". D. "After taking two tablets with no relief, I should call EMS."

A. "I can take nitroglycerin before sex so I won't develop chest pain".

The medical plan of treatment for chronic mitral regurgitation would include medications to reduce afterload, such as: A. Angiotensin-converting enzyme (ACE) inhibitors. B. Anticoagulants. C. Vasodilators. D. Diuretics

A. Angiotensin-converting enzyme (ACE) inhibitors. Afterload reduction refers to arterial dilation, which occurs with ACE inhibitors.

The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder? A. Aortic regurgitation B. Mitral insufficiency C. Tricuspid insufficiency D. Tricuspid stenosis

A. Aortic regurgitation The pulse pressure (i.e., difference between systolic and diastolic pressures) is considerably widened in patients with aortic regurgitation. One characteristic sign is the water-hammer (Corrigan's) pulse, in which the pulse strikes a palpating finger with a quick, sharp stroke and then suddenly collapses.

The nurse is working a cardiac care unit with a client on a diltizem intravenous drip for atrial fibrillation. What are electrocardiogram (ECG) changes that suggest the client is responding to the treatment? Select all that apply. A. decreasing R to R interval B. an absent P wave C. T-wave inversion D. slowing heart rate E. ST elevation

A. decreasing R to R interval D. slowing heart rate The ECG changes that occur with an MI are seen in the leads that view the involved surface of the heart. The expected ECG changes are T-wave inversion, ST-segment elevation, and development of an abnormal Q wave. The diltezam will slow the heart rate and decrease the R to R interval.

The nurse is assessing a client with suspected postpericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome? A. pericardial friction rub B. hypothermia C. decreased erythrocyte sedimentation rate (ESR) D. Decreased white blood cell (WBC) count

A. pericardial friction rub Postpericardiotomy syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR. Hypothermia is not a symptom of postpericardiotomy syndrome.

The child is having a seizure activity displayed as suddenly dropping a cup of soda but not falling. Her face looked blank and the eyelids were twitching. The child does not recall anything after the seizure denies an aura and was not incontinent. What term would best describe this seizure?

Absence Seizure

The nurse is caring for a patient who is being assessed for brain death. Which of the following are cardinal signs of brain death? Select all that apply.

Absence of brain stem reflexes Apnea Coma

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities Expl: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities. Pg. 2053

A 67-year-old firefighter now has a neurological defect and has been informed that he will be transferred to a nursing home because his son is unable to care for him at home. While receiving a bed bath, the patient yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified

Acute Expl: Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury. Pg. 2037

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Alcohol use, Young age, and Drug Abuse Expl: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention. Pg. 2048

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia Expl: Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury. Pg. 2057

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia Expl: Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis. 2057

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? A. Hyperkalemia B. Atelectasis C. Urinary tract infection (UTI) D. Elevated blood glucose level

B. Atelectasis Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin? A. Diltiazem B. Clopidogrel C. Felodipine D. Amlodipine

B. Clopidogrel Clopidogrel or ticlopidine is given to clients who are allergic to aspirin or are given in addition to aspirin to clients who are at high risk for MI. Amlodipine, diltiazem, and felodipine are calcium channel blockers.

A client is admitted for treatment of Prinzmetal's angina. When developing this client's care plan, the nurse should keep in mind that this type of angina is a result of what trigger? A. The same type of activity that caused previous angina episodes. B. Coronary artery spasm. C. An unpredictable amount of activity. D.Activities that increase myocardial oxygen demand.

B. Coronary artery spasm. Prinzmetal's angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; anginal pain becomes increasingly severe.

Which is a modifiable risk factor for coronary artery disease (CAD)? A. Increasing age B. Diabetes mellitus C. Race D. Gender

B. Diabetes mellitus While diabetes mellitus cannot be cured, blood glucose and symptomatology can be managed through healthy living. Gender, race, and increasing age are nonmodifiable risk factors.

A young mother brings her 4-year-old in to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The mother states the child has been healthy until about 3 weeks ago when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis? A. Staphylococcus aureus B. Group A beta-hemolytic strep C. Epstein-Barr virus D. Streptococcus viridians

B. Group A beta-hemolytic strep The inflammatory symptoms of rheumatic carditis are believed to be induced by antibodies originally formed to destroy the group A beta-hemolytic streptococcal microorganisms. Staphylococcus aureus and Streptococcus viridians are associated with infectious endocarditis. The Epstein-Barr virus is associated with myocarditis.

Which is a modifiable risk factor for coronary artery disease (CAD)? A. Family history B. Hyperlipidemia C. Male gender D. Increasing age

B. Hyperlipidemia Other modifiable risk factors for CAD include tobacco use, hypertension, diabetes, metabolic syndrome, obesity, and physical inactivity. Increasing age, male gender, and family history are nonmodifiable risk factors for CAD.

A nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize? A. Store the drug in a cool, well-lit place. B. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. C. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses. D. Restrict alcohol intake to two drinks per day.

B. Lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. The nurse should instruct the client to lie down or sit in a chair for 5 to 10 minutes after taking the drug. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container because sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.

The nurse is caring for a client who is being evaluated for lipid-lowering medication. The client's laboratory results reveal the following: total cholesterol 230 mg/dL, LDL 120 mg/dL, triglyceride level 310 mg/dL. Which class of medications would be most appropriate for the client based on these laboratory findings? A. HMG-CoA reductase inhibitor B. Nicotinic acid C. Fibric acid D. Bile acid sequestrant

B. Nicotinic acid The most appropriate class of medications based on the client's laboratory findings would be nicotinic acid. This class of medications is prescribed for clients with minimally elevated cholesterol and LDL levels or as an adjunct to a statin when the lipid goal has not been has not been achieved and triglyceride levels are elevated.

Which mitral valve condition generally produces no symptoms? A. Regurgitation B. Prolapse C. Stenosis D. Infection

B. Prolapse Mitral valve prolapse is a deformity that usually produces no symptoms and has been diagnosed more frequently in recent years, probably as a result of improved diagnostic methods. Mitral valve stenosis usually causes progressive fatigue. Mitral valve regurgitation, in its acute stage, usually presents as severe heart failure. Mitral valve infection, when acute, produces symptoms typical of infective endocarditis.

A client with a recent history of atrial fibrillation has been prescribed warfarin. What action will the nurse take to confirm safe dosing? A. Review the client's most recent warfarin blood levels. B. Review the client's international normalized ratio (INR). C. Assess the client's apical pulse. D.Assess the client's radial pulse.

B. Review the client's international normalized ratio (INR). Warfarin doses are adjusted on the basis of the client's INR. Blood levels are not taken for the drug, and the client's heart rate is not the indicator of efficacy or safety.

A nurse is conducting a heath history on a client with a primary diagnosis of mitral stenosis. Which disorder reported by the client is the most common cause of mitral stenosis? A. Atrial fibrillation B. Rheumatic endocarditis C. Myocardial infarction D. Congestive heart failure

B. Rheumatic endocarditis Mitral stenosis is most often caused by rheumatic endocarditis, which progressively thickens the mitral valve leaflets and chordate tendineae. Leaflets often fuse together. Eventually, the mitral valve orifice narrows and progressively obstructs blood flow into the ventricle.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? A. Impaired gas exchange B. Risk for infection C. Chronic pain D. Impaired memory

B. Risk for infection Clients with endocarditis have a Risk for infection. The nurse should stress to the client that he'll need to continue antibiotics for a minimum of 5 years and that he'll need to take prophylactic antibiotics before invasive procedures for life. There is no indication that the client has Chronic pain or Impaired memory. Because the client doesn't have valvular damage, Impaired gas exchange doesn't apply.

Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy? A. a nonambulatory client B. a client with a chronic, nonhealing skin lesion C. a client whose ulcer includes necrotic tissue D. a client with an infected stasis ulcer

B. a client with a chronic, nonhealing skin lesion Chronic, nonhealing skin lesions are treated with topical hyperbaric oxygen therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Necrotic tissue is debrided from a stasis ulcer. A client's infection is treated with an application of Silvadene, an antibacterial cream, or an antibiotic ointment and an occlusive transparent dressing such as Tegaderm that traps moisture and speeds healing.

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?

Body temperature Expl: It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor. Pg 2042

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

Which signs are manifestations of the Cushing triad? Select all that apply.

Bradycardia Hypertension Bradypnea

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication? A. 280-300 mg/dL B. 210-240 mg/dL C. 160-190 mg/dL D. 250-275 mg/dL

C. 160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

When starting a client on oral or I.V. diltiazem, for which potential complication should the nurse monitor? A. Hypertension B. Renal failure C. Atrioventricular block D. Flushing

C. Atrioventricular block The chief complications of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reported reactions include flushing, nocturia, and polyuria, but not renal failure. Although flushing may occur, it's an adverse reaction, not a potential complication.

While receiving a heparin infusion to treat deep vein thrombosis, a client reports bleeding in the gums when brushing teeth. What should the nurse do first? A. Stop the heparin infusion immediately. B. Administer a coumarin derivative, as ordered, to counteract heparin. C. Notify the health care provider. D. Reassure the client that bleeding gums are a normal effect of heparin.

C. Notify the health care provider. Because heparin can cause bleeding gums that may indicate excessive anticoagulation, the nurse should notify the health care provider, who will evaluate the client's condition. The health care provider should order laboratory tests such as partial thromboplastin time before concluding that the client's bleeding is significant. The ordered heparin dose may be therapeutic rather than excessive, so the nurse shouldn't discontinue the heparin infusion unless the health care provider orders this after evaluating the client. Protamine sulfate, not a coumarin derivative, is given to counteract heparin. Heparin doesn't normally cause bleeding gums.

A client is being evaluated for coronary artery disease (CAD) and is scheduled for an electron beam computed tomography (EBCT). The nurse understands that the primary advantage of this radiologic test is which of the following? A. Clear images B. Less invasive procedure C. Quantifies calcified plaque D. Less exposure to radiation

C. Quantifies calcified plaque The primary advantage of EBCT is to detect and quantify calcified plaque in the coronary arteries even before symptoms arise. EBCT is noninvasive and provides clearer images with less exposure to radiation than a CT scan but not the primary reason for use.

A nurse is preparing a teaching plan regarding biological tissue valve replacement. What is a disadvantage of this type of valve replacement? A. The patient's infections are easier to treat. B. The patient must take lifelong anticoagulant therapy. C. The valve has to be replaced frequently. D. There is a low incidence of thromboembolism.

C. The valve has to be replaced frequently. Biological valves deteriorate and need to be replaced frequently. They do not necessitate accompanying anticoagulant therapy. Infections are easier to treat and the risk of thromboembolism is lower as compared with mechanical valves.

A client is beginning to have more breathlessness with aortic stenosis. What is the treatment does the nurse anticipate for the client? A. cardiac catheterization B. cardiac graft procedure C. balloon valvuloplasty D. balloon angioplasty

C. balloon valvuloplasty Additional treatment eventually becomes critical because average survival is 2 to 3 years once symptoms develop. Balloon valvuloplasty is an invasive, nonsurgical procedure to enlarge a narrowed valve opening. Balloon angioplasty, cardiac catheterization, and cardiac graft procedure are not indicated treatments for symptomatic aortic stenosis.

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? A. cerebral bleeding B. skeletal muscle damage due to a recent fall C. myocardial necrosis D. I.M. injection

C. myocardial necrosis An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injuries such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.

The nurse is caring for a client after cardiac surgery. What is the most immediate concern for the nurse? A. weight gain of 6 ounces B. bilateral rales and rhonchi C. potassium level of 6 mEq/L D. serum glucose of 124 mg/dL

C. potassium level of 6 mEq/L Changes in serum electrolytes should be immediately reported, especially a potassium level of 6 mEq/L. An elevated blood sugar is common postoperatively, and the weight gain is not significant. The abnormal breath sounds are of concern, but the electrolyte imbalance is the most immediate condition that needs to be addressed.

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5 Expl: At level C5, there is full head and neck control. At C1 there is little or no sensation or control of the head and neck. At C2 to C3 there is head and neck sensation and some neck control. At C4 there is good head and neck sensation and motor control. Pg. 2052

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

C5 Expl: The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation. 2052

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be

Concussion A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time. Pg. 2037

Which describes a valve used in replacement surgery that is made from the client's own heart valve? A. Homograft B. Allograft C. Xenograft D. Autograft

D. Autograft An example of an autograft is when the surgeon excises the pulmonic valve and uses it for an aortic valve replacement. An allograft, also called a homograft, refers to replacement using human tissue. Xenograft refers to animal tissue used in tissue replacement.

A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display? A. Cholesterol plugs in the lumen of veins B. Blood clots in the arteries C. Emboli in the veins D. Fatty deposits in the lumen of arteries

D. Fatty deposits in the lumen of arteries Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.

Which of the following is inconsistent as a condition related to metabolic syndrome? A. Dyslipidemia B. Insulin resistance C. Abdominal obesity D. Hypotension

D. Hypotension A diagnosis of metabolic syndrome includes three of the following conditions: insulin resistance, abdominal obesity, dyslipidemia, hypertension, proinflammatory state, and prothrombotic state.

A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement? A. Assess the patient's chest tube output. B. Evaluate the patient's endotracheal lip line. C. Monitor the patient's chest drainage. D. Keep the patient's affected leg straight.

D. Keep the patient's affected leg straight. Balloon valvuloplasty is performed in the cardiac catheterization laboratory. A catheter is inserted into the femoral artery. The patient must keep the affected leg straight to prevent hemorrhage at the insertion site. It is not an open heart surgery requiring chest tubes nor a chest dressing. ET tubes are placed when someone has general anesthesia, and this procedure is performed using light or moderate sedation.

A nurse is caring for a client with acute mitral regurgitation related to an acute myocardial infarction. The nurse knows to monitor the client carefully for symptoms of which initial complication or result? A. Cerebral vascular accident (CVA) B. Kidney failure C. Infarcted bowel D. Severe heart failure

D. Severe heart failure Acute mitral regurgitation usually manifests as severe congestive heart failure, resulting from blood flowing backward from the left ventricle to the left atria and eventually into the lungs. Kidney failure could become a problem later if cardiac output is too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.

A client has a history of rheumatic fever as a child. Which instructions should be provided before the client has any dental work done? A. Take steroids. B. Take aspirin. C. Avoid any kind of activities. D. Take prophylactic antibiotics.

D. Take prophylactic antibiotics. Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are used to suppress the inflammatory response. Aspirin is an anticoagulant and used to control the formation of blood clots around heart valves. Many clients cannot appreciate the danger of a disease without seeing external signs of the damage. The nurse gently but firmly reminds the client to limit activity.

In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD? A. To dilate coronary arteries B. To decrease homocysteine levels C. To prevent angiotensin II conversion D. To decrease workload of the heart

D. To decrease workload of the heart Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and Bvitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.

The nurse is assessing a client admitted with acute left-sided infective endocarditis. What is the best diagnostic test to confirm the diagnosis? A. transesophageal echocardiogram B. urinalysis C. complete blood count D. blood cultures

D. blood cultures A definitive diagnosis of acute left-sided infective endocarditis is made when a micro-organism is found in two separate blood cultures. A complete blood count, urinalysis, and a transesophageal echocardiogram may contribute to the diagnosis, but are not the most definitive diagnostic tests for endocarditis.

The laboratory values for a client diagnosed with coronary artery disease (CAD) have just come back from the lab. The client's low-density lipoprotein (LDL) level is 112 mg/dL. This nurses recognizes that this value is A. extremely high. B. low. C. normal. D. high.

D. high. If the LDL level ranges from 100 mg/dL to 130 mg/dL, it is considered to be high. The goal is to decrease the LDL level below 100 mg/dL.

A client's elevated cholesterol levels are being managed with atorvastatin daily. What is a common side effect the nurse will teach the client that will require monitoring? A. hyperglycemia B. severe muscle pain C. hyperuricemia D. increased liver enzymes

D. increased liver enzymes Myopathy and increased liver enzymes are significant side effects of the statin Lipitor. Hyperuricemia occurs when too much uric acid is present in the blood; it is not a side effect of the statins. Hyperglycemia is increased blood glucose, which is not a side effect of the statins. Severe muscle pain is an adverse effect of statins, but it does not require monitoring.

A client has been brought to the Emergency Department (ED) after a fall off a roof. The client has no cord function below the point of injury. The ED nurse knows what about this client?

