Urden (Ch 1-3, 5-7, 11-15)

The patient is a visual learner and will be discharged with a new colostomy pouch. List the appropriate educational strategies that can be used for teaching the care of the new appliance. (Select all that apply, one, some, or all.) A. Provide a demonstration and return demonstration. B. Provide a pamphlet with pictures. C. Give the patient a brief lecture. D. Show the patient an instructional video. E. Have the patient listen to audiotape on colostomies.

A, B, D A pamphlet with pictures, showing the patient an instructional video, and providing a demonstration and return demonstration are strategies that can be used successfully with visual learners. A lecture and listening to an audiotape would work better with auditory learners.

It is important for the nurse to have an understanding of anxiety and stress. Which statements regarding stress and anxiety and their effect on healing are accurate? (Select all that apply, one, some, or all.) A. Critical care is a very stressful environment for the patients, family, and staff. B. Stress can impede healing. C. Anxiety can intensify pain. D. All patients respond the same way to stress. E. Anxiety can cause powerlessness, which can lead to hopelessness.

A, B, C, E Stress can impede healing; anxiety can cause powerlessness, which can lead to hopelessness; anxiety can intensify pain; and critical care is a very stressful environment for the patients, family, and staff. It is not true that all patients respond the same way to stress; patients respond differently to stress based on biopsychosocial and cultural needs as well as length of illness and support systems.

The nurse is leveling and rezeroing the patient's hemodynamic line upon returning from the radiology department. The patient asks the nurse, "Why are you doing that?" What is an appropriate response? (Select all that apply, one, some, or all.) A. "Zeroing removes the effects of atmospheric pressure on the readings." B. "If we use the same reference point, we will obtain consistent measurements." C. "It is important to line up the reference point to the left side of the top of your heart." D. "This is something we do periodically." E. "Leveling the transducer above or below the reference point on your body can result in erroneous readings."

A, B, C, E Leveling the transducer above or below the reference point on your body can result in erroneous readings; zeroing removes the effects of atmospheric pressure on the readings; if we use the same reference point, we will obtain consistent measurements; and it is important to line up the reference point to the left side of the top of your heart are all correct and appropriate statements to share with a patient. This is something we do periodically is an incomplete and inappropriate response to a patient's question.

Which care management tools can be modified by the nurse to individualize patient care? (Select all that apply, one, some, or all.) A. Algorithms B. Practice alerts C. Protocols D. Order sets E. Nursing standards

A, B, D Algorithms are decision trees that help the nurse decide on appropriate interventions for patients based on needs and responses. Practice alerts and order sets are evidence-based and research-oriented. Protocols are directive and rigid, and providers are not supposed to vary from them. Nursing standards are set by professional organizations.

Adult learners are sensitive about making mistakes, so it is important for the nurse to include which of the following in the teaching plan for a patient with diabetes who is learning to give insulin self-injections? (Select all that apply, one, some, or all.) A. Repetition of information B. Written information C. Correction of the patient in front of others D. Positive reinforcement of skills E. Information in short, frequent bursts

A, B, D, E Repetition of information; positive reinforcement of skills; written information; and information in short, frequent bursts are all useful for adult learners. Correction of the patient in front of others is embarrassing to the patient and would impede learning.

The nurse is concerned that the physician is ignoring the wishes of the patient and family in the care of a patient. The nurse should take these concerns to (Select all that apply, one, some, or all.) A. the nursing supervisor. B. the ANA (American Nurses Association). C. the hospital ethics committee. D. the policy and procedure committee. E. the nursing ethics committee.

A, C The nurse could discuss this dilemma with the supervisor or take it to the hospital or nursing ethics committee. Although the American Nurses Association (ANA) publishes the Code of Ethics, contacting the organization would not be appropriate. The policy and procedure committee would be responsible for writing policy but not enforcing it.

A patient in the acute phase of systolic heart failure is admitted to the intensive care unit. Which interventions would the nurse anticipate? (Select all that apply, one, some, or all.) A. Nitroglycerin to decrease preload and afterload B. Dopamine to decrease contractility of the heart C. Morphine for peripheral dilation and to decrease anxiety D. Nesiritide to decrease pulmonary artery occlusion pressure and dyspnea E. Diuretics to lower systemic vascular resistance (SVR)

A, C, D Morphine, nitroglycerine, and nesiritide are all used to treat patients in systolic heart failure. Diuretics will decrease preload, not systemic vascular resistance (SVR). Dopamine will increase myocardial contractility.

A stroke patient is having difficulty eating and is coughing and choking during meals. Which actions should be included in the dietary care plan? (Select all that apply, one, some, or all.) A. The patient should be allowed to take his time when eating. B. The patient should always use a straw. C. It is important to give the patient thinned liquids. D. Moist foods are easier to swallow than dry ones. E. Suction equipment should be kept nearby when the patient is eating.

A, D, E Moist foods and adequate time for eating should help reduce the risk of choking. Suction equipment should be kept nearby in case the patient does choke despite these precautions. The patient should be given thickened liquids and soft foods to eat with a spoon. The patient should not use a straw.

A critical care nurse is planning an interdisciplinary team conference regarding placement for a long-term ventilator patient. Team members include representatives from nursing, respiratory therapy, case management, physical therapy, dietary, and pharmacy. Which QSEN competencies are reflected by this team? (Select all that apply, one, some, or all.) A. Evidence-Based Practice B. Quality Improvement C. Informatics D. Patient-Centered Care E. Teamwork and Collaboration

A, D, E Teamwork and collaboration, patient-centered care, and evidence-based practice are represented. The team is designed to make the best decision for the patient based on the evidence using collaboration. There is no description of a quality improvement project, and an informatics project is not represented.

A new graduate asks the preceptor why the hospital is not using heparin in the hemodynamic flush bags. What is the correct response? A. "There is a correlation between heparin infusions in cardiac patients and heparin-induced thrombocytopenia." B. "Heparin infusions increase the occurrence of clots, so we no longer use them." C. "It is a cost-saving measure." D. "The pressure on the bag breaks down the heparin, so heparin infusions are not effective."

A. "There is a correlation between heparin infusions in cardiac patients and heparin-induced thrombocytopenia." A patient receiving heparin is at increased risk for heparin-induced thrombocytopenia. Although it may save money, this is not the reason many hospitals have stopped using heparin. Heparin decreases, not increases, the occurrence of clots. Pressure does not destabilize heparin.

The nurse caring for a patient with chronic kidney disease. The nurse is administering aluminium hydroxide suspension (Amphojel) before lunch. The patient says, "I am not having indigestion. Why do I need this?" Which statement is an appropriate response from the nurse? A. "This is a phosphate binder that will lower your serum phosphorus." B. "This is a calcium supplement. You need it for your bones." C. "You should take it because your doctor ordered it." D. "This is to prevent indigestion at lunchtime."

A. "This is a phosphate binder that will lower your serum phosphorus." Patients with chronic kidney disease are at risk of hyperphosphatemia and are often prescribed a phosphate binder. Aluminium hydroxide will not prevent indigestion and is not a calcium supplement, although lowering the patient's phosphorus will help improve low calcium levels. When a patient questions a medication, to reply merely that the doctor ordered it is not an appropriate or informative answer.