The client is in spinal shock.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

13. A 67-year-old client who was involved in a motor-vehicle collision is brought to the emergency department. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders that the client be prepared for surgery. In preparing the client for surgery, which of the following would be the least likely intervention you would expect?

a. Preoperative sedation

20. A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

a. Risk for injury related to neurologic deficit

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

When the nurse observes that the client has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the client's posture as

decerebrate

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign.

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency."

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

The nurse administers propranolol hydrochloride to a patient with a heart rate of 64 beats per minute (bpm). One hour later, the nurse observes the heart rate on the monitor to be 36 bpm. What medication should the nurse prepare to administer that is an antidote for the propranolol? A. Atropine B. Sodium nitroprusside C. Digoxin D. Protamine sulfate

A. Atropine Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). A dose of IV atropine is usually given to treat this response.

The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD? A. High-density lipoprotein (HDL), 80 mg/dL B. Cholesterol, 280 mg/dL C. A ratio of LDL to HDL, 4.5 to 1.0 D. Low density lipoprotein (LDL), 160 mg/dL

A. High-density lipoprotein (HDL), 80 mg/dL A fasting lipid profile should demonstrate the following values (Alberti et al., 2009): LDL cholesterol less than 100 mg/dL (less than 70 mg/dL for very high-risk patients); total cholesterol less than 200 mg/dL; HDL cholesterol greater than 40 mg/dL for males and greater than 50 mg/dL for females; and triglycerides less than 150 mg/dL.

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks? A. Troponin B. Total creatine kinase C. CK-MB D. Myoglobin

A. Troponin Troponin remains elevated for a long period, often as long as 2 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin peaks within 12 hours after the onset of symptoms. Total creatine kinase (CK) returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days.

The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with A. percutaneous coronary intervention (PCI). B. IV nitroglycerin. C. IV heparin. D. thrombolytics.

A. percutaneous coronary intervention (PCI). The client with a STEMI is often taken directly to the cardiac catheterization laboratory for an immediate PCI. Superior outcomes have been reported with the use of PCI compared to thrombolytics. IV heparin and IV nitroglycerin are used to treat NSTEMI.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours

The nurse completes an assessment of a client with mitral regurgitation. What statement represents the appropriate physical finding for a client with this condition? A. "I knew I would hear a diastolic murmur at the left sternal border." B. "The high-pitched blowing sound at the apex is indicative of a systolic murmur." C. "I auscultated a mitral click." D. "I heard a low-pitched diastolic murmur at the apex."

B. "The high-pitched blowing sound at the apex is indicative of a systolic murmur." A systolic murmur is heard as a high-pitched, blowing sound at the apex. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath on exertion, and cough from pulmonary congestion also occur. A mitral click will be present with valve replacement. A diastolic murmur is not heard with mitral regurgitation.

A nurse plans to have an education session with a client with cardiomyopathy and the client's spouse about ways to increase activity tolerance. What instructions would the nurse provide? A. Gradually work up to strenuous activity. B. Alternate active periods with rest periods. C. Avoid all physical and emotional stress. D. Include isometric exercises in the daily routine.

B. Alternate active periods with rest periods. The client should plan activities to occur in cycles, alternating rest with active periods. The client with cardiomyopathy must avoid strenuous activity and isometric exercises. It is impossible to avoid all physical and emotional stress.

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for? A. Hypertension B. Cardiac tamponade C. Decreased venous pressure D. Left ventricular hypertrophy

B. Cardiac tamponade The inflammatory process of pericarditis may lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade (see Chapter 29).

The nurse has created a care plan for a client admitted with acute pericarditis and a nursing diagnosis of acute pain related to pericardial inflammation. What is an appropriate nursing intervention for this client? A. Administering around-the-clock opioids as prescribed B. Placing the patient in the high-Fowler's position with an over-the-bed table for the patient to lean on C. Positioning the patient on the right side with the head of the bed elevated 15 degrees D. Promoting progressive relaxation techniques with the use of slow, deep breathing

B. Placing the patient in the high-Fowler's position with an over-the-bed table for the patient to lean on Clients with acute pericarditis require pain management with analgesics, positioning, and psychological support. Relief of pain is achieved by rest. Because sitting upright and leaning forward is the posture that tends to relieve pain, chair rest may be more comfortable. The pain has a sharp, pleuritic quality that changes with respiration, and patients take shallow breaths. Anti-inflammatory medications may be used to help pain; opioids are not usually indicated.

Which valve lies between the right ventricle and the pulmonary artery? A. Tricuspid valve B. Pulmonic valve C. Chordae tendineae D. Mitral valve

B. Pulmonic valve The pulmonic valve is a semilunar valve located between the right ventricle and the pulmonary artery. The tricuspid valve is an atrioventricular valve located between the right atrium and right ventricle. The mitral valve is an atrioventricular valve located between the left atrium and left ventricle. Chordae tendineae anchor the valve leaflets to the papillary muscle and ventricular wall.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture Expl: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Pg. 2035

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body temperature

Which one of the following signs and symptoms would be an indication of increased intracranial pressure in infants?

Bulging fontanels

A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client? A. Raynaud's disease B. Cardiogenic shock C. Coronary artery disease D. Venous occlusive disease

C. Coronary artery disease The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud's disease in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.

Which action will a public health nurse include when planning ways to decrease the incidence of rheumatic fever in the community? A. Educate individuals in the community about the importance of monitoring temperature when infections occur. B. Encourage susceptible groups in the community to receive immunizations with streptococcal vaccine. C. Teach individuals in the community to seek medical treatment for streptococcal pharyngitis. D. Provide prophylactic antibiotics to individuals with a family history of rheumatic fever.

C. Teach individuals in the community to seek medical treatment for streptococcal pharyngitis. Prevention of acute rheumatic fever is dependent upon effective antibiotic treatment of streptococcal pharyngitis. Family history is not a risk factor for rheumatic fever. No immunization effectively decreases the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever.

Which s the analgesic of choice for acute myocardial infarction (MI)? A. Ibuprofen B. Meperidine C. Aspirin D. Morphine

D. Morphine The analgesic of choice for acute MI is morphine administered in IV boluses to reduce pain and anxiety. Aspirin is an antiplatelet medication. Meperidine and Ibuprofen are not the analgesics of choice.

Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty? A. Remove hair from skin insertion sites. B. Inform client of diagnostic tests. C. Assess distal pulses. D. Withhold anticoagulant therapy.

D. Withhold anticoagulant therapy. The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

Establishing an intermittent catheterization routine every 4 hours Expl. The paraplegic client with an L1-L2 injury will demonstrate flaccid paralysis. Developing an intermittent catheterization routine offers a way of manually draining the bladder, eliminating the need for an indwelling urinary catheter. With an injury at L1-L2, ambulation may be possible with long leg braces but not with short leg braces. Spasticity and autonomic dysreflexia are seen in clients with upper motor injuries above T6, not L1-L2 injuries. Pg. 2056

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

Grade 3 concussion Expl: There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.

Hypertension, Diaphoresis, Nasal congestion Expl: Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the client may be diaphoretic, a fever does not accompany this condition. 2057

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern Expl: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern. Pg. 2051-2052

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

Insertion of a nasogastric tube Expl: Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary. Pg. 2056

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Loss of consciousness or Change in level of consciousness Expl: The earliest sign of increasing ICP is loss of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing Pg. 2034

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

More than 200 mL/h

Which are characteristics of autonomic dysreflexia?

Severe hypertension, slow heart rate, pounding headache, sweating Expl: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur. Pg. 2057

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?

The first thoracic vertebrae Expl: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae. 2048

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?

Turn the client to the side

Neurological testing of the patient by the nurse indicates impaired functioning of the left Glossopharyngeal nerve (CN IX) and the Vagus nerve (CN X) Based on these findings the nurse plans to:

Withhold oral fluids or foods

3. Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

a. Apply elastic stockings to lower extremities

26. A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?

a. Basilar i. Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture. A simple (linear) fracture is a break in the continuity of the bone. A comminuted fracture refers to a splintered or multiple fracture line.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

15. A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

Which Glasgow Coma Scale score is indicative of a severe head injury?

7 Expl: A score between 3 and 8 is generally accepted as indicating a severe head injury. (Less than 8, INTUBATE!)

An asymptomatic client questions the nurse about the diagnosis of mitral regurgitation and inquires about continuing an exercise routine. Which is the most appropriate response by the nurse? A. "Continue the exercise routine unless symptoms such as shortness of breath or fatigue develop." B. "Avoid strenuous cardiovascular exercise." C. "Avoid any type of exercise." D. "Continue the exercise routine but take ample rest after exercising."

A. "Continue the exercise routine unless symptoms such as shortness of breath or fatigue develop." Exercise is not limited until mild symptoms develop. Once symptoms of heart failure develop, the client needs to restrict his or her activity level to minimize symptoms. It is not important for an asymptomatic client to avoid exercise and to take ample rest after exercise.

The nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement? A. "I have to call my doctor so I can get antibiotics before seeing the dentist." B. "Can I take the antibiotics as a pill now?" C. "I need a referral to a dietician to understand a low-sodium diet." D. "If I quit smoking, it will help the endocarditis."

A. "I have to call my doctor so I can get antibiotics before seeing the dentist." Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after dental procedures.

A client asks the clinic nurse what the difference is between arteriosclerosis and atherosclerosis. What is the nurse's best response? A. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age. B. Atherosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age. C. Arteriosclerosis is a formation of clots in the inner lining of the arteries. D. Atherosclerosis is a formation of clots in the inner lining of the arteries.

A. Arteriosclerosis is a loss of elasticity, or hardening of the arteries, that happens as we age. Arteriosclerosis refers to the loss of elasticity or hardening of the arteries, that accompanies the aging process. Therefore, options B, C, and D are incorrect.

A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease? A. Assess chest pain and administer prescribed drugs and oxygen B. Assess the client's physical history C. Assess blood pressure and administer aspirin D. It is not important to assess the client or to notify the physician

A. Assess chest pain and administer prescribed drugs and oxygen The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply. A. Balance rest with activity. B. Carry nitroglycerin at all times. C. Stop smoking. D. Follow a diet high in saturated fats. E. Avoid all physical activity.

A. Balance rest with activity. B. Carry nitroglycerin at all times C. Stop smoking. Managing angina pectoris at home includes balancing rest with activity, participating in a regular daily program of activities that do not induce angina pain, stopping smoking, carrying nitroglycerin at all times, and following a diet low in saturated fat.

Clients with myocarditis are sensitive to which medication? A. Digoxin B. Corticosteroids C. Penicillin D. Furosemide

A. Digoxin The nurse must closely monitor these clients for digoxin toxicity, which is evidenced by arrhythmia, anorexia, nausea, vomiting, headache, and malaise. If the cause of the myocarditis is hemolytic streptococci, penicillin will be given. The use of corticosteroids remains controversial.

A client who had coronary artery bypass surgery is exhibiting signs of heart failure. What medications will the nurse anticipate administering for this client? Select all that apply. A. digoxin B. nitroprusside C. amlodipine D. diuretics E. inotropic agents

A. digoxin D. diuretics E. inotropic agents Medical management of cardiac failure includes digoxin, diuretics, and IV inotropic agents. Amlodipine and calcium channel blockers are not used due to systolic dysfunction. Nitroprusside is a vasodilator that is not used for heart failure.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

A client presents to the emergency department reporting chest pain. Which order should the nurse complete first? A. Troponin level B. 12-lead ECG C. 2 L oxygen via nasal cannula D. Aspirin 325 mg orally

B. 12-lead ECG The nurse should complete the 12-lead ECG first. The priority is to determine whether the client is suffering an acute MI and implement appropriate interventions as quickly as possible. The other orders should be completed after the ECG.

The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's international normalized ratio is 2.7. What action will the nurse take? A. Asses the client for abnormal bleeding. B. Administer the medication as ordered. C. Hold the medication and notify the HCP. D. Prepare to administer vitamin K.

B. Administer the medication as ordered. Patients with mechanical valve replacements who take warfarin usually have individualized target international normalized ratios (INRs) between 2.0 and 3.5. The nurse would give the medication as ordered. There is no need to adminsiter the antidote vitamin K. The medication should not be held because the INR is normal. The client should not have bleeding with the normal INR.

The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult? A. Coronary thrombosis B. Atherosclerosis C. Arteriosclerosis D. Raynaud's disease

B. Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.

The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)? A. Ventricular tachycardia B. Atrial fibrillation C. First-degree atrioventricular block D. Sinus dysrhythmia

B. Atrial fibrillation In mitral stenosis, the pulse is weak and often irregular because of atrial fibrillation (caused by strain on the atrium).

The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?"The nurse is most safe to speculate which of the following? A. From the fecal-oral route B. From a break in the skin C. From ingestion of a food D. From droplets from a cough

B. From a break in the skin The microorganisms that cause infective endocarditis include bacteria and fungi. Streptococci and staphylococci are the bacteria most frequently responsible for this disorder. Both bacteria are abundantly found on the skin. These organisms are not found in the other locations.

The nurse is beginning discharge teaching with a client diagnosed with a myocardial infarction (MI). The nurse will include teaching on what medications? Select all that apply. A. morphine B. aspirin C. enalapril D. atorvastatin E. sildenafil

B. aspirin C. enalapril D. atorvastatin Upon client discharge, there needs to be documentation that the client was discharged on a statin (atorvastatin), an ACE or angiotensin receptor blocking agent (enalapril), and aspirin. Morphine is used to reduce the client's pain and anxiety. Sildenafil is a medication used for pulmonary hypertension.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse? A. "Nitroglycerine causes headaches, but removing the patch decreases the incidence." B. "You do not need the effects of nitroglycerine while you sleep." C. "Removing the patch at night prevents drug tolerance while keeping the benefits." D. "Contact dermatitis and skin irritations are common when the patch remains on all day."

C. "Removing the patch at night prevents drug tolerance while keeping the benefits." Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while the client rests, there is less demand on the heart but not the primary reason for removing the patch.

The nurse is teaching a client with suspected acute myocardial infarction about serial isoenzyme testing. When is it best to have isoenzyme creatinine kinase of myocardial muscle (CK-MB) tested? A. 2 to 3 hours after admission B. 12 to 18 hours after admission C. 4 to 6 hours after pain D. 30 minutes to 1 hour after pain

C. 4 to 6 hours after pain Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.

A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? A. Cool, clammy skin and a diaphoretic, pale appearance B. Intermittent nausea and emesis for 3 days C. Chest discomfort not relieved by rest or nitroglycerin D. Anxiousness, restlessness, and lightheadedness

C. Chest discomfort not relieved by rest or nitroglycerin Chest pain or discomfort not relieved by rest or nitroglycerin is associated with an acute MI. The other findings, although associated with acute coronary syndrome or MI, may also occur with angina and, alone, are not indicative of an MI.

A clientt is given a prescription for metoprolol after being examined by the health care provider. What is the most important teaching for the nurse to give to the client? A. If dizziness occurs, adjust the medication. B. Take the medication at the same time each day. C. Don't suddenly stop taking the medication without calling your health care provider. D. Dress warmly. Blood circulation may be reduced in the extremities.

C. Don't suddenly stop taking the medication without calling your health care provider. All teaching points need to be covered, but the nurse needs to emphasize that metoprolol should not be suddenly stopped because some conditions can become worse.

In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum? A. Restrictive B. Dilated C. Hypertrophic D. Arrhythmogenic right ventricular

C. Hypertrophic Because of structural changes, hypertrophic cardiomyopathy had also been called idiopathic hypertrophic subaortic stenosis or asymmetric septal hypertrophy. Restrictive cardiomyopathy is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. What type of MI did this client have? A. lateral. B. inferior. C. anterior. D. posterior.

C. anterior. An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. Posterior, lateral, and inferior MI aren't usually associated with heart failure.

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Expl: Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Pg. 2036

A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complication(s)? A. Bleeding and wound dehiscence B. Evisceration C. Thrombosis and infection D. Bleeding and infection

D. Bleeding and infection Possible complications of an aortic balloon valvuloplasty include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, infection, and bleeding from the catheter insertion sites.

The nurse understands that which of the following medications will be administered to the client for 6 to 12 weeks following prosthetic porcine valve surgery? A. Digoxin B. Furosemide C. Aspirin D. Warfarin

D. Warfarin To reduce the risk of thrombosis in patients with porcine or bovine tissue valves, warfarin is required for 6 to 12 weeks, followed by aspirin therapy. Furosemide would not be given for 6 to 12 weeks following this type of surgery. Digoxin may be used for the treatment of arrhythmias, but not just for 6 to 12 weeks.

The nurse is performing a medication review of a client diagnosed with myocarditis. What medication may have precipated the client to have myocarditis? A. furosemide B. acetaminophen C. ciprofloxacin D. azathioprine

D. azathioprine Azathioprine is an immunosuppressive medication that can cause myocarditis. Furosemide is a diuretic and acetaminophen is an antiimflammatory; they are not known to cause myocarditis.Ciprofloxacin is a antibiotic not known to precipitate myocarditis.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Flat, except for logrolling as needed Expl: When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on. 2038

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?

Ineffective airway clearance related to altered LOC

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?

Multiple sclerosis (MS)

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Muscle weakness and hyporeflexia of the lower extremities

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?

Positive Kernig's sign

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

Neurological level of spinal cord injury refers to which of the following?

The lowest level at which sensory and motor function is normal. Expl:"Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal. 2048

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:

famotidine (Pepcid). Expl: Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant. 2051

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mmHg

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number ONLY.

97.5 g

Which of the following is the most common complication of prosthetic valves? A. Thromboembolism B. Infection C. Arrhythmias D. Hemolysis

A. Thromboembolism Thromboembolism is the most common complication of prosthetic valves and long-term anticoagulation with warfarin is initiated 48 hours after surgery. Overall, patients are at risk for thromboembolism, infection, arrhythmias, and hemolysis.

A nurse is teaching a client about mitral stenosis and the effect on blood flow in the heart. What is teaching point of the disruption to the normal flow of blood through the heart from the mitral stenosis? A. increased resistance of a narrowed orifice between the left atrium and the left ventricle B. atrial hypertrophy C. pulmonary circulation congestion D. inadequate left and right ventricle filling

A. increased resistance of a narrowed orifice between the left atrium and the left ventricle Left atrial pressure increases because of the slowed blood flow into the LV through the narrowed orifice. The left atrium dilates and hypertrophies because of the increased blood volume. Pulmonary venous pressure rises, and the circulation becomes congested. As a result, the RV and right atrium become enlarged. Eventually, the ventricle fails.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? A. rheumatic fever

A. rheumatic fever Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, may eventually lead to hypertension but doesn't damage heart structures.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

An Atlered level of consciousness (LOC) Expl: The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated. Pg. 2037

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone Expl: Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea. Pg. 2035

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

Apply elastic stockings to lower extremities. Expl: To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas. Pg.2054

he nurse completes an assessment of a client admitted with pericarditis. What client symptom will the nurse correlate with the diagnosis of pericarditis? A. dyspnea B. reports of constant chest pain C. elevated ESR and CRP D. fatigue lasting more than 1 month

B. reports of constant chest pain The most characteristic symptom of pericarditis is chest pain. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Other signs may include a mild fever, increased WBC count, anemia, and an elevated ESR or C-reactive protein level. Dyspnea and other signs and symptoms of heart failure may occur.

A client with a family history of coronary artery disease reports experiencing chest pain and palpitations during and after morning jogs. What would reduce the client's cardiac risk? A. exercise avoidance B. smoking cessation C. a protein-rich diet D. antioxidant supplements

B. smoking cessation The first line of defense for clients with CAD is lifestyle changes including smoking cessation, weight loss, stress management, and exercise. Clients with CAD should eat a balanced diet. Clients with CAD should exercise, as tolerated, to maintain a healthy weight. Antioxidant supplements, such as those containing vitamin E, beta carotene, and selenium, are not recommended because clinical trials have failed to confirm beneficial effects from their use.

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?

Bacteria

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Expl:Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord. 2046

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body Temperature Expl: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor. Pg. 1992

The charge nurse was discussing with the nursing student that studies have been published that suggest inflammation increases the risk of heart disease. Which modifiable factor would the nursing student target in teaching clients about prevention of inflammation that can lead to atherosclerosis? A. Encourage use of a multivitamin B. Avoid use of caffeine C. Addressing obesity D. Drink at least 2 liters of water a day

C. Addressing obesity Published information by Balistreri et al. (2010) indicated a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests decreasing obesity and body fat stores may help to reduce the risk. Avoiding the use of caffeine, encouraging the use of a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to artherosclerosis.

When a patient is taking an immunosuppressant following heart transplantation, the nurse would determine which of the following as the MOST important intervention? A. Place the patient in an isolation room. B. Educate the patient regarding signs and symptoms of infection. C. Assess vital signs every 4 hours. D. Prevent exposure to potentially harmful agents such as fresh fruit.

C. Assess vital signs every 4 hours. Cyclosporine is an immunosuppressant that greatly decreases the body's rejection of foreign proteins, such as transplanted organs. Unfortunately, cyclosporine also decreases the body's ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. Assessing for signs and symptoms of infection is most important and is required prior to implementing other appropriate interventions.

Incomplete closure of the mitral valve results in backflow of blood from the: A. Left atrium to left ventricle B. Right atrium to right ventricle C. Left ventricle to left atrium D. Right ventricle to the right atrium

C. Left ventricle to left atrium Incompetent closure of the mitral valve can result from disease processes that alter valve leaflets, mitral annulus, chordae tendineae, and the papillary muscle. When mitral valve leaflets thicken, fibrose, and contract, they cannot close completely during systole. This forces blood backward from the left ventricle into the left atrium during systole.

A client has had a 12-lead ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes that this finding indicates A. an evolving MI. B. variant angina. C. an old MI. D. a cardiac dysrhythmia.

C. an old MI. An abnormal Q wave may be present without ST-segment and T-wave changes, which indicates an old, not acute, MI.

The nurse is discharging a client recently diagnosed with aortic stenosis (AS). What are symptoms associated with aortic stenosis? A. dyspnea, angina, and diastolic murmur B. syncope, diastolic murmur, and angina C. angina, syncope, and dyspnea D. diastolic murmur, syncope, and dyspnea

C. angina, syncope, and dyspnea A triad of symptoms is associated with AS: (a) angina due to left ventricular hypertrophy and diminished coronary blood flow, (b) dyspnea due to heart failure, and (c) syncope, in particular with exertion, due to fixed cardiac output. A diastolic murmur is characteristic of aortic regurgitation, whereas a systolic ejection murmur is commonly heard with aortic stenosis.

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5 Expl: At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control. Pg. 2052

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? A. "I should eat foods rich in protein." B. "I'll enroll in an aerobic exercise program." C. "I should increase my fluid intake." D. "I can still drink coffee and tea."

D. "I can still drink coffee and tea." The client requires more teaching if he states that he may drink coffee and tea. Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.

A client asks the nurse how long to wait after taking nitroglycerin before experiencing pain relief. What is the best answer by the nurse? A. 60 minutes B. 15 minutes C. 30 minutes D. 3 minutes

D. 3 minutes Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally alleviates the pain of ischemia within 3 minutes.

A patient has had cardiac surgery and is being monitored in the intensive care unit (ICU). What complication should the nurse monitor for that is associated with an alteration in preload? A. Elevated central venous pressure B. Hypothermia C. Hypertension D. Cardiac tamponade

D. Cardiac tamponade Preload alterations occur when too little blood volume returns to the heart as a result of persistent bleeding and hypovolemia. Excessive postoperative bleeding can lead to decreased intravascular volume, hypotension, and low cardiac output. Bleeding problems are common after cardiac surgery because of the effects of cardiopulmonary bypass, trauma from the surgery, and anticoagulation. Preload can also decrease if there is a collection of fluid and blood in the pericardium (cardiac tamponade), which impedes cardiac filling. Cardiac output is also altered if too much volume returns to the heart, causing fluid overload.

A nurse evaluates a client and suspects pericarditis. What indicator is considered the most characteristic symptom of pericarditis? A. Orthopnea B. Fatigue C. Dyspnea D. Chest pain

D. Chest pain The most characteristic symptom of pericarditis is chest pain. The pain is typically persistent, sharp, pleuritic, and usually felt in the mid chest, although it also may be located beneath the clavicle, in the neck, or in the left trapezius region. The discomfort is usually fairly constant, but is aggravated by deep inspiration, coughing, lying down, or turning. It may be relieved with a forward-leaning or sitting position.

The nurse is caring for a client with cardiogenic shock in an critical care unit and the family is asking about the intra-aortic balloon pump (IABP). What will the nurse explain is the premise of using IABP? A. The IABP is another machine used in the intensive care unit to keep the kidneys working. B. The IABP is helping to circulate oxygen to the body tissue. C. The IABP is acting as the heart to pump blood through the body. D. The IABP is reducing the workload of the heart during the shock period.

D. The IABP is reducing the workload of the heart during the shock period. The IABP decreases the workload of the heart by reducing left ventricular afterload. Additionally, it improves coronary artery blood flow by increasing coronary artery perfusion pressure.The IABP does not perform the work of the heart. The IABP does not directly circulate oxygen or keep the kidneys working.

The nurse is teaching a client with cardiomyopathy. Which statement is a valid teaching point? A. Clients with cardiomyopathy have a goal to improve lung function. B. The disease was inherited, so there are no reversal treatments. C. Clients with cardiomyopathy often need to live in a skilled nursing care facility. D. The treatments include medications, medical devices, surgery, or transplantation.

D. The treatments include medications, medical devices, surgery, or transplantation. Treatments for clients with cardiomyopathy include medications, medical devices such as pacemakers, internal defibrillators, surgery or transplantation. The disease is not curable or reversible. Clients with cardiomyopathy do not need to live in a skilled facility. The main goal for clients with cardiomyopathy is to improve heart function.

The nurse completes an assessment of a client admitted with pericarditis. What client symptom will the nurse correlate with the diagnosis of pericarditis? A. dyspnea B. fatigue lasting more than 1 month C. elevated ESR and CRP D. reports of constant chest pain

D. reports of constant chest pain The most characteristic symptom of pericarditis is chest pain. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Other signs may include a mild fever, increased WBC count, anemia, and an elevated ESR or C-reactive protein level. Dyspnea and other signs and symptoms of heart failure may occur.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings?

Excessive urine output and decreased urine osmolality

Bell's palsy is a disorder of which cranial nerve?

Facial (VII)

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a nasogastric (NG) tube Expl: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily. Pg. 2042-2043

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris Expl: Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.2034

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury

It results from inadequate delivery of nutrients and oxygen to the cells. Expl: Secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually as a result of cerebral edema and increased intracranial pressure. Primary injury results from initial damage related to the traumatic event. Pg. 2034

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure Expl: The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage. Pg. 2037

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:

Loss of motor power and sensation in the upper extremities. Expl: Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. 2049

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness Expl: Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body. Pg. 2043

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur. Expl: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding. Pg. 2036

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?

Observe for any signs of behavioral changes. Expl: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve. 2037

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?

Pituitary carcinoma

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the Patient in a sitting position Expl: Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower blood pressure. 2057

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place the client in a sitting position. Expl: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure. Pg 2057

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which diagnosis is appropriate?

Risk for falls related to dizziness or weakness

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury Expl: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety. Pg. 2037

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity.

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

Spasticity

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity Expl: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles. Pg. 2061

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma Expl: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma. Pg. 2037

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

Substance Abuse, Young Age, Male Gender Expl: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention. Pg. 2048

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family?

Sweating Expl: Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety. Pg. 2057

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Take daily weights. Expl: A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F Expl: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits. Pg. 2043

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear. Expl: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury. Pg 2035

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply

Verbal Response, Eye Opening, Motor Response Expl: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS. Pg. 2039

18. While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Upon his arrival via squad at the ED where you practice nursing, he regained consciousness within an hour. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?

a. Concussion i. A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.

2.Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?

a. Subdural hematoma

1.A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

a.Keep the client's neck in a neutral position (no flexing).

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to

decrease the potential for brain damage. Expl: It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. 2042

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?

poor

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor

??Extreme thirst Intake and output Nutritional status Body temperature

Which technique is used to surgically revascularize the myocardium? A. Minimally invasive direct coronary bypass B. Balloon bypass C. Peripheral bypass D. Gastric bypass

A. Minimally invasive direct coronary bypass Several techniques are used to surgically revascularize the myocardium; one of them is minimally invasive direct coronary bypass. Balloon bypass is not used to revascularize the myocardium. If the client is experiencing acute pain in the leg, peripheral bypass is performed. Gastric bypass is a surgical procedure that alters the process of digestion.

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? A. enhance myocardial oxygenation B. decrease anxiety C. educate the client about his symptoms D. administer sublingual nitroglycerin

A. enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.

A nurse is monitoring the vital signs and blood results of a client who is receiving anticoagulation therapy. What does nurse identify as a major indication of concern? A. hematocrit of 30% B. hemoglobin of 16 g/dL C. heart rate of 87 bpm D. blood pressure of 129/72 mm Hg

A. hematocrit of 30% Hematocrit is a measurement of the proportion of blood volume that is occupied by red blood cells. A lower hematocrit can imply internal bleeding. Blood pressure of 129/72 and heart rate of 87 bpm are normal. A hemoglobin count of 16 g/dL is also normal.

The nurse is reviewing the laboratory results for a client diagnosed with coronary artery disease (CAD). The client's low-density lipoprotein (LDL) level is 115 mg/dL. The nurse interprets this value as A. high. B. low. C. critically high. D. within normal limits.

A. high. The normal LDL range is 100 to 130 mg/dL. A level of 115 mg/dL is considered to be high. The goal of treatment is to decrease the LDL level below 100 mg/dL (less than 70 mg/dL for very high-risk clients).

The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse? A. Dizziness B. Extra heart sound C. Fatigue D. Syncope

B. Extra heart sound Often the first and only sign of mitral valve prolapse is identified when a physical examination of the heart reveals an extra heart sound, referred to as a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral valve prolapse.

The nurse is educating a patient diagnosed with angina pectoris about the difference between the pain of angina and a myocardial infarction (MI). How should the nurse describe the pain experienced during an MI? (Select all that apply.) A. It subsides after taking nitroglycerin. B. It is viselike and radiates to the shoulders and arms. C. It is sudden in onset and prolonged in duration. D. It is substernal in location. E. It is relieved by rest and inactivity.

B. It is viselike and radiates to the shoulders and arms. C. It is sudden in onset and prolonged in duration. D. It is substernal in location. Chest pain that occurs suddenly, continues despite rest and medication, is substernal, and is sometimes viselike and radiating to the shoulders and arms is associated with an MI. Angina pectoris pain is generally relieved by rest and nitroglycerin.

A client comes into the emergency department reporting about chest pain that gets worse when taking deep breaths and lying down. After ruling out a myocardial infarction, a nurse would assess for which diagnosis? A. Mitral valve stenosis B. Pericarditis C. Cardiomyopathy D. Rheumatic fever

B. Pericarditis The primary symptom of pericarditis is pain, which is assessed by evaluating the client in various positions. The nurse tries to identify whether pain is influenced by respiratory movements while holding an inhaled breath or holding an exhaled breath; by flexing, extending, or rotating the spine, including the neck; by moving the shoulders and arms; by coughing; or by swallowing. Recognizing events that precipitate or intensify pain may help establish a diagnosis and differentiate pain of pericarditis from pain of myocardial infarction.

A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? A. Magnesium B. Potassium C. Sodium D. Calcium

B. Potassium Hyperkalemia (high potassium) can result in the following ECG changes: tall peaked T waves, wide QRS, and bradycardia. The nurse should be prepared to administer a diuretic or an ion-exchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose. Imbalances in the other electrolytes listed would not result in peaked T waves.

The nurse is caring for a client diagnosed with aortic stenosis prescribed digoxin. What clinical manifestation will be the rationale for the medication? A. dyspnea B. left ventricular dysfunction C. edema D. angina

B. left ventricular dysfunction Digoxin may be used to treat left ventricular dysfunction. Diuretics may be used for dyspnea. Nitrates may be prescribed for the treatment of angina, but must be used with caution due to the risk of orthostatic hypotension and syncope.

A client has just arrived in the ER with a possible myocardial infarction (MI). The electrocardiogram (ECG) should be obtained within which time frame of arrival to the ER? A. 5 minutes B. 20 minutes C. 10 minutes D. 15 minutes

C. 10 minutes The ECG provides information that assists in diagnosing acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the emergency department. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored.

he nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis? A. Serum cardiac antigens B. Immunosuppressant assay C. Positive blood culture D. Complete blood count

C. Positive blood culture A positive blood culture identifies the microorganism circulating in the blood. Slight leukocytosis is common but can be associated with other disease processes. Serum cardiac antigens and immunosuppressant assay are not typical diagnostic studies.