Cardiac output is the amount of blood ejected from the heart in 1 minute. If a patient's heart rate (HR) is 72 beats/min and the stroke volume (SV) is 70 mL/beat, what is the patient's cardiac output? A. 5.04 L/min B. 120 L/min C. 142 L/min D. 2 L/min

A. 5.04 L/min Cardiac output is heart rate (HR) × stroke volume (SV) = 70 × 72 beats/min × 70 mL/beat = 5040 mL/min = 5.04 L/min.

A patient with a history of aortic stenosis is admitted for surgery to repair the valve. During cardiac assessment, the nurse would expect to hear which murmur? A. A low-pitched systolic murmur B. A high-pitched systolic murmur C. A low-pitched diastolic murmur D. A high-pitched diastolic murmur

A. A low-pitched systolic murmur The murmur of aortic stenosis occurs during systole. It is auscultated at the aortic area (second intercostal space, right sternal border). Aortic stenosis produces a low-pitched murmur that does not radiate.

A patient admitted for elective aortic aneurysm repair, scheduled for the next day, suddenly complains of severe back pain. Vital signs are blood pressure, 180/110 mm Hg; heart rate, 127 beats/min; and respiratory rate, 23 breaths/min. The nurse suspects that the patient has developed which problem? A. Aortic dissection B. Duodenal ulcer perforation C. Pulmonary embolism D. Papillary muscle rupture

A. Aortic dissection The classic clinical presentation an aortic dissection is the sudden onset of intense, severe, tearing pain, which may be localized initially in the chest, abdomen, or back. As the aortic tear (dissection) extends, pain radiates to the back or distally toward the lower extremities. Many patients have hypertension on initial presentation.

Many patients experience powerlessness when admitted to the intensive care unit. Which action by a nurse might decrease a patient's sense of powerlessness? A. Ask before moving the patient's personal belongings. B. Have the patient's spouse complete the patient's diet request form. C. Schedule the patient patient's physical therapy after lunch. D. Conduct shift hand-off outside the patient's room.

A. Ask before moving the patient's personal belongings. To decrease the patient's sense of powerlessness the nurse should ask before moving the patient's personal belongings as this allows the patient some control over the environment. Having the spouse complete the patient's diet request form, scheduling physical therapy without asking the patient's preference and conducting hand-off outside of the patient's room all deny the patient control and may enhance the patient's sense of powerlessness.

A patient is scheduled to have a permanent pacemaker placed for cardiac resynchronization (CRT) therapy. What is the goal of these therapy? A. Decrease heart failure symptoms. B. Prevent ventricular dysrhythmias. C. Improve coronary blood flow. D. Minimize risk of myocardial infarction.

A. Decrease heart failure symptoms. A number of clinical trials have shown that cardiac resynchronization therapy (CRT) improves symptoms, functional status, and mortality in patients with moderate to advanced heart failure. New research indicates that CRT may also be beneficial in preventing the progression of heart failure in less symptomatic patients.

A patient is transferred from the medical-surgical unit to the intensive care unit with an acute anterolateral myocardial infarction (MI). Fibrinolytic therapy has been ordered to dissolve the thrombus. What is considered a reliable indicator that fibrinolytic therapy has been successful? A. Decrease in ST elevations in affected leads B. Absence of premature ventricular contractions C. Return of creatinine kinase to normal levels D. Gradual decrease in chest pain

A. Decrease in ST elevations in affected leads When fibrinolytic therapy is successful, ST elevations rapidly resolve. ST elevations indicate myocardial injury; reperfusion restores blood flow and prevents injury. For the same reason, chest pain, which is caused by inadequate oxygen supply to myocardial tissue, is suddenly, not gradually, relieved. Creatinine kinase rapidly increases in reperfusion, a phenomenon known as "washout." Premature ventricular contractions, nonsustained ventricular tachycardia, and other dysrhythmias increase. These are known as reperfusion dysrhythmias and usually do not require treatment.

Prompt use of nutrition support is especially important for patients with head injuries. Head-injured patients rapidly exhaust glycogen stores and begin to use body proteins to meet energy needs. What is this process called? A. Hypercatabolism B. Acute inflammatory response C. Hyperlipidemia D. Malnutrition

A. Hypercatabolism Prompt use of nutrition support is especially important for patients with head injuries because head injury causes marked catabolism, even in patients who receive barbiturates, which should decrease metabolic demands. Head-injured patients rapidly exhaust glycogen stores and begin to use body proteins to meet energy needs, a process that can quickly lead to protein-calorie malnutrition (PCM).

On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to "bother the physician this early." During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform? A. Implementation B. Evaluation C. Planning D. Assessment

A. Implementation The nurse failed to communicate critical laboratory values to the physician in a timely manner. Because the laboratory report was available, this was not an issue with assessment, planning, or evaluation.

A nurse admits a patient from the emergency department with a diagnosis of acute coronary syndrome (ACS) and anterior wall myocardial infarction (MI). Per physician order, the nurse administers oxygen and nitroglycerin. This therapy should reduce or relieve chest pain by which mechanism? A. Increasing oxygen delivery and decreasing oxygen demand B. Increasing preload and decreasing afterload C. Minimizing plaque formation and preventing vasospasm D. Preventing dysrhythmias and decreasing cardiac contractility

A. Increasing oxygen delivery and decreasing oxygen demand In the acute period, if severe heart muscle damage has occurred, myocardial oxygen supply is increased by the administration of supplemental oxygen to prevent tissue hypoxia. Myocardial oxygen supply can be further enhanced by the use of coronary artery vasodilators. Nitroglycerin is recommended for the first 48 hours to increase vasodilatation and prevent myocardial ischemia.

A patient recovering from a myocardial infarction (MI) notifies the nurse that he is having chest pain. Upon listening to the patient's heart sounds, the nurse hears a grating sound that is present during both systole and diastole. The nurse suspects that the patient's chest pain is most likely caused by which condition? A. Inflammation of the pericardium B. Papillary muscle rupture C. Ventricular septal rupture D. Another MI

A. Inflammation of the pericardium A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction (MI). The friction rub is from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding with cardiac motion within the pericardial sac. It is often associated with chest pain, which can be aggravated by deep inspiration, coughing, swallowing, and changing position.

While performing an admission assessment, the nurse identifies a high-pitched systolic murmur and suspects that the patient has which condition? A. Mitral regurgitation B. Aortic regurgitation C. Mitral stenosis D. Aortic stenosis

A. Mitral regurgitation A murmur of mitral regurgitation produces a high-pitched systolic murmur. A murmur of mitral stenosis produces a low-pitched diastolic murmur. A murmur of aortic regurgitation produces a high-pitched diastolic murmur, and a murmur of aortic stenosis produces a low-pitched systolic murmur.

The nurse is assessing a patient's lower extremities. Which condition is consistent with arterial disease? A. Skin on the leg is thin and shiny with a painful ulceration surrounded by eschar. B. Painless, pink fluid drains from an ulceration just above the right ankle. C. The nail beds are normal with a capillary refill time of 2 seconds. D. Varicose veins are noted on both legs. E. The feet become cyanotic when the patient sits in a chair.

A. Skin on the leg is thin and shiny with a painful ulceration surrounded by eschar. Skin on the leg that is thin and shiny with a painful ulceration surrounded by eschar is characteristic of an arterial disease of the lower extremity. Painless, pink fluid draining from an ulceration just above the right ankle, the feet becoming cyanotic when the patient sits in a chair, and varicose veins noted on both legs are consistent with a venous disease. Nail beds with a capillary refill time of 2 seconds is a normal finding.

Many patients experience stress when they are admitted to the intensive care unit. Which statement about stress is accurate? A. Stress of any type can elicit the same physical responses. B. Stress overload does not have to be differentiated from other stresses of the critical care experience. C. The appropriate nursing response to a patient at risk for stress overload is to maintain stressors to enable the patient to use adequate coping mechanisms. D. Stress overload occurs because the patient or family members have coping deficiencies or psychologic disorders.

A. Stress of any type can elicit the same physical responses. Stress of any type—whether positive or negative, biologic, psychologic, spiritual, or social—elicits the same physical responses. Stress overload should be differentiated from other stressors. The nurse should seek to alleviate the patient's stress as it affects the patient's outcome. Stress overload is not due to coping deficiencies or psychologic disorders.

The nurse would assess for symptoms of a pneumothorax after placement of a central line into which vein? A. Subclavian B. Internal jugular C. External jugular D. Femoral

A. Subclavian The subclavian vein is more difficult to access and carries a higher risk of iatrogenic pneumothorax or hemothorax.

Which central venous catheter site has the lowest incidence of catheter-related blood infection? A. Subclavian vein B. Internal jugular vein C. External jugular vein D. Femoral vein

A. Subclavian vein Studies have shown that the subclavian vein has the lowest infection rate. Internal and external jugular vein catheters may be contaminated by oral or tracheal secretions. Femoral vein catheters may be contaminated because of their proximity to urine and stool in an incontinent patient.

Anorexia may interfere with oral intake. Patients who are unable to meet their caloric needs on their own require nutrition intervention. Which statement best describes the goal of initiating a nutrition intervention for a patient with anorexia? A. Total parenteral nutrition (TPN) should be reserved for patients who are absolutely unable to tolerate oral and enteral feeding. B. Small, frequent feedings are usually tolerated less than are three regular meals daily. C. Diarrhea from concurrent administration of lactulose coincides with feeding intolerance. D. Standard nasogastric feeding tubes can be used safely without increasing the risk of variceal bleeding.

A. Total parenteral nutrition (TPN) should be reserved for patients who are absolutely unable to tolerate oral and enteral feeding. Small-bore nasoenteric feeding tubes can be used safely without increasing the risk of variceal bleeding. Total parenteral nutrition (TPN) should be reserved for patients who are absolutely unable to tolerate enteral feeding. Diarrhea from concurrent administration of lactulose should not be confused with feeding intolerance.

What is the best description of a posttraumatic stress reaction? A. Undesired recall of a distressing event triggered by a noise, sound, sight, smell, event, or memory B. Values, beliefs, and ideas that form a person's self-knowledge and relationships with others C. An essential, protective, inherent reaction to a stressor designed to mobilize the body's response to threats D. Inability of a person to differentiate him- or herself as a separate human being from others within an environment

A. Undesired recall of a distressing event triggered by a noise, sound, sight, smell, event, or memory Posttraumatic stress reactions involve a wide range of cardiovascular, neuromuscular, gastrointestinal, cognitive, emotional, mood, and memory responses. They may be triggered by noises, sounds, sights, smells, events, or memories and produce an acute stress response. Acute stress response is an essential, protective, inherent reaction to a stressor designed to mobilize the body's response to threats for the purposes of survival. A patient's self-concept is his or her values, beliefs, and ideas that form his or her self-knowledge. An identity disturbance is the inability to differentiate oneself as a separate human being.

Which action would be considered a breach of the standard of care for the registered nurse, thus exposing the nurse to malpractice? (Select all that apply, one, some, or all.) A. Failure to administer medication, resulting in no injury B. Administration of the wrong medication to a patient due to misidentification of the patient, resulting in injury C. Failure to administer a medication to a patient, resulting in injury D. Failure to administer a medication to a coworker's patient, resulting in injury

B, C Failure to administer a medication to a patient and administration of the wrong medication to a patient caused by misidentification of the patient, both resulting in injury, demonstrate a duty to the patient and a failure to act as a prudent practitioner would in a similar situation; damages were incurred by the patient. In failure to administer medication with no resulting injury, although the nurse failed to follow hospital policy and would be subject to disciplinary action, no harm occurred. In failure to administer a medication to a coworker's patient, resulting in injury, the nurse does not have a duty to provide care in the place of another practitioner (unless the nurse was officially covering for the other nurse).

The nurse is assessing a newly admitted patient. Which finding would indicate a chronic cardiac history? (Select all that apply, one, some, or all.) A. The patient has a capillary refill time of 2 seconds. B. The patient has a visible pulse at the fifth intercostal space just lateral to the midclavicular line. C. The patient states he has a "beer belly." D. The patient's fingernails are thickened, yellow, brittle, and cracked. E. The patient has a large, firm bulge noted on the left upper chest.

B, C, E Abdominal adipose is often related to cardiac problems (an "apple-shaped" body). A visible point of maximal impulse (PMI) is associated with a cardiac history. A large, firm bulge on the left upper chest is a sign of an implanted pacemaker. Thickened, yellow, brittle, and cracked fingernails are a sign of nail infection, and a capillary refill time of 2 seconds is normal.

The nurse is explaining the function of the atrioventricular (AV) node to the student nurse. Which statement is true? (Select all that apply, one, some, or all.) A. The AV is located on the left side of the interatrial septum. B. The conduction time of impulses from the sinoatrial (SA) to the AV node allows the ventricles to fill with blood during diastole. C. The AV node provides a backup pacemaker if the SA node fails. D. The AV node sends impulses forward only. E. The AV node prevents rapid heart rates from destabilizing the heart.

B, C, E The conduction time of impulses from the sinoatrial (SA) to the atrioventricular (AV) node allows the ventricles to fill with blood during diastole, the AV node prevents rapid heart rates from destabilizing the heart, and the AV node provides a backup pacemaker if the SA node fails are all true statements about the function of the AV node. The AV node conducts impulses forward and backward (retrograde) and is located on the right side of the interatrial septum.

The nurse is providing education to the patient concerning a new medication. Which situation will have to be dealt with before the patient can effectively learn? (Select all that apply, one, some, or all.) A. The patient has a new magazine. B. The patient has been sitting up in the chair for the first time and is tired. C. The patient's blood pressure is 120/70 mm Hg. D. The patient needs to use the bedpan. E. The patient's blood sugar is 60 mg/dL.

B, D, E The blood sugar level and the need to use the bedpan are physiologic needs that will interfere with teaching. Being tired will interfere with the teaching because of the patient's lack of concentration. Blood pressure is normal, and the magazine is a higher level need that can wait until after the teaching has occurred.