Following cardiac surgery, the nurse assesses the client for any common complication of hypovolemia. What significant indication of a complication should the nurse monitor? A. Central venous pressure (CVP) reading of 8 mm Hg B. Heart rate of 60 bpm C. Pulmonary artery wedge pressure (PAWP) of 6 mm Hg D. Blood pressure reading of 130/95 mm Hg

C. Pulmonary artery wedge pressure (PAWP) of 6 mm Hg In the presence of hypovolemia, the circulating blood volume would be significantly decreased. Therefore, the PAWP would be lower than 8 to 10 mm Hg. The normal CVP reading (2 to 8 mm Hg) would be decreased. The heart rate would be increased and the blood pressure decreased.

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis? A. Cardiac cauterization B. Chest x-ray C. Computed tomography D. Echocardiography

D. Echocardiography Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following? A. Fluid increase to 2500cc B. Warm, salt water gargling C. Administering antiseptic lozenges D. Obtaining a throat culture

D. Obtaining a throat culture When a child has a sore throat and symptoms of a possible infection occur, it is essential that a culture is obtained. A culture can identify group A beta-hemolytic streptococcal infection, which needs to be eliminated with use of an antibiotic. Warm, salt gargles; increasing fluids; and administering antiseptic lozenges are helpful for symptom control. Obtaining a throat culture is a priority.

The health care provider has scheduled a client with mitral stenosis for mitral valve replacement. What condition will the nurse expect to see as a complication of mitral stenosis? A. left ventricular hypertrophy B. myocardial ischemia C. left-sided heart failure D. pulmonary hypertension

D. pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.

A client is admitted to the hospital with suspected rheumatic endocarditis. What diagnostic test will the nurse anticipate being ordered? A. electrophysiological studies B. complete blood count C. electrocardiogram D. throat culture

D. throat culture Rheumatic fever is a preventable disease. Diagnosing and effectively treating streptococcal pharyngitis can prevent rheumatic fever and, therefore, rheumatic heart disease. If signs and symptoms of streptococcal pharyngitis are present, a throat culture is necessary to make an accurate diagnosis. An electrophysiology study will confirm abnormal heart rhythms. An electrocardiogram will monitor heart ryhthm disturbances, not diagnose the endocarditis. A complete blood count will not confirm the endocarditis diagnosis, but will add information for treatment.

A client who is resting quietly reports chest pain to the nurse. The cardiac monitor indicates the presence of reversible ST-segment elevation. What type of angina is the client experiencing? A. silent angina B. stable angina C. intractable angina D. variant angina

D. variant angina Variant or Prinzmetal's angina is distinguished by pain occurrence during rest. Stable angina occurs with activity. Silent angina occurs without symptoms, and intractable angina is evidenced by incapacitating pain.

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate Expl: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet. Pg. 2038

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?

Decerebrate posturing and loss of corneal reflex

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

Decorticate

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except:

Glasgow Coma Scale of 6 Expl: The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal. Pg. 2039

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing). Expl: To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired). Pg. 2046

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume Expl: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities. Pg. 2083

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories. i. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintaining cerebral perfusion pressure from 50 to 70 mm Hg Expl: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation. Pg. 2046

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter. A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia. Pg. 2057

A 68-year-old retired salesman was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how the client reported a severe headache, shortly after he was unable to talk or move his right arm and leg. His wife indicates the client has hypertension. What should be your focus of management during this phase?

Preventing further neurologic damage

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

Racoon's eyes and Bettle sign Expl: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Pg. 2035

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position. Expl: The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed. Pg. 2057

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

Rebound hypotension Expl. When the cause is removed and the symptoms abate, the blood pressure goes down. The antihyperstensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before. Pg. 2057

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

Reduced muscle spasticity

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?

Reorient the client while gently holding their arms.

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI. Expl: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient. Pg. 2039

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Traction with weights and pulleys

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

Vomits Expl: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, a severe headache should be reported or treated immediately. Weakness of one side of the body should be reported or treated immediately. Difficulty in waking the patient should be reported or treated immediately. Pg. 2037

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure Expl: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations become rapid, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body. Pg. 2042

21. A client with quadriplegia is in spinal shock. What finding should the nurse expect?

a. Absence of reflexes along with flaccid extremities i. During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

19. A 65-year-old client was hit in the head with a ball and knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?

a. Acute i. Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

11. You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

a. Autonomic dysreflexia i. Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsidesautonomic dysreflexia develops in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6). Autonomic dysreflexia causes an imbalanced reflex sympathetic discharge, leading to potentially life-threatening hypertension.

The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse. What statement made by the client demonstrates understanding of the teaching? A. "I will avoid caffeine, alcohol, and smoking." B. "I can get my tongue pierced at a store in the shopping mall." C. "I can get a tattoo at a local parlor." D. "I will take antibiotics before getting my teeth cleaned."

A. "I will avoid caffeine, alcohol, and smoking." In mitral valve prolapse, if dysrhythmias are documented and cause symptoms, the client is advised to eliminate caffeine and alcohol from the diet and to stop the use of tobacco products. Antibiotics to prevent endocarditis are no longer prescribed. Tattoos and piercings are not recommended for clients with mitral valve prolapse to prevent unneccessary exposure to bacteria.

The nurse determines that a patient has a characteristic symptom of pericarditis. What symptom does the nurse recognize as significant for this diagnosis? A. Constant chest pain B. Dyspnea C. Uncontrolled restlessness D. Fatigue lasting more than 1 month

A. Constant chest pain The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. Pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning.

A client with aortic regurgitation is admitted to the hospital. Which assessment findings would indicate left ventricular failure? A. Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND) B. Distended jugular veins, pedal edema, nausea C. Orthopnea, nausea, pedal edema D. Dyspnea, distended jugular veins, orthopnea

A. Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND) Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea and PND. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right-sided heart failure.

When the nurse notes that, after cardiac surgery, the client demonstrates low urine output (less than 25 mL/h) with high specific gravity (greater than 1.025), the nurse suspects which condition? A. Inadequate fluid volume B. Anuria C. Normal glomerular filtration D. Overhydration

A. Inadequate fluid volume Urine output less than 0.5 mL/kg/h may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. Indices of normal glomerular filtration are output of 0.5 mL/kg/h or more and specific gravity between 1.010 and 1.025. Overhydration is manifested by high urine output with low specific gravity. The anuric client does not produce urine.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Expl: Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache. Pg 2037

The nurse is caring for a client diagnosed with unstable angina who is receiving IV heparin. The client requires bleeding precautions. Bleeding precautions include which measure? A. Avoid subcutaneous injections B. Avoid continuous BP monitoring C. Use an electric toothbrush D. Avoid the use of nail clippers

B. Avoid continuous BP monitoring The client receiving heparin receives bleeding precautions, which can include applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, and avoiding tissue injury and bruising from trauma or constrictive devices (e.g., continuous use of an automatic BP cuff). Subcutaneous injections are permitted; a soft toothbrush should be used, and the client may use nail clippers, but with caution.

A nurse is teaching about risk factors that increase the probability of heart disease to a community group. Which risk factors will the nurse include in the discussion? Select all that apply. A. Body mass index (BMI) of 23 B. Family history of coronary heart disease C. Elevated C-reactive protein D. Age greater than 45 years for men E. African-American descent

B. Family history of coronary heart disease C. Elevated C-reactive protein D. Age greater than 45 years for men E. African-American descent Risk factors for coronary heart disease (CHD) include family history of CHD, age older than 45 years for men and 65 years for women, African-American race, BMI of 25 or greater, and elevated C-reactive protein.

Understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the development of the disorder and an outcome? A. Obesity B. Hypertension C. Hyperlipidemia D. Glucose intolerance

B. Hypertension Increases in diastolic and systolic blood pressure are associated with an increased incidence of atherosclerosis, often an inherited factor. Elevation of blood pressure results when the vessels cannot relax and impairs the ability of the artery to dilate. Hyperlipidemia, diabetes, and obesity are all risk factors for atherosclerosis but do not result from the disorder.

The nurse is caring for a client after cardiac surgery. What laboratory result will lead the nurse to suspect possible renal failure? A. an hourly urine output of 50 to 70 mL B. a serum BUN of 70 mg/dL C. a serum creatinine of 1.0 mg/dL D. a urine specific gravity reading of 1.021

B. a serum BUN of 70 mg/dL These four laboratory results should always be assessed after cardiac surgery. Serum osmolality (N = >800 mOsm/kg) should also be included. A BUN reading of greater than 21 mg/dL is abnormal; a reading of greater than 60 mg/dL is indicative of renal failure. Urine output needs to be greater than 30 mL/hr. Normal urine specific gravity is 1.005-1.030. Normal serum creatinine values are between 0.5-1.2 mg/dL.

A client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6 °F (37.6 °C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. What assessment is the nurse's highest priority? A. cardiac output B. acute pain C. anxiety D. body temperature

B. acute pain The assessment of pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis. The client's blood pressure and heart rate do not suggest adecreased cardiac output. Anxiety may be an important assessment, but addressing acute pain (the priority concern) may alleviate the client's anxiety.

The client is asking the nurse about heart-healthy food choices for lunch. What are foods that are heart healthy? Select all that apply. A. baked chicken leg B. broiled trout c. white rice with butter D. soy yogurt E. blueberries

B. broiled trout D. soy yogurt E. blueberries Heart-healthy foods include soy products, fish high in omega-3s, and fruit. The chicken leg has more fat than a chicken breast. The white rice does not have enough fiber, so brown rice is a better option.

What is a modifiable risk factor for the development of atherosclerosis? A. gender B. consumption of a high-fat diet C. infection with chlamydia pneumonia D. family history

B. consumption of a high-fat diet There are many known risk factors for development of atherosclerosis. Factors that are modifiable, or that a client can change, include diet, activity level, and smoking cessation. Some that are nonmodifiable include gender, heredity, certain diseases, and history of infection with Chlamydia pneumoniae. These factors individually or collectively contribute to hyperlipidemia, which then triggers atherosclerotic changes.

Statistics show an increase in the prevalence of infective endocarditis among older adults. Which factor places older adults at risk for developing infective endocarditis? A. higher rate of tuberculosis B. increased use of prosthetic valve replacements C. greater incidence of a history of repaired congenital heart defects D. increase in IV drug use

B. increased use of prosthetic valve replacements The prevalence of infective endocarditis among older adults has increased in part due to the increased number of prosthetic valve replacements, including replacements for older adults, and an increase in hospital-acquired bacteremia. While history of a repaired congenital heart defect does place a client at greater risk for developing infective endocarditis in the future, it has not been shown as a contributing factor in the prevalence of infective endocarditis among older adults. IV drug use and IV drug abuse places individuals at greater risk for infective endocarditis. However, this risk has not been attributed to an increase in its prevalence among older adults. Tuberculosis is known to contribute to pericarditis among the general population and is not specific to the older adult client.

A nurse is assigned to the medical intensive care unit. The nurse ascultates a water-hammer pulse. What will the sound resemble? A. low-pitched diastolic murmur at the apex B. quick, sharp strokes that suddenly collapse C. high-pitched blowing sound at the apex D. mitral click

B. quick, sharp strokes that suddenly collapse With the water-hammer (Corrigan's) pulse, the pulse strikes the palpating finger with a quick, sharp stroke and then suddenly collapses. Water-hammer pulse is not low or high pitched. A clicking sound is heard with a valve replacement.

While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate: A. atrial gallop. B. valve damage. C. cardiac tamponade. D. pericarditis.

B. valve damage. Acute rheumatic fever may lead to cardiac complications; a heart murmur suggests valve damage. Endocarditis may lead to cardiac complications; a pericardial friction rub indicates pericarditis. Muffled heart sounds may indicate cardiac tamponade in clients with pericarditis. Atrial gallop is an abnormal heart sound, or S4, and is often associated with hypertensive heart disease.

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

A new surgical patient who has undergone a coronary artery bypass graft (CABG) is receiving opioids for pain control. The nurse must be alert to adverse effects of opioids. Which of the following effects would be important for the nurse to document? A. Urinary incontinence B. Hyperactive bowel sounds C. Hypertension D. Hypotension

D. Hypotension The patient is observed for any adverse effects of opioids, which may include respiratory depression, hypotension, ileus, or urinary retention. If serious side effects occur, an opioid antagonist, such as Narcan, may be used.

A client diagnosed with a myocardial infarction (MI) is being moved to the rehabilitation unit for further therapy. Which statement reflects a goal of rehabilitation for the client with an MI? A. Prevention of another cardiac event B. Ability to return to work and a preillness functional capacity C. Limitation of the effects and progression of atherosclerosis D. Improvement in quality of life

D. Improvement in quality of life Overall, cardiac rehabilitation is a complete program dedicated to extending and improving quality of life. Immediate objectives of rehabilitation of a client with an MI patient are to limit the effects and progression of atherosclerosis, to return the client to work and a preillness lifestyle, and to prevent another cardiac event.

Which is the most important postoperative assessment parameter for a client recovering from cardiac surgery? A. Mental alertness B. Blood glucose concentration C. Activity intolerance D. Inadequate tissue perfusion

D. Inadequate tissue perfusion The nurse must assess the client for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood glucose and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for clients undergoing cardiac surgery.

Which discharge instruction for self-care should the nurse provide to a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? A. Cleanse the site with disinfectants and dress the wound appropriately B. Normal activities of daily living can be resumed the first day after surgery C. Refrain from sexual activity for 1 month D. Monitor the site for bleeding or hematoma.

D. Monitor the site for bleeding or hematoma. The nurse provides certain discharge instructions for self-care, such as monitoring the site for bleeding or the development of a hard mass indicative of hematoma. A nurse does not advise the client to clean the site with disinfectants or refrain from sexual activity for 1 month.

Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? A. Isosorbide mononitrate (Isordil) B. Nitroglycerin transdermal patch C. Meperidine hydrochloride (Demerol) D. Morphine sulfate (Morphine)

D. Morphine sulfate (Morphine) Morphine sulfate not only decreases pain perception and anxiety but also helps to decrease heart rate, blood pressure, and demand for oxygen. Nitrates are administered for vasodilation and pain control in clients with angina-type pain, but oral forms (such as isosorbide dinitrate) have a large first-pass effect, and transdermal patch is used for long-term management. Meperidine hydrochloride is a synthetic opioid usually reserved for treatment of postoperative or migraine pain.

The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer? A. Fever B. Dyspnea C. Respiratory symptoms D. Precordial pain

D. Precordial pain Precordial pain is the main characteristic of pericarditis. Dyspnea, fever, and respiratory symptoms are not the main characteristics of pericarditis.

A patient with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this patient? A. Perform a 12-lead ECG. B. Assess the patient's heart and lung sounds. C. Request STAT cardiac enzymes. D. Prepare for pericardiocentesis.

D. Prepare for pericardiocentesis. The nurse notifies the physician immediately and prepares to assist with pericardiocentesis, the emergency treatment for cardiac tamponade. Cardiac enzymes may be elevated but would not be ordered nor would a 12-lead ECG. The nurse's assessment of the lungs and heart is not a collaborative, but an independent action.

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? A. Variant B. Intractable C. Refractory D. Unstable

D. Unstable Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

The nurse is reevaluating a client 2 hours after a percutaneous transluminal coronary angioplasty (PTCA) procedure. Which assessment finding may indicate the client is experiencing a complication of the procedure? A. Heart rate of 100 bpm B. Potassium level of 4.0 mE/qL C. Dried blood at the puncture site D. Urine output of 40 mL

D. Urine output of 40 mL Complications that may occur following a PTCA include myocardial ischemia, bleeding and hematoma formation, retroperitoneal hematoma, arterial occlusion, pseudoaneurysm formation, arteriovenous fistula formation, and acute renal failure. The urine output of 40 mL over a 2-hour period may indicate acute renal failure. The client is expected to have a minimum urine output of 30 mL/h. Dried blood at the insertion site is a finding that warrants no acute intervention. A serum potassium level of 4.0 mEq/L is within the normal range. The heart rate of 100 bpm is within the normal range and indicates no acute distress.

A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will be prescribed long-term administration of which drug? A. penicillin V or erythromycin. B. pentoxifylline or acetaminophen. C. aspirin or acetaminophen. D. aspirin or clopidogrel.

D. aspirin or clopidogrel. After PTCA, the client begins long-term aspirin or clopidogrel therapy to prevent thromboembolism. Health care providers order heparin for anticoagulation during this procedure; some health care providers discharge clients with a prescription for long-term warfarin or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn't required after PTCA because the procedure itself opens the vessel. The health care provider may order short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn't warranted. The client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn't necessary.