A patient with a family history of coronary artery disease (CAD) has the following laboratory results: total cholesterol, 250 mg/dL; high-density lipoprotein, 35 mg/dL; low-density lipoprotein, 160 mg/dL; and triglycerides, 240 mg/dL. Which interventions should the nurse anticipate? (Select all that apply, one, some, or all.) A. Document the normal findings. B. Monitor and control blood pressure. C. Educate on increasing saturated fat and decreasing fiber in the diet. D. Instruct the patient to increase exercise to 30 minutes a day, 5 days a week. E. Enroll in smoking cessation classes.

B, D, E The patient with elevated lipids and a history of coronary artery disease (CAD) should be instructed to increase exercise, monitor blood pressure, and stop smoking. Documenting the findings as normal would be inappropriate because the laboratory test results are not normal. The patient should be educated to decrease saturated fats and increase fiber.

A patient with metastatic cancer tells the nurse, "I am tired and do not want to be put on a breathing machine." The patient's out-of-town son wants "everything done for my mother" when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply, one, some, or all.) A. Paternalism B. Nonmaleficence C. Justice D. Autonomy E. Beneficence

B, D, E The patient's autonomy is in danger. Harm (nonmaleficence), in the form of complications from a treatment that the patient does not want, is also involved. Doing the right thing (beneficence) for the patient is in question, owing to the patient's wishes and the prognosis of her illness. The principle of justice means that there is an equitable distribution of limited resources. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient or by disregarding the patient's preferences. This scenario does not involve the principle of justice or the concept of paternalism.

The nurse is providing dietary education for the patient with hypertension. The patient asks what the DASH diet is. Which comment is appropriate for the nurse to make? A. "DASH refers to the salt-free spices you should learn to cook with now." B. "DASH stands for dietary approach to stop hypertension." C. "The DASH diet eliminates fruits from the diet." D "It means you must eliminate all salt from your diet."

B. "DASH stands for dietary approach to stop hypertension." Dietary Approach to Stop Hypertension is the correct definition for DASH. The object is to consume a diet rich in fruits and vegetables, potassium, and calcium and low in saturated fat to help control hypertension. The DASH diet does not refer to salt-free spices. One cannot eliminate all salt from the diet, but lower salt is advisable for those sensitive to increased salt levels. The DASH diet is high in both fruits and vegetables.

The nurse is educating the patient on guided imagery. Which statement indicates the patient requires more education? A. "This technique will help me reduce my pain." B. "This technique will help me eliminate my infection." C. "This technique will help alleviate my anxiety." D. "This technique will help decrease my stress."

B. "This technique will help me eliminate my infection." Guided imagery can help reduce stress, anxiety, and pain levels, but it cannot eliminate an infection.

The time from the beginning of the cardiac action potential (AP) until the time when the fiber can accept another AP is known as which period? A. Excitability B. Absolute refractory C. Depolarization D. Relative refractory

B. Absolute refractory The time from the beginning of the action potential (AP) until the fiber can accept another AP is called the effective or absolute refractory period. During this period, the cell cannot be depolarized regardless of the amount or intensity of the stimulus.

A patient admitted 3 days ago is complaining that snakes are in the corner of his room, and he thinks he is at home in his room. His heart rate is 134 beats/min and respiratory rate is 36 breaths/min, and he is diaphoretic with tremors noted in both arms. Which intervention should the nurse do first? A. Restrain the patient with soft wrist restraints B. Administer an ordered dose of lorazepam C. Notify the nursing supervisor D. Notify the family that the patient is confused

B. Administer an ordered dose of lorazepam The patient is demonstrating signs of alcohol withdrawal syndrome, and lorazepam is an appropriate treatment. Restraints, notifying the supervisor, or telling the family would not be the first intervention for this patient.

A patient has low albumin, prealbumin, and transferrin levels with a decreased total lymphocyte count. Which nursing diagnosis is a priority for this patient? A. Altered nutrition, more than body requirement B. Altered nutrition, less than body requirement C. Risk for infection D. Fluid volume overload

B. Altered nutrition, less than body requirement In this case, the patient is showing signs of malnutrition and protein deficiency that must be corrected. There is a risk for infection, but an actual problem is more of a priority than a potential one. The patient would have a fluid volume deficit, not an overload.

A patient is admitted with syncope, exertional dyspnea, and a systolic murmur. Cardiac catheterization reveals significantly increased left ventricular end-diastolic pressure (LVEDP). The nurse suspects the patient may be experiencing which problem? A. Tricuspid stenosis B. Aortic stenosis C. Pulmonary regurgitation D. Mitral stenosis

B. Aortic stenosis Symptoms of aortic stenosis include syncope, exertional dyspnea, increased left ventricular end-diastolic pressure (LVEDP), and systolic murmur. Mitral and tricuspid stenoses are associated with a diastolic murmur as is pulmonary regurgitation.

A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform? A. Act as a patient advocate to postpone the examination. B. Assess and analyze the level of care needed by the patient. C. Make the proper nursing diagnosis. D. Communicate findings in a timely manner.

B. Assess and analyze the level of care needed by the patient. The nurse failed to properly assess and analyze the patient's need to be transported with a cardiac monitor and professional staff. Misdiagnosis and lack of communication were not the issues. There is not enough evidence to determine whether postponing the examination would have prevented the event.

A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a "no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates the patient. The nurse states she was unaware of the "no code" order. What part of the nursing process did the nurse fail to perform? A. Planning B. Assessment C. Evaluation D. Implementation

B. Assessment The nurse failed to ascertain and follow the patient's wishes. Nurses caring for acutely and critically ill patients have a legal and ethical obligation to act in accordance with a patient's wishes with regard to self-determination. This is not an issue with planning, implementation, or evaluation.

A patient is admitted with fever, hematuria, and new onset of a cardiac murmur. The patient has a history of intravenous drug abuse and complains of tender spots on the pads of her fingers. She has a low-grade fever, and the nurse notes an enlarged spleen on physical examination. What is the priority nursing diagnosis? A. Knowledge deficit related to discharge plans B. Decreased cardiac output related to alteration in contractility C. Risk for anxiety related to lack of availability of narcotics D. Risk for infection related to invasive procedures

B. Decreased cardiac output related to alteration in contractility Because the patient is experiencing endocarditis, the most important nursing diagnosis is decreased cardiac output related to alteration in contractility. Infection and anxiety are only potential problems, and although knowledge deficit is important, it is not the priority on admission.

Which hemodynamic changes are associated with mitral stenosis? A. Elevated left atrial pressure, pulmonary artery diastolic pressure, and left ventricular end-diastolic pressure; normal pulmonary artery occlusive pressure B. Elevated left atrial pressure, pulmonary artery occlusive pressure, and pulmonary artery diastolic pressure; normal left ventricular end-diastolic pressure C. Elevated pulmonary artery occlusive pressure, pulmonary artery diastolic pressure, and left ventricular end-diastolic pressure; normal left atrial pressure D. Elevated left atrial pressure, pulmonary artery occlusive pressure, and left ventricular end-diastolic pressure; normal pulmonary artery diastolic pressure

B. Elevated left atrial pressure, pulmonary artery occlusive pressure, and pulmonary artery diastolic pressure; normal left ventricular end-diastolic pressure In mitral valve stenosis, left atrial pressure and pulmonary artery occlusive pressure are increased and cause pulmonary congestion; however, these elevated values do not reflect the left ventricular end-diastolic pressure (LVEDP) because a stenotic mitral valve decreases normal blood flow from the left atrium to the left ventricle, decreasing left ventricular preload and consequently lowering LVEDP. The other options do not accurately describe the hemodynamic effects of mitral stenosis.

A patient is receiving enteral nutrition feeding. Which intervention should be included to reduce the risk of aspiration? A. Maintain head of bed at less than 30 degrees. B. Feed into the small bowel rather than the stomach. C. Deflate the endotracheal tube cuff during feeding administration. D. Hold feedings for gastric residual volume of 50 mL.

B. Feed into the small bowel rather than the stomach. Pulmonary aspiration of enteral formulas and subsequent pneumonia is a serious complication of enteral feeding in critically ill patients. To reduce the risk of pulmonary aspiration of formula during enteral feeding, the nurse must keep the head of the bed elevated unless contraindicated; temporarily stop feedings when the patient must be supine for prolonged periods; position the patient in the right lateral decubitus position when possible to encourage gastric emptying; use postpyloric feeding methods; keep the cuff of the endotracheal tube inflated as much as possible during enteral feeding, if applicable; and be alert to any increase in abdominal distention. Except in selected high-risk patients, there is little evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL.

Which action by a nurse might decrease a patient's sense of spiritual distress? A. Preparing the patient by discussing the fact that recovery may be long and painful B. Listening to the patient's concerns and consulting the spiritual care department C. Assuring the patient that God is not to blame for the nature of the illness D. Encouraging the patient to pray for a swift and uncomplicated recovery

B. Listening to the patient's concerns and consulting the spiritual care department Listening to patients' concerns, offering support, being present, enhancing dignity, and developing caring trusting relationships give hope. Facilitating patients' access to religious rituals, prayer, and scripture reading may help patients make connections to their spiritual or cultural communities. Collaboration with the spiritual care department may be useful for a patient who has unmet or unaddressed spiritual questions or needs.

A patient is admitted for worsening heart failure (HF). While administering medications per practitioner order, the nurse assesses the patient's response. What is the goal of therapy for this patient? A. Maximizing systemic vascular resistance B. Managing fluid overload and improving cardiac output C. Increasing preload while decreasing afterload D. Enhancing the renin-angiotensin-aldosterone system (RAAS)

B. Managing fluid overload and improving cardiac output The goal of therapy is management of the fluid overload and improvement of cardiac output to promote adequate tissue perfusion. Although decreasing afterload is desired, increasing preload would worsen the heart failure (HF). Inhibiting, rather than enhancing, the renin-angiotensin-aldosterone system (RAAS) using medications such as angiotensin-converting-enzyme inhibitors will improve HF. In the same manner, decreasing, not maximizing, systemic vascular resistance (SVR) improves HF. SVR, which measures afterload, should be decreased in HF to lessen myocardial workload and improve cardiac output.

Arterial blood pressure monitoring is used for the assessment of cardiac output, fluid status, and tissue perfusion. Which parameter is observed with arterial blood pressure monitoring? A. End-diastolic pulmonary pressure B. Mean arterial pressure C. Peripheral vascular resistance D. Mixed venous oxygenation

B. Mean arterial pressure Intraarterial blood pressure monitoring is indicated for any major medical or surgical condition that compromises cardiac output, tissue perfusion, or fluid volume status. The system is designed for continuous measurement of three blood pressure parameters: systole, diastole, and mean arterial blood pressure. The direct arterial access is helpful in the management of patients with acute respiratory failure who require frequent arterial blood gas measurements.

A patient with facial trauma is unable to eat after surgery. His albumin level is 1.5. Which nutritional alteration is the patient experiencing? A. Nitrogen equilibrium B. Negative nitrogen balance C. Positive nitrogen balance D. Nitrogen disequilibrium

B. Negative nitrogen balance The patient has a negative nitrogen balance and is experiencing a high rate of gluconeogenesis and is burning up his protein stores. Muscle mass will break down unless nutrition is given. A positive nitrogen balance means the patient is eating more than he is excreting (healing). Nitrogen equilibrium occurs in normal, healthy adults. Nitrogen disequilibrium is a nonexistent condition.

A patient who is in the cardiac intensive care unit with an acute myocardial infarction (AMI) suddenly becomes hypotensive, tachycardic, and short of breath. Upon further assessment, the nurse hears a high-pitched holosystolic blowing murmur. The nurse is concerned that the patient may have developed which complication? A. Cardiac tamponade B. Papillary muscle rupture C. Pericardial friction rub D. Ventricular septal rupture

B. Papillary muscle rupture The auscultation of a new, high-pitched, holosystolic, blowing murmur at the cardiac apex heralds mitral valve regurgitation resulting from papillary muscle dysfunction. Cardiac tamponade is associated with distant heart sounds and bulging neck veins. Ventricular septal rupture is also a serious complication of acute myocardial infarction (AMI) that causes sudden hemodynamic compromise, but it presents with a harsh holosystolic murmur that is loudest along the left sternal border.

What action should be performed prior to insertion of an arterial line? A. Check the patient's platelets for indication of heparin-induced thrombocytopenia. B. Perform an Allen test to confirm adequate arterial blood flow. C. Set up a double transducer tubing system. D. Obtain a 100-mL bag of 0.9% saline for the flush system.

B. Perform an Allen test to confirm adequate arterial blood flow. The major advantage of the radial artery is the supply of collateral circulation to the hand provided by the ulnar artery through the palmar arch in most people. Before radial artery cannulation, collateral circulation must be assessed by using Doppler flow or by the modified Allen test according to institutional protocol. In the Allen test, the radial and ulnar arteries are compressed simultaneously. The patient is asked to clench and unclench the hand until it blanches. One of the arteries is then released, and the hand should immediately flush from that side. The same procedure is repeated for the remaining artery.

What is the volume of blood in the left ventricle at the end of diastole called? A. Contractility B. Preload C. Stroke volume D. Afterload

B. Preload Preload is the volume of blood in the left ventricle at the end of diastole. Contractility refers to the heart's contractile force. Afterload can be defined as the ventricular wall tension or stress during systolic ejection.

When caring for the patient in atrial fibrillation (AF), the nurse understands which statement is true? A. A label of persistent AF is claimed when the dysrhythmia has persisted for 3 days without interruption. B. Rate control and therapeutic anticoagulation are optional management strategies for patients in permanent AF. C. Pulmonary veins frequently serve as a trigger site to initiate and maintain AF. D. AF maintains some regularity due to the consistent blockage of atrial impulses by the atrioventricular (AV) node.