The nurse is removing a client's femoral sheath after cardiac catheterization. What medication will the nurse have available? A. protamine sulfate B. adenosine C. heparin D. atropine sulfate

D. atropine sulfate Removing the sheath after cardiac catheterization may cause a vasovagal response, including bradycardia. The nurse should have atropine sulfate on hand to increase the client's heart rate if this occurs. Heparin changes clotting of blood; clients should stop taking it before the sheath removal. Protamine sulfate is an antidote to heparin, but the nurse shouldn't administer it during sheath removal. Adenosine treats tachydysrhythmias.

A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate: A. rheumatic fever. B. dilated cardiomyopathy. C. myocarditis. D. infective endocarditis.

D. infective endocarditis. Subacute endocarditis infections progress insidiously over weeks to months with vague manifestations, such as headache, malaise, fatigue, and sleep disturbances. Small, painless, red-blue macular lesions or Janeway lesions may appear on the palms of the hands and soles of the feet. Clients with myocarditis may complain of sharp stabbing or squeezing chest discomfort that resolves upon sitting up. Clients with dilated cardiomyopathy are likely to experience fatigue and leg swelling and may also have palpitations and chest pain.

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Suction the airway. Expl: Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently. Pg. 2055

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. Expl: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position. 1991

The Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents Expl: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. Cushing's response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function. 2034

24. The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly describes Battle's sign?

a. Ecchymosis over the mastoid

A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). Which evaluation statement suggests that the client needs more instruction? A. "Client walks 4 miles in 1 hour every day." B. "Client performs relaxation exercises three times per day to reduce stress." C. "Client verbalizes an understanding of the need to seek emergency help if heart rate increases markedly while at rest." D. "Client's 24-hour dietary recall reveals low intake of fat and cholesterol."

A. "Client walks 4 miles in 1 hour every day." Four weeks after an MI, a client's walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises, following a low-fat, low-cholesterol diet, and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? A. "Client will verbalize the intention to stop smoking." B. "Client will verbalize the intention to avoid exercise." C. "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." D. "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."

A. "Client will verbalize the intention to stop smoking." A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).

When teaching a client with rheumatic carditis and a history of recurrent rheumatic fever, which statement by the client indicates that teaching has been successful? A. "I may have to take prophylactic antibiotics for up to 10 years." B. "I will avoid milk, yogurt, and other dairy products." C. "I will avoid any kind of activity." D. "I will take a nonsteroidal anti-inflammatory medication every day."

A. "I may have to take prophylactic antibiotics for up to 10 years." Antibiotic prophylaxis for recurrent rheumatic fever with rheumatic carditis may require 10 or more years of antibiotic coverage (e.g., penicillin G intramuscularly every 4 weeks, penicillin V orally twice a day [BID], sulfadiazine orally daily, or erythromycin orally BID). Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are prescribed to suppress the inflammatory response and aspirin to control the formation of blood clots around heart valves. Activities that require minimal activity are recommended to reduce the work of the myocardium and counteract the boredom of weeks of bed rest.

A client with a confirmed DVT is being discharged from the ED. Which client statement indicates that the client has received proper nursing instruction and understands how to manage this condition? A. "I need to do my leg exercises five times or more every hour." B. "I should lie on my side with my knees bent when sleeping." C. "I should try not to drink too much during the daytime." D. "I need to ice my leg every 2 hours for about 20 minutes."

A. "I need to do my leg exercises five times or more every hour." Exercise prevents venous stasis by promoting venous circulation, relieves swelling, and reduces pain. Promoting venous blood flow prevents the formation of thrombi and subsequent potential for emboli in the unaffected extremity. Bending the knees is contraindicated for a client with DVT because it interferes with venous circulation and may increase the size of the existing clot or contribute to the formation of additional thrombi. Clients with DVT should apply warm, moist compresses to the area of discomfort because warmth dilates blood vessels, improves circulation, and relieves swelling, all of which relieve discomfort; moist heat is more comforting than dry heat. Adequate fluid volume dilutes blood cells in plasma and reduces the risk for platelet aggregation.

A nurse is teaching a client about valve replacement surgery. Which statement by the client indicates an understanding of the benefit of an autograft replacement valve? A. "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." B. "The valve is from a tissue donor, and I will not need to take any blood-thinning drugs when I am discharged." C. "The valve is made from a pig tissue, and I will not need to take any blood-thinning drugs when I am discharged." D. "The valve is mechanical, and it will not deteriorate or need replacing."

A. "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." Autografts (i.e., autologous valves) are obtained by excising the client's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the client's own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, clients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.

A client is receiving anticoagulant therapy. What question will the nurse ask the client to detect any signs of bleeding? A. "What color is your urine?" B. "How is your appetite?" C. "Is your skin drier than normal?" D. "Do you have any breathing problems?"

A. "What color is your urine?" The patient receiving anticoagulation therapy should be monitored for signs and symptoms of bleeding, such as changes in the color of the stool or urine. Anticoagulation therapy should not cause dry skin. The anticoagulation therapy should not change the client's breathing or appetite.

A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? A. 3.8 B. 3.0 C. 2.6 D. 3.4

A. 3.8 Warfarin patients usually have individualized target international normalized ratios (INRs) between 2 to 3.5 to maintain adequate anticoagulation. Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.

Which would the nurse stress as a lifelong necessity for a client managing infective endocarditis? A. Antibiotic therapy B. Exercise regimen C. Potassium replacement D. Antihypertensive medication

A. Antibiotic therapy The nurse informs the client that periodic antibiotic therapy is a lifelong necessity because the client will be vulnerable to diseases for the rest of his life. Antihypertensive therapy is not always prescribed. Limited activity is stressed. Potassium replacement is typical when combined with diuretic therapy.

An older adult is postoperative day one, following a coronary artery bypass graft (CABG). The client's family members express concern to the nurse that the client is uncharacteristically confused. After reporting this change in status to the health care provider, what additional action should the nurse take? A. Assess for factors that may be causing the client's delirium. B. Educate the family about how confusion is expected in older adults postoperatively. C. Reorient the client to place and time. D. Document the early signs of dementia and ensure the client's safety.

A. Assess for factors that may be causing the client's delirium. Uncharacteristic changes in cognition following cardiac surgery are suggestive of delirium. Dementia has a gradual onset with organic brain changes and is not an acute response to surgery. Assessment is a higher priority than reorientation, which may or may not be beneficial. Even though delirium is not rare, it is not considered to be an expected part of recovery.

The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which measures should the nurse complete to prevent the development of deep venous thrombosis (DVT) and possible pulmonary embolism (PE)? Select all that apply. A. Avoid elevating the knees on the bed. B. Initiate passive exercises. C. Encourage the client to cross their legs. D. Place pillows in the popliteal space. E. Apply antiembolism stockings.

A. Avoid elevating the knees on the bed B. Initiate passive exercises. E. Apply antiembolism stockings. Preventive measures used to prevent venous stasis include application of sequential pneumatic compression devices; discouraging crossing of legs; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; and beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.

The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply. A. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists. B. Put some of the tablets in a small metal or plastic pillbox that can be easily carried at all times and be accessible quickly, when needed. C. Renew the supply every 6 months. D. Keep the tablets at home on the kitchen counter or bedside table so they can be reached quickly. E. Take the tablet in anticipation of any activity that can produce pain. F. Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed.

A. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists. C. Renew the supply every 6 months. E. Take the tablet in anticipation of any activity that can produce pain. F. Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Nitroglycerine is very unstable and should be carried securely in its original container (capped, dark, glass bottle). The tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerine is also volatile and is inactivated by heat, moisture, air, light, and time. Therefore, storage and replacement is recommended every 6 months. Refer to Box 14-3 in the text.

The nurse is providing education about the nutrient content of the Therapeutic Lifestyle Changes (TLC) diet to a community group. What information will the nurse provide? Select all that apply. A. Carbohydrates should make up 50% to 60% of the total calories. B. Cholesterol should be less than 1 gram per day. C. Dietary fiber should be 20 to 30 grams per day. D. Protein should make up approximately 15% of total calories. E. Total fat should make up only 5% of the total calories.

A. Carbohydrates should make up 50% to 60% of the total calories. C. Dietary fiber should be 20 to 30 grams per day. D. Protein should make up approximately 15% of total calories. According to the nutrient content of the TLC diet, cholesterol should make up less than 200 mg/day, carbohydrates should make up 50% to 60% of the total calories, dietary fiber should be 20 to 30 grams per day, protein should make approximately 15% of the total calories, and fat should make up 25% to 30% of the total calories.

Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? A. Cardiac tamponade B. Hypothermia C. Hypertension D. Fluid overload

A. Cardiac tamponade Cardiac tamponade is fluid and clot accumulation in the pericardial sac, which compresses the heart, preventing the blood from filling the ventricles. Fluid overload is exhibited by high pulmonary artery wedge pressure, central venous pressure, and pulmonary artery diastolic pressure, as well as crackles in the lungs. Hypertension results from postoperative vasoconstriction. Hypothermia is a low body temperature that leads to vasoconstriction.

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The health care provider diagnoses acute coronary syndrome. When the client arrives on the unit, vital signs are stable and the client does not report any pain. In addition to the medications already given, which medication does the nurse expect the health care provider to order? A. Carvedilol B. Digoxin C. Nitroprusside D. Furosemide

A. Carvedilol A client with suspected myocardial infarction should receive aspirin, nitroglycerin, morphine, and a beta-adrenergic blocker such as carvedilol. Digoxin treats arrhythmias; there is no indication that the client is having arrhythmias. Furosemide is used to treat signs of heart failure, which isn't indicated at this point. Nitroprusside increases blood pressure. This client has stable vital signs and isn't hypotensive.

Which term describes the splitting or separating of fused cardiac valve leaflets? A. Commissurotomy B. Chordoplasty C. Valvuloplasty D. Annuloplasty

A. Commissurotomy Commissurotomy is performed to split or separate fused cardiac valve leaflets. Annuloplasty is a repair of a cardiac valve's outer ring. Chordoplasty is repair of the stringy, tendinous fibers that connect the free edges of the atrioventricular valve leaflets to the papillary muscle. Valvuloplasty is a repair of a stenosed or regurgitant cardiac valve by commissurotomy, annuloplasty, leaflet repair, or chordoplasty.

A nurse is educating a client with coronary artery disease about nitroglycerin administration. The nurse tells the client that nitroglycerin has what actions? Select all that apply. A. Dilates blood vessels B. Relieves pain C. Decreases ischemia D. Decreases the urge to use tobacco E. Reduces myocardial oxygen consumption

A. Dilates blood vessels B. Relieves pain C. Decreases ischemia E. Reduces myocardial oxygen consumption Nitroglycerin dilates blood vessels and reduces the amount of blood returning to the heart, which reduces the workload of the heart and myocardial oxygen consumption. As the dilated vessels allow more blood supply to the heart, ischemia and pain are reduced. Nitroglycerin does not affect the urge to use tobacco.

A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate the development of left ventricular failure? A. Dyspnea, orthopnea, pulmonary edema B. Dyspnea, distended jugular veins, orthopnea C. Orthopnea, nausea, pedal edema D. Distended jugular veins, pedal edema, nausea

A. Dyspnea, orthopnea, pulmonary edema Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea, PND, and pulmonary edema. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right sided heart failure.

A client comes to the emergency department reporting chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? A. Elevated ST segment B. Absent Q wave C. Prolonged PR interval D. Widened QRS complex

A. Elevated ST segment Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

A nurse is preparing home care instructions for a client with infective endocarditis. What will the nurse include in the instructions? Select all that apply. A. Encourage oral hygiene at least twice daily with a soft toothbrush. B. Inform all health care providers of the history of endocarditis. C. Record urine output and report anything less than 240 mL per day to your physician. D. Monitor intravenous catheter sites for signs of infection

A. Encourage oral hygiene at least twice daily with a soft toothbrush. B. Inform all health care providers of the history of endocarditis. D. Monitor intravenous catheter sites for signs of infection Increased vigilance is required for patients with intravenous catheters and during invasive procedures. Equally important is ongoing good oral hygiene. Poor dental hygiene can lead to bacteremia, particularly in the setting of a dental procedure. Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures, so making dentists and other health care professionals aware of the history is important. Recording urine output is not necessary.

The nurse is caring for a client with cardiac compromise related to mitral valve impairment. Which outcome of the eroding of the mitral valve is most significant? A. Heart failure B. Presence of a heart murmur C. Pulmonary congestion D. Activity intolerance

A. Heart failure The most significant outcome of the eroding of the mitral valve is heart failure. Blood leaking between the heart chambers diminishes the hearts ability to circulate blood efficiently. Eventually, the heart cannot keep up with the body's metabolic need, and heart failure occurs.

An adult client with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. The medical history reveals diabetes mellitus, hypertension, and pernicious anemia. The client underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. What history finding is a major risk factor for infective endocarditis? A. History of aortic valve replacement

A. History of aortic valve replacement A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.

An ED nurse is assessing a 71-year-old female client 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 clients? Select all that apply. A. Indigestion B. Chest pain C. Nausea D. Shortness of breath E. Anxiety

A. Indigestion C. Nausea Many women experiencing coronary events including--unstable angina, MIs, or sudden cardiac death events--are asymptomatic or present with atypical symptoms including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among clients of all ages and genders.

An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region? A. Leads V3 and V4 B. Leads II, III, and aVF C. Leads I, aVL, V5, and V6 D. Leads V1 and V2

A. Leads V3 and V4 Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.

The nurse reviews laboratory tests for cardiac biomarkers for a client suspected of suffering an MI. What is the earliest marker of an MI? A. Myoglobin B. Total creatinine kinase (CK) C. Troponin I and T D. Creatinine kinase-myocardial band (CK-MB)

A. Myoglobin Myoglobin is a heme protein that transports oxygen. Its levels can increase as early as 1 hour after an MI. Negative results are an excellent parameter for ruling out an acute MI. The other biomarker choices start to increase in 2 to 4 hours.

A client with infective endocarditis (IE) and a fever is admitted to the intensive care unit. Which of these physician orders should the nurse implement first? A. Order blood cultures drawn from two sites B. Obtain a transesophageal echocardiogram C. Administer ceftriaxone 1 g IVPB q 12 hours D. Give acetaminophen pro re nata for fever higher than 100.3 F

A. Order blood cultures drawn from two sites Blood cultures (with each set including one aerobic and one anaerobic culture) drawn from different venipuncture sites over a 24-hour period (each set at least 12 hours apart), or every 30 minutes if the client's condition is unstable, should be obtained before any antimicrobial agents are administered. It is essential to obtain blood cultures before initiating antibiotic therapy in order to obtain accurate sensitivity results.

The nurse is teaching a client diagnosed with coronary artery disease about nitroglycerin. What is the cardiac premise behind administration of nitrates? A. Preload is reduced. B. More blood returns to the heart. C. It increases myocardial oxygen consumption. D. It functions has a vasoconstrictor.

A. Preload is reduced. Nitroglycerin dilates primarily the veins, and in higher dosages, also the arteries. Dilation of the veins causes venous pooling of the blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload) is reduced. Nitroglycerine is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain.

A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is? A. Relieved by rest and nitroglycerin B. Associated with nausea and vomiting C. Accompanied by diaphoresis and dyspnea D. Described as crushing and substernal

A. Relieved by rest and nitroglycerin One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.

A client with CAD has been prescribed a transdermal nitroglycerin patch. What instructions should the nurse provide to to the client? Select all that apply. A. Remove the transdermal patch at night and reapply in the morning. B. Seek emergency treatment if flushing or nausea occurs. C. Store the patch in its original container when not in use. D. Cover the patch in plastic wrap after applying.

A. Remove the transdermal patch at night and reapply in the morning. C. Store the patch in its original container when not in use. Transdermal nitroglycerin systems are applied to the skin and slowly release nitroglycerin. Clients should be instructed to store the patch in its original container when not in use and keep tightly closed, remove the patch each night and reapply in the morning to prevent diminishing vasodilating effects, and expect possible side effects, such as headache, flushing, or nausea.

A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential to avoid which preventable disease? A. Rheumatic fever B. Pericarditis C. Mitral stenosis D. Cardiomyopathy

A. Rheumatic fever Rheumatic fever is a preventable disease. Diagnosing and effectively treating streptococcal pharyngitis can prevent rheumatic fever and thereby rheumatic heart disease.