B. Rate control and therapeutic anticoagulation are optional management strategies for patients in permanent AF. The four pulmonary veins that drain into the left atrium are a trigger site for early atrial foci to initiate and propagate re-entry circuits to maintain atrial fibrillation (AF). The atrioventricular (AV) node acts as a filter to protect the ventricles from the hundreds of atrial impulses that occur each minute. When the atrial muscle tissue immediately surrounding the AV node is in a refractory state, impulses generated in other areas of the atria cannot reach the AV node, which helps to explain the wide variation in R-R intervals during AF. AF sustained beyond 7 days or with multiple bouts of paroxysmal AF is labeled persistent. For long-term management of permanent AF, rate control is the recommended approach, and therapeutic anticoagulation to prevent embolic stroke is mandatory.

Nutrition intervention in heart failure is aimed at a reduction in fluid retention and sodium limitation in order to achieve which goal? A. Increase end-diastolic volume B. Reduce preload C. Increase central venous pressure D. Reduce afterload

B. Reduce preload Interventions in heart failure are designed to reduce fluid retention, thereby reducing the preload.

A burn patient is crying, constantly ringing the call bell, and thinking of excuses to keep the staff in the room. What defense mechanism is the patient exhibiting? A. Suppression B. Regression C. Depression D. Transgression

B. Regression Regression is a coping mechanism that involves retreating to an earlier developmental level in the face of stress. Suppression is the act of pushing ideas and problems out of the mind, depression is a mental state characterized by sadness and despair, and transgression is the violation of a norm.

A patient is admitted with acute exacerbation of his heart failure. When auscultating for heart sounds, the nurse would anticipate the presence of which finding? A. Systolic murmur B. S3 heart sound C. Pericardial friction rub D. Diastolic murmur

B. S3 heart sound The presence of S3 may be normal in children, young adults, and pregnant women because of rapid filling of the ventricle in a young, healthy heart. An S3 in the presence of cardiac symptoms is an indicator of heart failure in a noncompliant ventricle with fluid overload.

The nurse wants to join a professional, multidisciplinary critical care association. Which organization would be the best choice? A. ANA (American Nurses Association) B. SCCM (Society for Critical Care Medicine) C. AACN (American Association of Critical Care Nurses) D. AORN (Association of Operating Room Nurses)

B. SCCM (Society for Critical Care Medicine The Society for Critical Care Medicine (SCCM) is a multidisciplinary organization of physicians, nurses, pharmacists, and respiratory therapists who work with critically ill patients. The American Nurses Association (ANA) is a political nursing organization for all nurses, the American Association of Critical Care Nurses (AACN) is a specialty organization for critical care nurses, and the Association of Operating Room Nurses (AORN) is a specialty organization for perioperative care nurses.

On admission to the progressive care unit after a colon resection, the nurse assesses the patient's risk for venous thromboembolism (VTE). Prevention measures for VTE include which therapy? A. Bedrest B. Subcutaneous low-molecular-weight heparin (LMWH) C. Unfractionated heparin (UFH) infusion D. Inferior vena cava filter

B. Subcutaneous low-molecular-weight heparin (LMWH) Preventive measures include prophylactic anticoagulation with subcutaneous low-molecular-weight heparin (LMWH) or unfractionated heparin infusion (UFH), increasing mobility, and use of sequential compression devices placed on the lower extremities. Unfractioned heparin infusion and placement of an inferior vena cava filter are measures for management of a diagnosed VTE.

A patient woke up from a sound sleep in a cold sweat with nausea and light-headedness and now has chest pain (8 of 10 on the pain scale) that is unrelieved by nitroglycerin (NTG) after 5 minutes. The nurse suspects the patient is experiencing which problem? A. Stable angina B. Unstable angina C. Variant angina D. Silent ischemia

B. Unstable angina The patient is showing signs of unstable angina. Stable angina occurs with predictable precipitating factors and improves with rest or nitroglycerin (NTG) within 5 minutes. Variant angina is caused by spasm of a coronary artery, usually occurs at the same time every day, and is relieved by NTG. Silent ischemia is painless.

In an effort to improve cardiac output, a positive inotropic drug is given to A. increase the automaticity of the heart. B. increase the contractility of the heart. C. increase the heart rate. D. increase the conduction velocity.

B. increase the contractility of the heart. Positive inotropic drugs increase the force of contraction of the heart to improve cardiac output. A drug that increases heart rate would be a positive chronotrope. A drug that increases conduction velocity would speed conduction from the sinoatrial (SA) to the atrioventricular (AV) node, and a drug that increases automaticity would stimulate electrical impulses.

The patient is cool, clammy, and diaphoretic. He keeps opening and closing his left fist and rubbing his sternum. When his daughter asks him to go to the emergency department, he states that he just has a little indigestion. What coping mechanism is this patient exhibiting? A. Suppression B. Regression C. Denial D. Hope

C. Denial Patients with an acute myocardial infarction often blame their chest pain on indigestion in an effort to deny the seriousness of the condition. Suppression would be correct if the patient was denying that the pain was occurring. Regression would be correct if the patient was exhibiting behaviours from a lower developmental stage. Hope would be correct if the patient made a statement such as: "I am going to be just fine."

What are the advantages to performing preoperative patient and family teaching about the recovery phase of surgery? (Select all that apply, one, some, or all.) A. The family will not bother the nurse after surgery. B. The physician will not have to talk to the family after surgery. C. The patient will experience less stress when waking up from anesthesia by knowing what to expect. D. The family will be prepared for how the patient will look after surgery and not be frightened. E. The patient will be more likely to follow the postoperative plan of care if it has been discussed ahead of time.

C, D, E The patient will experience less stress when waking up from anesthesia by knowing what to expect, the family will be prepared for how the patient will look after surgery and not be frightened, and the patient will be more likely to follow the postoperative plan of care if it has been discussed ahead of time are advantages of preoperative teaching. It is untrue that the family will not bother the nurse after surgery and the physician will not have to talk to the family after surgery.

Which statement by the nurse reflects his or her passion to support patient coping? A. "I'll pull the shades so the sunlight doesn't bother you." B. "We will assist you to clean up or bathe every morning around 10:00 am." C. "Can I hang your granddaughter's picture up on the cork board?" D. "Your family may visit for 10 minutes every hour."

C. "Can I hang your granddaughter's picture up on the cork board?" A relaxed visitation policy humanizes the environment and facilitates healing. Giving unrestricted access of hospitalized patients to a chosen support person is a national practice recommendation. One of the most effective ways to decrease stress is to give patients as much control over their care as possible. Allowing for natural sunlight is recommended. In addition, familiarizing patient rooms by displaying photographs, cards, and drawings is a way to alter the physical environment to create a healing environment and support patient coping.

The nurse is discussing the patient's home medications. Which question will elicit the most information from the patient regarding the patient's understanding of the diuretic? A. "When do you take this pill at home?" B. "Is this what you take at home?" C. "Why are you taking this pill?" D. "Do you really take this pill at home?"

C. "Why are you taking this pill?" "Why are you taking this pill?" is an open-ended question that will allow the patient to describe the medication in his or her own words. "Is this what you take at home?" is a "yes" or "no" question. "When do you take this pill at home?" is narrow and will elicit only a time from the patient. "Do you really take this pill at home?" sounds accusing and will also elicit only a "yes" or "no" response.