The nurse is caring for a client presenting to the emergency department (ED) reporting chest pain. Which electrocardiographic (ECG) finding would be most concerning to the nurse? A. ST elevation B. Frequent premature atrial contractions (PACs) C. Isolated premature ventricular contractions (PVCs) D. Sinus tachycardia

A. ST elevation The first signs of an acute MI are usually seen in the T wave and the ST segment. The T wave becomes inverted; the ST segment elevates (it is usually flat). An elevated ST segment in two contiguous leads is a key diagnostic indicator for MI (i.e., ST-elevation MI). This client requires immediate invasive therapy or fibrinolytic medications. Although the other ECG findings require intervention, elevated ST elevations require immediate and definitive interventions.

A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? A. Shortness of breath B. Tachycardia C. Hypertension D. A loud, blowing murmur

A. Shortness of breath Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitation (e.g., resulting from a myocardial infarction) usually manifests as severe congestive heart failure. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath upon exertion, and cough from pulmonary congestion also occur. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.

The nursing instructor is teaching a class on thrombophlebitis. What should the nurse tell the students about the inflammatory response in thrombophlebitis? A. The inflammatory response is caused by accumulated waste products in the blocked vessel. B. The inflammatory response is caused by the irritation of blood trying to flow through the vessel. C. The inflammatory response is caused by the irritation of the clot. D. The inflammatory response is caused by an excess for fibrin in the blocked vessel.

A. The inflammatory response is caused by accumulated waste products in the blocked vessel. Accumulated waste products in the blocked vessel irritate the vein wall, initiating an inflammatory response. The other options are incorrect because they do not cause the inflammatory response in thrombophlebitis.

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL) 32 mg/dl. The client asks the nurse how to lower his cholesterol. What is the best response by the nurse? A. The nurse will ask the dietitian to talk with the client about modifying the diet. B. Cholesterol is within the recommended guidelines and the client doesn't need to lower it. C. Client should begin a running program, working up to 2 miles per day. D. Client should take statin medication and not worry about cholesterol.

A. The nurse will ask the dietitian to talk with the client about modifying the diet. A dietitian can help the client decrease the fat in the diet and make other beneficial dietary modifications. This client's total cholesterol isn't within the recommended guidelines; it should be less than 200 mg/dl. LDL should be less than 79 mg/dl, and HDL should be greater than 40 mg/dl. Although this client should take statin medication, the client should still be concerned about cholesterol levels and make other lifestyle changes, such as dietary changes, to help lower it. The client should increase activity level, but doesn't need to run 2 miles per day.

A patient with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the patient to have a coronary artery bypass graft (CABG)? A. The patient has at least a 70% occlusion of a major coronary artery. B. The patient has an ejection fraction of 65%. C. The patient has had angina longer than 3 years. D. The patient has compromised left ventricular function.

A. The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).

Which term refers to preinfarction angina? A. Unstable angina B. Variant angina C. Refractory angina D. Silent angina

A. Unstable angina Preinfarction angina is also known as unstable angina. Stable angina has predictable and consistent pain that occurs upon exertion and is relieved by rest. Variant angina is exhibited by pain at rest and reversible ST-segment elevation. Silent angina manifests through evidence of ischemia, but the client reports no symptoms.

A client is diagnosed with pericarditis. What symptom will be the nurse's priority for treatment? A. acute pain B. anxiety C. fatigue D. denial

A. acute pain Pain is the primary symptom of the client with pericarditis. Pain relief and the absence of complications are two major nursing goals.The client may have anxiety, fatigue, or denial, but these symptoms are not the nurse's priority for care.

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply. A. adequate cough and gag reflexes B. breathing without assistance of the ventilator C. acceptable arterial blood gas values D. labile vital signs E. inability to speak

A. adequate cough and gag reflexes B. breathing without assistance of the ventilator C. acceptable arterial blood gas values Before being extubated, the client should have cough and gag reflexes and stable vital signs; be able to lift the head off the bed or give firm hand grasps; have adequate vital capacity, negative inspiratory force, and minute volume appropriate for body size; and have acceptable arterial blood gas levels while breathing without the assistance of the ventilator. Inability to talk is expected when intubated with an endotracheal tube.

An client who has been diagnosed with arteriosclerosis is confused by what this means. The nurse explains that arteriosclerosis is: A. an expected part of the aging process. B. high level of blood fat. C. a condition in which the lumen of arteries fill with scar tissue. D. a vascular occlusive disease.

A. an expected part of the aging process Arteriosclerosis is loss of elasticity or hardening of the arteries that accompanies the aging process. While arteriosclerosis is a contributing factor to vascular occlusive disease, it is a term that refers to a loss of elasticity or hardening of the arteries that accompanies the aging process. Arteriosclerosis does not involve scar tissue formation. Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.

A client is recovering from coronary artery bypass graft (CABG) surgery. During discharge preparation, the nurse should advise the client and family members to expect which common symptom that typically resolves spontaneously? A. depression B. ankle edema C. memory lapses D. dizziness

A. depression For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise family members that symptoms of depression don't always resolve on their own. They should make sure they recognize worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate notification to a health care provider.

A client was transferring a load of firewood in the morning and experienced a heaviness in the chest and dyspnea. The client arrives in the emergency department four hours after the heaviness and the health care provider diagnoses an anterior myocardial infarction (MI). What orders will the nurse anticipate? A. sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry B. morphine administration, stress testing, and admission to the cardiac care unit C. serial liver enzyme testing, telemetry, and a lidocaine infusion D. streptokinase, aspirin, and morphine administration

A. sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry, as the client's chest pain began 4 hours before diagnosis. The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn't be performed during an MI. The client doesn't exhibit symptoms that indicate the use of lidocaine.

A nurse is caring for a young female adult client diagnosed with atrial fibrillation who has just had a mitral valve replacement. The client is being discharged with prescribed warfarin. The client mentions to the nurse that she relies on the rhythm method for birth control. What education will be a priority for the nurse to provide to this client? A. the high risk for complications if she becomes pregnant while taking warfarin B. instructions for using the rhythm method C. foods to limit (green leafy vegetables) while taking warfarin D. symptoms to report of worsening tachycardia related to atrial fibrillation

A. the high risk for complications if she becomes pregnant while taking warfarin Women of childbearing age should not take warfarin (pregnancy X category) if they plan to become pregnant. There is danger to the placenta and risk for the mother to bleed. The fetus may also be affected. This client should practice a more reliable method of birth control. The rhythm method for birth control is not always accurate.The symptoms of worsening tachycardia are important, but do not correspond to the warfarin therapy. Limiting green leafy vegetables is important with warfarin therapy, but risk for fetal harm is more important.

During a teaching session, a client who is having a valuloplasty tomorrow asks the nurse about the difference between a mechanical valve replacement and a tissue valve. What answer from the nurse is correct? A. "Mechanical valves are used for women of childbearing age." B. "A mechanical valve is thought to be more durable and so requires replacement less often." C. "Mechanical valves are not always available and are very expensive." D. "A mechanical valve is less likely to generate blood clots, so long-term anticoagulation therapy is not required."

B. "A mechanical valve is thought to be more durable and so requires replacement less often." Mechanical valves are thought to be more durable than tissue valves and so require replacement less often. Tissue valves are less likely to generate blood clots and so long-term anticoagulation therapy is not required. Homografts (human valves) are not always available and are very expensive.

The nurse obtains a health history from a client with a prosthetic heart valve and new symptoms of infective endocarditis. Which question by the nurse is most appropriate to ask? A. "Have you recently vacationed outside of the United States?" B. "Have you been to the dentist recently?" C. "Do you have a family history of endocarditis?" D. "Do you live with any domesticated animals in your home?"

B. "Have you been to the dentist recently?" Invasive procedures, particularly those involving mucosal surfaces (e.g., those involving manipulation of gingival tissue or periapical regions of teeth), can cause a bacteremia, which rarely lasts more than 15 minutes. However, if a client has any anatomic cardiac defects or implanted cardiac devices (e.g., prosthetic heart valve, pacemaker, implantable cardioverter defibrillator), bacteremia can cause bacterial endocarditis.

A nurse is teaching a client who is awaiting a heart transplant. Which statement indicates the client understands what is required to help minimize rejection? A. "I will need medication following surgery to prevent rejection, but if my body does not reject the new heart, I will not have to take any medication at home." B. "I will need to take three different types of medications for the rest of my life to help prevent rejection." C. "I will receive medication before and during surgery, which will eliminate the risk of rejection." D. "There is no risk of rejection if the donor heart is an exact match."

B. "I will need to take three different types of medications for the rest of my life to help prevent rejection." Clients who have had heart transplants are constantly balancing the risk of rejection with the risk of infection. They must adhere to a complex regimen of diet, medications, activity, follow-up laboratory studies, biopsies of the transplanted heart (to diagnose rejection), and clinic visits. Three classes of medications are prescribed for a transplant client to help minimize rejection: corticosteroids (e.g., prednisone), calcineurin inhibitors (tacrolimus, cyclosporin), and antiproliferative agents (mycophenolate mofetil, azathioprine, or sirolimus).

A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response? A. "It is fine to let the child recover naturally; it will save you time and money." B. "It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." C. "Health care providers tend to overtreat children with antibiotics so the child recovers quickly." D. "It is not a good idea to give antibiotics for every sore throat that your child has because of the overuse of antibiotics."

B. "It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." A sore throat may be streptoccocal pharyngitis. Diagnosing and treating the sore throat can prevent rheumatic fever and, therefore, rheumatic heart disease. Letting children recover naturally can be dangerous if the sore throat is a strotococcal infection. The use of antibiotics is considered by each prescribing heath care provider. General statements about treatments are not helpful.

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for angina, the nurse should plan to include which instructions? A. "Only take one nitroglycerin tablet for each episode of angina." B. "See if rest relieves the chest pain before using the nitroglycerin." C. "Place the nitroglycerin tablet between cheek and gum." D. "Call 911 if you develop a headache following nitroglycerin use."

B. "See if rest relieves the chest pain before using the nitroglycerin." Decreased activity may relieve chest pain; sitting will prevent injury should the nitroglycerin lower BP and cause fainting. The client should expect to feel dizzy or flushed or to develop a headache following sublingual nitroglycerin use. The client should place one nitroglycerin tablet under the tongue if 2-3 minutes of rest fails to relieve pain. Clients may take up to three nitroglycerin tablets within 5 minutes of each other to relieve angina. However, they should call 911 if the three tablets fail to resolve the chest pain.

A nurse is caring for a client newly diagnosed with mitral valve prolapse. The health care provider indicates the client has probably had this condition for years. What factor is important for the nurse to consider when teaching the client about valular disease? A> "The client may have to wear antiembolism stocking to help with venous return." B. "The client with mitral valve prolapse probably had no health symptoms." C. "The client needs premium insurance to cover the cost of medications." D. "The client's religion may prohibit the client from seeking medical attention."

B. "The client with mitral valve prolapse probably had no health symptoms." Most people with mitral valve prolapse (which occurs more often in women) never have symptoms. Frequently, the first and only sign is identified during a routine physical assessment, when the examiner hears an extra heart sound on auscultation. Mitral value prolapse is treated with beta blockers or valve repair so premium insurance is not necessary. The client's religion is not a factor in teaching. The use of antiembolism stockings is not a treatment for mitral vale prolapse.

To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? A. 30 minutes B. 60 minutes C. 9 days D. 6 to 12 months

B. 60 minutes The 60-minute interval is known as "door-to-balloon time" in which a PTCA can be performed on a client with a diagnosed MI. The 30-minute interval is known as "door-to-needle time" for the administration of thrombolytics after MI. The time frame of 9 days refers to the time until the onset of vasculitis after administration of streptokinase for thrombolysis in a client with an acute MI. The 6- to 12-month time frame refers to the time period during which streptokinase will not be used again in the same client for acute MI.

The nurse is assessing a postoperative patient who had a percutaneous transluminal coronary angioplasty (PTCA). Which possible complications should the nurse monitor for? (Select all that apply.) A. Aortic dissection B. Abrupt closure of the artery C. Nerve root pressure D. Arterial dissection E. Coronary artery vasospasm

B. Abrupt closure of the artery D. Arterial dissection E. Coronary artery vasospasm Complications that can occur during a PTCA procedure include coronary artery dissection, perforation, abrupt closure, or vasospasm. Additional complications include acute myocardial infarction, serious dysrhythmias (e.g., ventricular tachycardia), and cardiac arrest. Some of these complications may require emergency surgical treatment. Complications after the procedure may include abrupt closure of the coronary artery and a variety of vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion (Bhatty, Cooke, Shettey, et al., 2011).

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? A. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. B. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. C. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. D. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the health care provider.

B. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement? A. Prepare to insert a unilateral chest tube. B. Ask the patient to lean forward and listen again. C. Notify the health care provider. D. Document that the pericarditis has resolved.

B. Ask the patient to lean forward and listen again. The most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border. Having the patient lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. These assessment data are not life-threatening and do not require a call to the health care provider. The nurse should try multiple times to auscultate the friction rub before deciding that the rub is gone. Chest tubes are not the treatment of choice for not hearing friction rubs. Reference

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? A. Assess the client's level of anxiety and provide emotional support. B. Assess the client's level of pain and administer prescribed analgesics. C. Ensure that the client's family is kept informed of the client's status. D.Prepare the client for pulmonary artery catheterization.

B. Assess the client's level of pain and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and family members should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed? A. Placement of an autograft valve B. Balloon percutaneous valvuloplasty C. Placement of a xenograft valve D. Antibiotic therapy

B. Balloon percutaneous valvuloplasty Definitive treatment for aortic stenosis is surgical replacement of the aortic valve. Clients who are symptomatic, but not good surgical candidates may benefit from a one or two balloon percutaneous valvuloplasty. Antibiotic therapy will not open the valve. The client does not want to have a valve replacement of any kind.

A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse? A. Pain score 5/10 B. Central venous pressure reading of 1 C. Heart rate 66 bpm D. Blood pressure 110/68 mm Hg

B. Central venous pressure reading of 1 The central venous pressure (CVP) reading of 1 is low (2-6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.

Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic? A. Allow unrestricted physical activity B. Check regularly for dependent edema C. Administer oxygen D. Maintain bed rest

B. Check regularly for dependent edema The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.

The nurse is reviewing the laboratory results for a patient having a suspected myocardial infarction (MI). What cardiac-specific isoenzyme does the nurse observe for myocardial cell damage? A. Alkaline phosphatase B. Creatine kinase MB C. Troponin D. Myoglobin

B. Creatine kinase MB There are three creatine kinase (CK) isoenzymes: CK-MM (skeletal muscle), CK-MB (heart muscle), and CK-BB (brain tissue). CK-MB is the cardiac-specific isoenzyme; it is found mainly in cardiac cells and therefore increases when there has been damage to these cells. Elevated CK-MB is an indicator of acute MI; the level begins to increase within a few hours and peaks within 24 hours of an infarct.

A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart have begun to fail. The nurse will monitor the client carefully for which initial symptoms? A. Syncope, fever, vomiting B. Exertional dyspnea, orthopnea, pulmonary edema C. Nausea, vomiting, exertional fatigue D. Dizziness, nausea, diarrhea

B. Exertional dyspnea, orthopnea, pulmonary edema When symptoms develop, clients with aortic stenosis usually first have exertional dyspnea, caused by increased pulmonary venous pressure from left heart failure. Orthopnea, paroxysmal nocturnal dyspnea, dizziness, and pulmonary edema may also occur. Nausea and vomiting may be signs of gastrointestinal congestion, but would be related to right heart failure, which does not occur initially with aortic stenosis.

A client admitted to the coronary care unit (CCU) diagnosed with a STEMI is anxious and fearful. Which medication will the nurse administer to relieve the client's anxiety and decrease cardiac workload? A. Atenolol B. IV morphine C. IV nitroglycerin D. Amlodipine

B. IV morphine IV morphine is the analgesic of choice for the treatment of an acute MI. It is given to reduce pain and treat anxiety. It also reduces preload and afterload, which decreases the workload of the heart. IV nitroglycerin is given to alleviate chest pain. Administration of atenolol and amlodipine are not indicated in this situation.

Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis? A. Administer a prescribed antipyretic. B. Maintain the client on bed rest. C. Elevate the client's head. D. Administer supplemental oxygen.

B. Maintain the client on bed rest. The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. Bed rest also helps decrease myocardial damage and the complications of myocarditis. The nurse should administer supplemental oxygen to relieve tachycardia that may develop from hypoxemia. If the client has a fever, the nurse should administer a prescribed antipyretic along with independent nursing measures such as minimizing layers of bed linen, promoting air circulation and evaporation of perspiration, and offering oral fluids. The nurse should elevate the client's head to promote maximal breathing potential.