What is the pulse pressure of a patient with a blood pressure of 120/84 mm Hg? A. 84 mm Hg B. 96 mm Hg C. 36 mm Hg D. 204 mm Hg

C. 36 mm Hg Pulse pressure describes the difference between the systolic and diastolic values. In this example the pulse pressure is 36 mm Hg. The normal pulse pressure is 40 mm Hg.

To perfuse the coronary arteries, a patient needs a mean arterial pressure (MAP) of at least 60 mm Hg. Which blood pressure reading will not provide an adequate MAP? A. 120/70 mm Hg B. 120/90 mm Hg C. 90/40 mm Hg D. 110/50 mm Hg

C. 90/40 mm Hg 90/40 mm Hg equals a mean arterial pressure (MAP) of 90 + 80/3 = 57, which is inadequate for this patient. The other options are adequate as follows: 110/50 mm Hg = MAP of 110 + 100/3 = 70; 120/70 mm Hg = MAP of 120 + 140/3 = 87; and 120/60 mm Hg = MAP of 120 + 120/3 = 80.

A female patient has just been transferred to a cardiac step-down unit after a lengthy stay in the intensive care unit (ICU) after coronary artery bypass grafting. A short time after the transfer, the patient starts to repeatedly question the nurse as to the time of arrival of the physician and accuses the nurse of keeping the physician from her. She begins to complain of dyspnea and is becoming more and more tachycardic. The nurse recognizes the patient is showing signs of which condition? A. Alteration in self-concept B. Situational low self-esteem C. Anxiety D. Posttraumatic stress disorder

C. Anxiety Anxiety can range from a vague, generalized feeling of discomfort to a state of panic and loss of control. As anxiety levels increase, sympathetic nervous system stimulation ensues, with feelings of heightened awareness followed by decreases in problem-solving abilities and coping skills. The stressful experience of having an acute illness and being discharged from a critical care unit can trigger high degrees of patient anxiety. Research suggests that women, patients with less social support, and those with longer critical care lengths of stay are at higher risk for developing anxiety upon transfer out of the unit to a less intense level of care.

The nurse is caring for a patient who underwent cardiac catheterization earlier in the day. The nurse will monitor the femoral site to identify which complication? A. Infection B. Reocclusion of the coronary artery C. Bleeding D. Nephropathy

C. Bleeding After cardiac catheterization, removal of the arterial and venous catheters places the patient at risk for bleeding. Lying flat for 6 hours, using a clamp device, or deploying a collagen plug can decrease the incidence of bleeding. Bleeding usually occurs within the first few hours after the procedure but can occur at any time. Infection would not be apparent for several days. Reocclusion of the coronary artery presents with chest pain and electrocardiogram changes unrelated to the catheter site. Nephropathy occurs as a result of osmotic diuresis from the contrast dye and is prevented by encouraging the patient to drink or possibly with an infusion of a crystalloid solution such as 0.9% saline.

A patient with acute lung failure is being evaluated for nutrition therapy. The nurse knows that the preferred method of nourishment includes initiation of what type of nutrition support? A. Peripheral parenteral nutrition B. Bolus enteral feedings C. Continuous enteral nutrition D. Total parenteral nutrition

C. Continuous enteral nutrition If patients are unable to meet their caloric needs, they may require oral supplements or enteral feeding. Typically in this situation the patient requires continuous enteral feedings to ensure adequate nutritional supplementation. Bolus feedings are generally not used in this situation.

A patient has been displaying apathy, anxiety, and the inability to perform basic activities of daily living. When asked the patient states "I just can't do it." What psychosocial problem is the patient displaying? A. Spiritual distress B. Identity disturbance C. Ineffective coping D. Low self-esteem

C. Ineffective coping Ineffective coping is defined as the impairment of a person's adaptive behaviors and problem-solving abilities when meeting life's demands and necessary roles. Manifestations of ineffective coping in critical illness include verbalization of an inability to cope, anxiety, and being unable to meet basic needs. The patient may display apathy or destructive behavior toward self and others. Patients experiencing spiritual distress may question the meaning of suffering and death in relation to their personal belief system. Identity disturbance is defined as an inability of a person to differentiate the self as a unique and separate human being from others within a social environment. Low self-esteem impairs one's ability to adapt. A patient may refuse to participate in self-care, exhibit self-destructive behavior, or become too compliant—asking no questions and permitting others to make all decisions.

Aortic valve dysfunction pathologically alters which structure of the heart? A. Left atrium B. Right ventricle C. Left ventricle D. Mitral valve

C. Left ventricle Aortic valve dysfunction from any cause not only affects the valve leaflets but also pathologically alters the shape of the left ventricle.

A patient is admitted with an acute myocardial infarction. Upon assessment, the patient is noted to be confused. The nurse suspects that the confusion is most likely attributable to which cause? A. Early onset of dementia B. Poor oxygen exchange C. Low cardiac output D. Anxiety over chest pain

C. Low cardiac output When assessing a patient with an altered cardiac function, confusion is most likely because of a decrease in cardiac output, hypotension, or hypoxemia. There is no indication from the patient's history to support a consideration of dementia. Anxiety may cause distraction, but confusion is uncommon.

The nurse auscultates a murmur at the fifth intercostal space at the midclavicular line on the left side. The nurse realizes that this is caused by which incompetent heart valve? A. Tricuspid B. Pulmonic C. Mitral D. Aortic

C. Mitral This is the correct location of the mitral valve. The aortic valve is located at the second right intercostal space at the right sternal border. The pulmonic valve is located at the second left intercostal space at the left sternal border. The tricuspid valve is located at the fourth left intercostal space at the left sternal border.

A patient with a history of chronic obstructive pulmonary disease (COPD) and heart failure presents with severe shortness of breath (SOB). Which laboratory test will assist with differentiation of the SOB? A. Troponin B. Creatinine kinase C. NT-pro-BNP D. Calcium

C. NT-pro-BNP NT-pro-BNP is one of several tests measuring brain natriuretic peptide, which is secreted from cells in the ventricle in response to the ventricular stretch that occurs in heart failure. NT-pro-BNP has a longer half-life than BNP. Troponin and creatinine kinase are biomarkers for damaged cardiac cells. Calcium is measured for many reasons, including its effect on cardiac contractility.

The nurse observes a coworker diverting narcotics by administering normal saline to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse? A. Justice B. Veracity C. Nonmaleficence D. Autonomy

C. Nonmaleficence Failure to report the impaired nurse puts the patient in a dangerous situation that the observing nurse could prevent, violating nonmaleficence. This does not affect autonomy or justice for the patient, and it is not the observing nurse who is violating veracity.

The nurse hesitates to report a critical laboratory value to a physician for fear of receiving an angry, inappropriate response. By waiting for the next shift, the nurse does not promote which of the following Healthy Work Environment Initiatives? A. Meaningful recognition B. Authentic leadership C. Skilled communication D. Appropriate staffing

C. Skilled communication Failing to report the value is a violation of true communication. Staffing is not the problem unless the reason was "too busy" to report. This is not a recognition issue. Although authentic leadership would support the nurse, the main issue is communication.