Which nursing intervention would reduce cardiac workload in a client with myocarditis? A. Administer a prescribed antipyretic. B. Maintain the client on bed rest. C. Eliminate all phone calls and visitors. D. Lower the client's head.

B. Maintain the client on bed rest. The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse would administer a prescribed antipyretic only if the client has a fever. The nurse elevates the client's head to promote maximal breathing potential. Treatment for myocarditis does not preclude allowing the client to have visitors or use the telephone.

A patient at the clinic describes shortness of breath, periods of feeling "lightheaded," and feeling fatigued despite a full night's sleep. The nurse obtains vital signs and auscultates a systolic click. What does the nurse suspect from the assessment findings? A. Mitral regurgitation B. Mitral valve prolapse C. Aortic regurgitation D. Aortic stenosis

B. Mitral valve prolapse Most people with mitral valve prolapse never have symptoms. A few have fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, or anxiety. Fatigue may occur regardless of activity level and amount of rest or sleep. Often the first and only sign of mitral valve prolapse is an extra heart sound, referred to as a mitral click. A systolic click is an early sign that a valve leaflet is ballooning into the left atrium.

After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time? A. Troponin I B. Myoglobin C. WBC (white blood cell) count D. C-reactive protein

B. Myoglobin Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels due not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.

A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of what medication? A. Amantadine B. Nitroglycerin C. Digoxin D. Diphenhydramine

B. Nitroglycerin A cholinergic blocking agent may cause dry mouth and delay the sublingual absorption of nitroglycerin. The nurse should offer the client sips of water before administering nitroglycerin. Amantadine, digoxin, and diphenhydramine can interact with a cholinergic blocking agent but not through delayed absorption. Amantadine and diphenhydramine enhance the effects of anticholinergic agents.

The nurse is caring for a client with aortic regurgitation. The nurse knows to expect what symptoms during the physical examination? A. Increased urine output B. Orthopnea and dyspnea C. Headache and vomiting D. Nausea and low urine output

B. Orthopnea and dyspnea Aortic regurgitation usually manifests as progressive left ventricular failure, resulting from blood flowing backward from the aorta to the left ventricle, and eventually into the lungs. Urine output would be decreased from lower cardiac output. Nausea and vomiting are symptoms of increased gastrointestinal pressure, which would result from right heart failure. Kidney failure could become a problem later if cardiac output became too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.

After undergoing cardiac surgery, a client discovers a painless lump and reports this to the nurse. What is the most important nursing intervention for this client? A. Inform the client that the lump will be removed by the surgeon. B. Reassure the client by informing him or her that the lump will disappear with time. C. Reassure the client by informing him or her that the lump will disappear after a course of drug therapy. D. Reassure the client and direct the client to the health care provider.

B. Reassure the client by informing him or her that the lump will disappear with time. The nurse will reassure the client by informing him or her that the lump will disappear with time and will not require surgery, drug therapy, or a visit to the health care provider.

A client with infective endocarditis is assessed by the nurse for the presence of Janeway lesions. On inspection, the nurse recognizes these lesions by identifying which characteristic sign? A. Patterns of petechiae on the chest B. Red or purple macules found on the palms of the hands C. Erythematosus modules on the pads of the fingers D. Splinter hemorrhages seen under the fingernails

B. Red or purple macules found on the palms of the hands Janeway lesions are painless, red or purple macules found on the palms and soles.

A nurse reviews an ECG strip for a client who is admitted with symptoms of an acute MI. The nurse should recognize what classic ECG changes that occur with an MI? Select all that apply. A. Absent P-waves B. ST-segment elevations C. U-wave elevations D. Abnormal Q-waves E. T-wave hyperactivity and inversions

B. ST-segment elevations D. Abnormal Q-waves E. T-wave hyperactivity and inversions These three signs are classic ECG changes suggestive of a myocardial infarction. Changes can be diagnostic to the area of cellular damage. P wave and U wave changes are not characteristic of an MI.

A nurse is assigned to care for a recently admitted client who has been diagnosed with refractory angina. What symptom will the nurse expect the client to exhibit? A. Pain that occurs more frequently and lasts longer than the pain usually seen with stable angina B. Severe, incapacitating chest pain C. Predictable and consistent pain that occurs on exertion and is relieved by rest D. Pain that may occur at rest, but the threshold for pain is lower than expected

B. Severe, incapacitating chest pain

Which symptom occurs in the client diagnosed with mitral regurgitation when pulmonary congestion occurs? A. A loud, blowing murmur B. Shortness of breath C. Tachycardia D. Hypertension

B. Shortness of breath If pulmonary congestion occurs, the client with mitral regurgitation develops shortness of breath. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate? A. "Would you like something to calm your nerves?" B. "Don't cry; you have the best team of doctors." C. "Tell me what concerns you most." D. "Everything will be fine. Your family is here for you."

C. "Tell me what concerns you most." Allowing the client to share feelings tends to relieve or reduce emotional distress. Telling a client that everything is fine negates the feelings they are expressing. Telling a client not to cry can be viewed as insensitive to the feelings being expressed. Providing a prescribed sedative may be helpful but does not address the fears and concerns of the client.

The nurse is teaching the client about coronary artery damage after an abnormal fasting lipid profile. The client asks the nurse what type of lipid is most troublesome. What is the nurse's best response? A. "The higher the high-density lipoproteins (HDL), the more at risk you are for heart damage or a stroke." B. "The total cholesterol level of 252 mg/dL warrants medication treatment alone." C. "The low-density lipoproteins (LDL) pose a threat to plague formation and can cause a heart attack of stroke." D. "The triglycerides levels measure good fat, so the higher the level, the less risk you are for a heart attack or stroke."

C. "The low-density lipoproteins (LDL) pose a threat to plague formation and can cause a heart attack of stroke." When there is an excess of LDL, these particles adhere to vulnerable points in the arterial endothelium. Here, macrophages ingest them, leading to the formation of foam cells and the beginning of plaque formation. A harmful effect is exerted on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. The cholesterol level should be <200 mg/dL but it is not the only indication for treatment. The lower the HDL, the more the client is at risk for heart attack or stroke. The combination of the client's triglycerides, LDL, and HDL levels is used to direct treatment.

A nurse working in the medical intensive care unit has a client admitted with mitral stenosis. The nurse is precepting a graduate nurse and explains the pathophysiology of the condition. What statement made by the graduate nurse will reflect an appropriate understanding of the disease process? Select all that apply. A. "Mitral stenosis affects the coronary blood flow and can lead to angina." B. "Mitral stenosis is caused by an obstruction between the right atrium and ventricle." C. "There is a narrowing between the left atrium and left ventricle." D. "It is caused by a tear that leads to the lungs becoming congested." E. "Increased blood flow in the left atrium causes left atrial hypertrophy."

C. "There is a narrowing between the left atrium and left ventricle." E. "Increased blood flow in the left atrium causes left atrial hypertrophy." Poor left ventricular filling can cause decreased cardiac output. The increased blood volume in the left atrium causes it to dilate and hypertrophy. The left atrium and ventricle are affected with mitral stenosis. Mitral regurgitation causes the lungs to become congested. Mitral stenosis does not interfer with coronary blood flow.

Heparin therapy is usually considered therapeutic when the client's activated partial thromboplastin time (aPTT) is how many times normal? A. .25 to .75 B. .75 to 1.5 C. 2.0 to 2.5 D. 2.5 to 3.0

C. 2.0 to 2.5 The amount of heparin administered is based on aPTT results, which should be obtained during the follow-up to any alteration of dosage. The client's aPTT value would have to be greater than .25 to .75 or .75 to 1.5 times normal to be considered therapeutic. An aPTT value that is 2.5 to 3 times normal would be too high to be considered therapeutic.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. With regards to partial thromboplastin time (PTT), when should the nurse plan to remove the femoral sheath? A. 100 seconds or less. B. 125 seconds or less. C. 50 seconds or less. D. 75 seconds or less.

C. 50 seconds or less. Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 50 seconds or less before the sheath is removed. Removing the sheath before the PTT drops below 50 seconds can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.

A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? A. A client with hypertrophic cardiomyopathy B. A client 1 day post coronary stent placement C. A client 4 days postoperative after mitral valve replacement D. A client with a history of repaired ventricular septal defect

C. A client 4 days postoperative after mitral valve replacement Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's first priority ? A. Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the results. B. Notify the next nurse on afternoon shift to hold the evening dose of warfarin. C. Assess the client for bleeding and notify the health care provider of the results. D.Notify the health care provider to request an increase in the warfarin dose.

C. Assess the client for bleeding and notify the health care provider of the results. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the health care provider of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a health care provider's order. The nurse should notify the health care provider before holding a medication scheduled to be administered during another shift.

The nurse is caring for a client with Raynaud's disease. What is an important instruction for a client who is diagnosed with this disease to prevent an attack? A. Report changes in the usual pattern of chest pain. B. Avoid fatty foods and exercise. C. Avoid situations that contribute to ischemic episodes. D. Take over-the-counter decongestants

C. Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.

A client is diagnosed with mitral regurgitation. What does the nurse consider with the mechanics of cardiac hemodynamics? A. Blood flows backward from the aorta into the left ventricle. B. Blood flows backward from the right ventricle into the right atrium. C. Blood flows backward from the left ventricle into the left atrium during systole. D. Blood flows backward from the left atrium into the pulmonary system.

C. Blood flows backward from the left ventricle into the left atrium during systole. When the mitral valve leaflets thicken, fibrose, and contract, they cannot close completely. With each heartbeat, blood is forced backward into the left atrium during systole. Regurgitation of blood into the left atrium causes the left atrial pressure to rise.

The nurse is assisting with a bronchoscopy at the bedside in a critical care unit. The client experiences a vasovagal response. What should the nurse do next? A. Suction the airway. B. Prepare to administer intravenous fluids. C. Check blood pressure. D. Assess pupils for reactiveness.

C. Check blood pressure. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it in turn may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate, leading to syncope. The nurse will need to assess blood pressure to assure circulation. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

A client had a percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse administer to prevent thrombus formation in the stent? A. Diltiazem B. Isosorbide mononitrate C. Clopidogrel D. Metoprolol

C. Clopidogrel Because of the risk of thrombus formation following a coronary stent placement, the patient receives antiplatelet medications, such as clopidogrel or aspirin. Isosorbide mononitrate is a nitrate used for vasodilation. Metoprolol is a beta blocker used for relaxing blood vessels and slowing heart rate. Diltiazem is a calcium channel blocker used to relax heart muscles and blood vessels.

The nurse is caring for a client who was admitted to the telemetry unit with a diagnosis of "rule/out acute MI." The client's chest pain began 3 hours earlier. Which laboratory test would be most helpful in confirming the diagnosis of a current MI? A. CK-MM B. Troponin C level C. Creatinine kinase-myoglobin (CK-MB) level D. Myoglobin level

C. Creatinine kinase-myoglobin (CK-MB) level Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (as a result of thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. Three isomers of troponin exist: C, I, and T. Troponins I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

A patient has had a successful heart transplant for end-stage heart disease. What immunosuppressant will be necessary for this patient to take to prevent rejection? A. Vancomycin B. Nifedipine C. Cyclosporine D. Verapamil

C. Cyclosporine Because of advances in surgical techniques and immunosuppressive therapies, heart transplantation is now a therapeutic option for patients with end-stage heart disease. Cyclosporine and tacrolimus are immunosuppressants that decrease the body's rejection of foreign proteins, such as transplanted organs.

A nurse is caring for a client who experienced an MI. The client is ordered to received metoprolol. The nurse understands that this medication has which therapeutic effect? A. Decreases platelet aggregation B. Increases cardiac output C. Decreases resting heart rate D. Decreases cholesterol level

C. Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. In general, the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

he diagnosis of aortic regurgitation (AR) is confirmed by which of the following? A. Myocardial biopsy B. Cardiac catheterization C. Echocardiography D. Exercise stress testing

C. Echocardiography Diagnosis is confirmed by echocardiography. Cardiac catheterization is not necessary in most patients with AR. Exercise stress testing will assess functional capacity and symptom response. A myocardial biopsy may be performed to analyze myocardial tissue cells in patients with cardiomyopathy.

he diagnosis of aortic regurgitation (AR) is confirmed by which of the following? A. Myocardial biopsy B. Exercise stress testing C. Echocardiography D. Cardiac catheterization

C. Echocardiography Diagnosis is confirmed by echocardiography. Cardiac catheterization is not necessary in most patients with AR. Exercise stress testing will assess functional capacity and symptom response. A myocardial biopsy may be performed to analyze myocardial tissue cells in patients with cardiomyopathy.

A client is diagnosed with rheumatic endocarditis. What bacterium is the nurse aware causes this inflammatory response? A. Staphylococcus aureus B. Pseudomonas aeruginosa C. Group A, beta-hemolytic streptococcus D. Serratia marcescens

C. Group A, beta-hemolytic streptococcus Acute rheumatic fever, which occurs most often in school-age children, may develop after an episode of group A beta-hemolytic streptococcal pharyngitis (Chart 28-2). Clients with rheumatic fever may develop rheumatic heart disease as evidenced by a new heart murmur, cardiomegaly, pericarditis, and heart failure.

Which type of graft is used when a heart valve replacement is made of tissue from an animal heart valve? A. Allograft B. Autograft C. Heterograft D. Homograft

C. Heterograft Heterograft, also called bioprosthesis, refers to replacement of tissue from animal tissue, usually pigs but also cows or horses. An autograft is a heart valve replacement made from the client's own heart valve. Allograft refers to replacement using human tissue and is a synonym for homograft.

When the postcardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which electrolyte imbalance? A. Hypokalemia B. Hyperkalemia C. Hypermagnesemia D. Hypomagnesemia

C. Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, and cardiac arrest. Signs and symptoms of hypokalemia include signs of digitalis toxicity and dysrhythmias (U wave, AV block, flat or inverted T waves). Signs of hyperkalemia include mental confusion, restlessness, nausea, weakness, paresthesias of extremities, dysrhythmias (tall, peaked T waves; increased amplitude, widening QRS complex; prolonged QT interval). Signs and symptoms of hypomagnesemia include paresthesias, carpopedal spasm, muscle cramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia, cardiac dysrhythmias (prolonged PR and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

The nurse notes that the post cardiac surgery client demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025). What will the nurse anticipate the health care provider will order? A. Decrease intravenous fluids B. Prepare the client for diaylsis C. Increase intravenous fluids D. Irrigate the urinary catheter

C. Increase intravenous fluids Urine output of less than 25 mL/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine, which occurs with inadequate fluid volume. The heallthcare provider may increase intravenous fluids. Irrigating the urinary catheter will be done if there is a suspected blockage. Dialysis is not indicated by urinary volumes.

A client has been recently placed on nitroglycerin. Which instruction by the nurse should be included in the client's teaching plan? A. Instruct the client to renew the nitroglycerin supply every 3 months. B. Instruct the client to place nitroglycerin tablets in a plastic pill box. C. Instruct the client on side effects of flushing, throbbing headache, and tachycardia. D. Instruct the client not to crush the tablet.

C. Instruct the client on side effects of flushing, throbbing headache, and tachycardia. The client should be instructed about side effects of the medication, which include flushing, throbbing headache, and tachycardia. The client should renew the nitroglycerin supply every 6 months. If the pain is severe, the client can crush the tablet between the teeth to hasten sublingual absorption. Tablets should never be removed and stored in metal or plastic pillboxes. Nitroglycerin is very unstable and should be carried in its original container.

A client who suffered blunt chest trauma in a motor vehicle accident reports chest pain during deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. To relieve this chest pain, which position should the nurse encourage the client to assume? A. Prone B. Semi-Fowler's C. Leaning forward while sitting D. Supine

C. Leaning forward while sitting The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, thus helping to relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action, and therefore, do not relieve chest pain associated with pericarditis.

A nurse is caring for a client with end-stage cardiomyopathy and the client's spouse asks the nurse to clarify one of the last treatment options available that the health care provider mentioned earlier. What option will the nurse most likely discuss? A. Chordoplasty B. Annuloplasty C. Left ventricular assist device D. Open commissurotomy

C. Left ventricular assist device When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Because of the limited number of organ donors, many clients die waiting. In some cases, a left ventricular assist device is implanted to support the failing heart until a suitable donor becomes available. The other three choices have to do with failing valves and valve repairs.

The nurse is caring for a client following a coronary artery bypass graft (CABG). The nurse notes persistent oozing of bloody drainage from various puncture sites. The nurse anticipates that the physician will order which medication to neutralize the unfractionated heparin the client received? A. Clopidogrel B. Aspirin C. Protamine sulfate D. Alteplase

C. Protamine sulfate Protamine sulfate is known as the antagonist for unfractionated heparin (it neutralizes heparin). Alteplase is a thrombolytic agent. Clopidogrel is an antiplatelet medication that is given to reduce the risk of thrombus formation after coronary stent placement. The antiplatelet effect of aspirin does not reverse the effects of heparin.

It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the: A. Aorta to the left ventricle. B. Left atrium to the left ventricle. C. Right ventricle to the right atrium. D. Right atrium to the right ventricle.

C. Right ventricle to the right atrium. The tricuspid valve is located between the right atrium and the right ventricle. Therefore, incomplete closure results in the backward flow of blood from the right ventricle to the right atrium.

The nurse assessing a patient with pericardial effusion at 0800 notes the apical pulse is 74 and the BP is 140/92. At 1000, the patient has neck vein distention, the apical pulse is 72, and the BP is 108/92. Which action would the nurse implement first? A. Notify the health care provider immediately. B. Administer morphine by intravenous push slowly. C. Stay with the patient, use a calm voice, and ask for assistance via call light. D. Place the patient in the left lateral recumbent position.

C. Stay with the patient, use a calm voice, and ask for assistance via call light. The nurse stays with the patient and continues to assess and record signs and symptoms while intervening to decrease patient anxiety. The pulse pressure is narrowing, and the patient is experiencing neck vein distention, indicative of rising central venous pressure. After reaching assistance via the call light from the patient's beside, the nurse notifies the physician immediately and prepares to assist with diagnostic echocardiography and pericardiocentesis. A left lateral recumbent position is used when administering enemas. Morphine would be given to someone who may be experiencing a myocardial infarction, not cardiac tamponade.

The client is prescribed nadolol for hypertension. What is the reason the nurse will teach the client not to stop taking the medication abruptly? A. The abrupt stop can trigger a migraine headache. B. The abrupt stop can lead to formation of blood clots. C. The abrupt stop can cause a myocardial infarction. D. The abrupt stop will precipitate internal bleeding.

C. The abrupt stop can cause a myocardial infarction. Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or the onset of a migraine headache.

A nurse is caring for a client with pericarditis and auscultates a pericardial friction rub.What action does the nurse ask the client to do to distinguish a pericardial friction rub from a pleural friction rub? A. The nurse has the client stand during auscultation. B. There is really no question to ask the client to tell the difference. C. The nurse asks the client to hold the breath during auscultation. D. The nurse places the client flat for at least 4 minutes.

C. The nurse asks the client to hold the breath during auscultation. A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid as a result of inflammation. The audible rub on auscultation is synchronous with the heartbeat. To distinguish between a pleural rub and a pericardial rub, the client should hold the breath. The pericardial rub will continue. Length of auscultation and standing would not assist in distinguishing one kind of rub from the other.

Two female nursing assistants approach a nurse on a cardiac step-down unit to report that a client who experienced an acute myocardial infarction made sexual comments to them. How should the nurse intervene? A. The nurse should explain that the client most likely wants extra attention. B. The nurse should instruct the nursing assistants to avoid answering his call light. C. The nurse should explain that the client might have concerns about resuming sexual activity but is afraid to ask. D. The nurse should report the incident to her supervisor immediately.

C. The nurse should explain that the client might have concerns about resuming sexual activity but is afraid to ask. Sometimes clients are concerned about resuming sexual activity but are afraid to ask. Making inappropriate sexual comments provides a forum for asking questions. It isn't necessary to report the incident to the nursing supervisor immediately without investigating the situation further. The client's call light must be answered in a timely fashion. More information is needed before assuming that the client is asking for extra attention.

A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant? A. The patient reports chest pain after eating a large meal. B. The patient's has an enlarged liver and oedematous abdomen. C. The patient reports shortness of breath when walking. D. The patient has jugular vein distention and 3+ pedal edema.

C. The patient reports shortness of breath when walking. Dyspnea on exertion is typically the earliest manifestation of mitral valve stenosis. Late signs of right-sided heart failure are jugular vein distention, edema, and enlarged liver. Chest pain rarely occurs with mitral valve stenosis.

The nurse is explaining the cause of angina pain to a client. What will the nurse say caused the pain? A. complete closure of an artery B. incomplete blockage of a major coronary artery C. a lack of oxygen in the heart muscle that causes the death of cells D. a destroyed part of the heart muscle

C. a lack of oxygen in the heart muscle that causes the death of cells Impeded blood flow, due to blockage in a coronary artery, deprives the cardiac muscle cells of oxygen, thus leading to a condition known as ischemia. Artery blockage or closure leads to myocardial death. The destroyed part of the heart is a myocardial infarction.

A client who has been diagnosed with Prinzmetal's angina will present with which symptom? A. chest pain of increased frequency, severity, and duration B. radiating chest pain that lasts 15 minutes or less C. chest pain that occurs at rest and usually in the middle of the night D. prolonged chest pain that accompanies exercise

C. chest pain that occurs at rest and usually in the middle of the night A client with Prinzmetal's angina will complain of chest pain that occurs at rest, usually between 12 and 8:00 AM, is sporadic over 3-6 months, and diminishes over time. Clients with stable angina generally experience chest pain that lasts 15 minutes or less and may radiate. Clients with Cardiac Syndrome X experience prolonged chest pain that accompanies exercise and is not always relieved by medication. Clients with unstable angina experience chest pain of increased frequency, severity, and duration that is poorly relieved by rest or oral nitrates.

The nurse suspects a client has developed pericarditis after a week of cold-like symptoms. Which of the client's signs and symptoms indicate pericarditis? A. lethargy, anorexia, and heart failure B. pitting edema, chest discomfort, and nonspecific ST-segment elevation C. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) D. low urine output secondary to left ventricular dysfunction

C. fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema, result from acute renal failure.

A nurse caring for a client with cardiomyopathy determines a diagnosis of anxiety related to a fear of death. Which behavior would indicate to the nurse recognizes that the client's level of anxiety has decreased when the client A. is resting in bed watching TV. B. answers questions about physical status with no problem. C. is able to discuss the prognosis freely. D. eagerly awaits visits from family.

C. is able to discuss the prognosis freely. As anxiety decreases, clients will be able to discuss prognosis freely, verbalize fears and concerns, participate in support groups, and demonstrate appropriate coping mechanisms.

A client presents to the ED with a myocardial infarction. Prior to administering a prescribed thrombolytic agent, the nurse must determine whether the client has which absolute contraindication to thrombolytic therapy? A. shellfish allergy B. recent consumption of a meal C. prior intracranial hemorrhage D. use of heparin

C. prior intracranial hemorrhage History of a prior intracranial hemorrhage is an absolute contraindication for thrombolytic therapy. An allergy to iodine, shellfish, radiographic dye, and latex are of primary concern before a cardiac catheterization but not a known contraindication for thrombolytic therapy. Administration of a thrombolytic agent with heparin increases risk of bleeding; the primary healthcare provider usually discontinues the heparin until thrombolytic treatment is completed.

The nurse is teaching a school community parent group about heart wellness. What risk factor is a common leading cause for mitral stenosis? A. Marfan's syndrome B. infective endocarditis C. rheumatic fever D. dissecting aortic aneurysm

C. rheumatic fever The most significant risk factor for mitral stenosis is rheumatic fever, which gradually causes the mitral valve leaflets to thicken and can result in leaflet fusion. Risk factors for aortic regurgitation are infective endocarditis, Marfan's syndrome, and a dissecting aortic aneurysm.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?

Client maintains mechanical ventilation with minimal mucus accumulation. Expl: A client with a lumbar spinal injury would not require mechanical ventilation. Pg 2053

23. Which type of brain injury has occurred if the patient may be aroused with effort, but soon slips back into unconsciousness?

Contusion i. A patient with a contusion may be aroused with effort but soon slips back into unconsciousness. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brain stem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? A. "The pain got worse when I took a deep breath." B. "The pain resolved after I ate a sandwich." C. "The pain lasted about 45 minutes." D. "The pain occurred while I was mowing the lawn."

D. "The pain occurred while I was mowing the lawn." Decreased oxygen supply to the myocardium causes angina pectoris. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and may precipitate this chest pain. Anginal pain typically is self-limiting, lasting 5 to 15 minutes. Food consumption doesn't reduce angina pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.

A nurse and a nursing student are performing a physical assessment of a client with pericarditis. The client has an audible pericardial friction rub on auscultation. When leaving the room, the student asks the nurse what causes the sound. The nurse's best response is which of the following? A. "The layers of the heart become loose from each other and rub together with each heart beat." B. "The lung surfaces lose their lubrication and rub against the myocardium with each heart beat." C. "The great vessels rub against the pericardium with each heart beat." D. "The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other."

D. "The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other." A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid due to inflammation. The rub is audible on auscultation and is synchronous with the heartbeat. The layers of the heart never become loose from each other. The great vessels are not in contact with the inside of the pericardium, where the inflammation is located. The lungs have nothing to do with a pericardial friction rub.

The nurse is caring for a client experiencing an acute MI (STEMI). The nurse anticipates the physician will prescribe alteplase. Before administering this medication, which question is most important for the nurse to ask the client? A. "Do your parents have heart disease?" B. "What is your pain level on a scale of 1 to 10?" C. "How many sublingual nitroglycerin tablets did you take?" D. "What time did your chest pain start today?"

D. "What time did your chest pain start today?" The client may be a candidate for thrombolytic (fibrolytic) therapy. These medications are administered if the client's chest pain lasts longer than 20 minutes and is unrelieved by nitroglycerin, if ST-segment elevation is found in at least two leads that face the same area of the heart, and if it has been less than 6 hours since the onset of pain. The most appropriate question for the nurse to ask is in relations to when the chest pain began. The other questions would not aid in determining whether the client is a candidate for thrombolytic therapy.

A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which finding requires immediate intervention by the nurse? A. Minimal oozing of blood from the IV site B. Presence of reperfusion dysrhythmias C. Chest pain 2 of 10 (on a 1-to-10 pain scale) D. Altered level of consciousness

D. Altered level of consciousness A client receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness may indicate hypoxia and intracranial bleeding, and the infusion should be discontinued immediately. Minimal bleeding requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low and indicates the client's chest pain is subsiding, an expected outcome of this therapy.

Following a percutaneous coronary intervention (PCI), a client is returned to the nursing unit with large peripheral vascular access sheaths in place. The nurse understands that which method to induce hemostasis after sheath is contraindicated? A. Direct manual pressure B. Application of a vascular closure device C. Application of a mechanical compression device D. Application of a sandbag to the area

D. Application of a sandbag to the area Applying a sandbag to the sheath insertion site is ineffective in reducing the incidence of bleeding and is not an acceptable standard of care. Application of a vascular closure device (Angio-Seal, VasoSeal), direct manual pressure to the sheath introduction site, and application of a mechanical compression device (a C-shaped clamp) are all appropriate methods used to induce hemostasis after removal of a peripheral sheath.

Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is most effective? A. Direct manual pressure B. Application of a sandbag to the area C. Application of a pneumatic compression device (e.g., FemoStop) D. Application of a vascular closure device such as Angio-Seal or VasoSeal

D. Application of a vascular closure device such as Angio-Seal or VasoSeal Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site and application of a pneumatic compression device after PTCA have been demonstrated to be effective; the former was the first method used to induce hemostasis after PTCA. Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding.

After percutaneous transluminal coronary angioplasty (PTCA), the nurse confirms that a client is experiencing bleeding from the femoral site. What will be the nurse's initial action? A. Notify the health care provider. B. Review the results of the latest blood cell count, especially the hemoglobin and hematocrit. C. Decrease anticoagulant or antiplatelet therapy. D. Apply manual pressure at the site of the insertion of the sheath.

D. Apply manual pressure at the site of the insertion of the sheath. The immediate nursing action would be to apply pressure to the femoral site. Reviewing blood studies will not stop the bleeding. The nurse cannot decrease anticoagulation therapy independently. If the bleeding does not stop, the health care provider needs to be notified.

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following? A. Disturbed sensory perception B. Autonomic dysreflexia C. Ineffective airway clearance D. Decreased cardiac output

D. Decreased cardiac output A primary nursing diagnosis for cardiomyopathy is decreased cardiac output related to structural disorders caused by cardiomyopathy or to dysrhythmia from the disease process and medical treatments. Dyspnea on exertion, fatigue, and fluid retention are related to poor cardiac output. Nausea is related to poor perfusion of the gastrointestinal system. Autonomic dysreflexia is related to a spinal cord injury. Ineffective airway clearance relates to the inability to clear secretions from the airway, which is not an initial problem with cardiomyopathy. Disturbed sensory perception is related to specific senses and not to initial cardiomyopathy.

A client reporting heart palpitations is diagnosed with atrial fibrillation caused by mitral valve prolapse. To relieve the symptoms, the nurse should teach the client which dietary intervention? A. Decrease the amount of sodium and saturated fat B. Decrease the amount of acidic beverages and fruits C. Eliminate dairy products and carbonated beverages D. Eliminate caffeine and alcohol

D. Eliminate caffeine and alcohol To minimize symptoms of mitral valve prolapse, the nurse should instruct the client to avoid caffeine and alcohol. The nurse encourages the client to read product labels, particularly on over-the-counter products such as cough medicine, because these products may contain alcohol, caffeine, ephedrine, and adrenaline, which may produce arrhythmias and other symptoms. The nurse also explores possible diet, activity, sleep, and other lifestyle factors that may correlate with symptoms.

A nurse reviewing a client's echocardiogram report reads the following statements: "The heart muscle is asymmetrically thickened and the overall size and mass are increased, especially along the septum. The ventricular walls are thickened, reducing the size of the ventricular cavities. Several areas of the myocardium show evidence of scaring." The nurse knows these manifestations are indicative of which type of cardiomyopathy? A. Arrhythmogenic right ventricular B. Dilated C. Restrictive D. Hypertrophic

D. Hypertrophic In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically increases in size and mass, especially along the septum. It often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole. The coronary arteriole walls are also thickened, which decreases the internal diameter of the arterioles. The narrow arterioles restrict the blood supply to the myocardium, causing numerous small areas of ischemia and necrosis. The necrotic areas of the myocardium ultimately fibrose and scar, further impeding ventricular contraction. Because of the structural changes, HCM had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH). Restrictive (or constrictive) cardiomyopathy (RCM) is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation? A. Urine output B. Hourly IV infusion C. Vascular sites for bleeding D. Prothrombin time (PT) or international normalized ratio (INR)

D. Prothrombin time (PT) or international normalized ratio (INR) The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.

Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch. A. Arrhythmogenic right ventricular cardiomyopathy (ARVC) B. Dilated cardiomyopathy (DCM) C. Hypertrophic cardiomyopathy (HCM) D. Restrictive cardiomyopathy (RCM)

D. Restrictive cardiomyopathy (RCM) RCM may be associated with amyloidosis (amyloid, a protein substance, is deposited within cells) and other such infiltrative diseases. However, the cause is idiopathic in most cases. Hypertrophic cardiomyopathy occurs when the heart muscle asymmetrically increases in size and mass, especially along the septum. Dilated cardiomyopathy is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A nurse is teaching a client about maintaining a healthy heart. What information will the nurse include with the teaching? A. Exercise one or two times per week. B. Smoke in moderation. C. Consume a diet high in saturated fats. D. Use alcohol in moderation.

D. Use alcohol in moderation. The nurse should advise the client that alcohol may be used in moderation as long as there are no other contraindications for its use. Smoking, a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat.

A client is admitted to the emergency department with chest pain and doesn't respond to nitroglycerin. The health care team obtains an electrocardiogram and administers I.V. morphine. The health care provider also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? A. Within 12 hours B. Within 24 to 48 hours C. Within 5 to 7 days D. Within 6 hours

D. Within 6 hours For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Health care providers initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

An 89-year-old retired government clerk is being admitted to your rehabilitation hospital as a result of the tetraplegia caused by stroke. Her condition is stable, and after admission, she will begin physical and psychological therapy. An important part of your nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?

Maintain sufficient integument capillary pressure

A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?

Maintain sufficient integument capillary pressure Expl: Changing position every 2 hours relieves pressure over bony prominences and maintains sufficient capillary pressure to promote intact skin integrity. Pg. 2055

The nurse is admitting a client from the Emergency Department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Traction with weights and pulleys Expl: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine. Pg. 2052

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply.

Vomiting, Slurred speech, Weakness on one side of the body Expl: Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately. 2037

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. Expl: When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status. Pg. 2043