An elderly female patient is complaining of "heartburn." While considering further assessment, the nurse understands which statement to be true? A. There is a high correlation between the severity of discomfort and the gravity of its cause. B. Patients are very consistent and objective when describing their physical complaints. C. The assumption should be made that chest discomfort is caused by myocardial ischemia until proven otherwise. D. Heartburn has little to no correlation to cardiac disease and is typically gastric in nature.

C. The assumption should be made that chest discomfort is caused by myocardial ischemia until proven otherwise. If there is any evidence of coronary artery disease (CAD) or risk of heart disease, assume that the chest pain is caused by myocardial ischemia until proven otherwise. There may be little correlation between the severity of chest discomfort and the gravity of its cause. This is a result of the subjective nature of pain and the unique presentation of ischemic disease in women, elderly patients, and individuals with diabetes. Subjective descriptors vary greatly among individuals. There is not always a correlation between the location of chest discomfort and its source.

The family of a patient who is receiving mechanical ventilation for respiratory distress associated with an inoperable brain tumor asks that the patient be extubated to "allow natural death" to occur. This is an example of what situation? A. A criminal act B. Rationing care C. Withdrawing treatment D. Withholding treatment

C. Withdrawing treatment Withdrawing is the removal of treatment in the event of medical futility. Withholding would have been not to place the patient on the ventilator in the first place. Rationing care and a criminal act are not accurate.

Which question is appropriate for the nurse to ask to determine the quality of the patient's chest pain? A. "How long does it last?" B. "How severe is it?" C. "When did it begin?" D. "What is it like?"

D. "What is it like?" "What is it like?" is an open-ended question that allows the patient to describe the quality of the chest pain. "How severe is it?" and "How long does it last?" are questions related to the quantity of the chest pain. "When did it begin?" will elicit a reply that refers to the chronology of the chest pain.

The nurse is caring for a patient admitted with an anterior wall myocardial infarction (MI) who has developed a third-degree atrioventricular (AV) block as evidenced by which electrocardiogram (ECG) finding? A. A regular QRS rhythm with wide QRS, no identifiable P waves, and a rapid rate B. A regular QRS rhythm with inverted P waves, PR interval less than 0.12 second, and a slow rate C. An irregular QRS rhythm with a wavy baseline, no identifiable P waves, and a rapid rate D. A regular QRS rhythm with regular P waves, variable PR interval, and a slow rate

D. A regular QRS rhythm with regular P waves, variable PR interval, and a slow rate On the electrocardiogram (ECG), P waves are present and usually occur at regular intervals. If a junctional focus is pacing the heart, normal QRS complexes are present but occur at a rate and timing interval totally independent of the P waves. The PR intervals vary widely because the P wave and QRS are not related to each other. If a ventricular focus is pacing the heart, the QRS complex is wide and unrelated to the P waves.

Education for a patient with chronic heart failure would include which information? A. Signs of negative changes in cardiac symptoms and when to notify the physician B. The need for accurate daily weights C. Appropriate diet choices D. All of the above

D. All of the above Education for a patient with acute or chronic heart failure caused by valvular dysfunction includes (1) information related to diet, (2) fluid restrictions, (3) the actions and side effects of heart failure medications, (4) the need for prophylactic antibiotics before undergoing any invasive procedures, and (5) when to call a health care provider to report a negative change in cardiac symptoms.

When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely, resulting in which condition? A. Acute myocardial infarction B. Aortic valve failure C. Systemic venous congestion D. Cardiac murmur

D. Cardiac murmur A dysfunction of the chordae tendineae or of a papillary muscle can cause incomplete closure of an atrioventricular valve, which results in backflow of blood into the atrium and produces a murmur. If a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely. Clinically, this causes acute mitral regurgitation and an audible murmur that can be auscultated with a stethoscope.

Which finding is a clinical manifestation of left-sided heart failure? A. Decreased systemic vascular resistance B. Vasodilatation of the arterial bed C. Increased cardiac output D. Cool, pale extremities

D. Cool, pale extremities Failure of the left ventricle is defined as a disturbance of the contractile function of the left ventricle, resulting in a low cardiac output state. This leads to vasoconstriction of the arterial bed that raises systemic vascular resistance, a condition also described as "high afterload," and creates congestion and edema in the pulmonary circulation and alveoli. Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance, (2) fluid retention, or (3) discovery during examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and in later stages, peripheral cyanosis.

A patient has sustained a traumatic injury resulting in an above-the-knee amputation to the right leg. The patient states, "I was a triathlete 2 weeks ago with my whole life ahead of me. I cannot go on like this; I do not want to live like this at all." What is the most likely cause of the patient's reaction? A. A personal identity disturbance B. Regression of behavior to an earlier developmental level C. Alarm reaction phase of the stress response D. Disturbance in body image and feelings of hopelessness

D. Disturbance in body image and feelings of hopelessness Body image includes attitudes and feelings about one's appearance, body build, health, performance, ability, and gender. Disturbances in body image arise when a person fails to perceive or adapt to the changes that are imposed by the situation.

A pericardial friction rub is best heard in which area? A. Pulmonic area B. Tricuspid area C. Mitral area D. Erb point

D. Erb point Pericardial friction rubs are best heard at the third intercostal space (ICS) on the left sternal border, known as Erb point.

Which intervention can facilitate healing and humanization of the critical care environment? A. Space activities throughout the day and night. B. Allow the patient to view the interior of the unit. C. Keep the environment bright and cheery. D. Give unrestricted access of the patient to a chosen support person.

D. Give unrestricted access of the patient to a chosen support person. While practices vary among critical care units, a more relaxed visitation policy humanizes the environment and facilitates healing. The American Association of Critical-Care Nurses' AACN Practice Alert recommends giving unrestricted access of hospitalized patients to a chosen support person. Giving family members access to their loved ones enhances patient and family satisfaction and improves safety of care. Control lighting for individual patient preference, allow for natural sunlight if possible, and position patients so that they can see out of windows. To prevent light exposures that awaken patients, nurses should group care activities to limit nighttime interruptions and collaborate with lab personnel to decrease sleep interruptions.

When caring for a patient postoperatively after aortic aneurysm repair, the nurse must closely monitor the patient for hypertension because it can cause which complication? A. Pulmonary edema B. Tachycardia C. Ischemic stroke D. Graft disruption

D. Graft disruption In the immediate postoperative period, hypertension, which is the most common cause of aortic aneurysm, can cause bleeding at the site of the graft. If hypertension occurs, it may require treatment with a continuous infusion of a vasodilating drug. Ischemic stroke is not a complication of aortic aneurysm repair unless the aneurysm is located close to the aortic arch; even then, it is uncommon. Tachycardia may occur if the patient has inadequate pain control but is not a complication of the surgery itself. Pulmonary edema is a consequence of hypertensive crisis; monitoring and controlling hypertension prevent any chance of the hypertension becoming that severe.

A patient has been admitted with the symptoms of alcohol withdrawal syndrome (AWS). The nurse would expect which finding when the patient is assessed? A. Fatigue B. Hypotension C. Bradycardia D. Hallucinations

D. Hallucinations The signs and symptoms of AWS are easily confused with other conditions. Patients with AWS exhibit altered concentration, tremulousness, autonomic hyperarousal, hallucinations, disorientation, psychosis, tachycardia, hypertension, low-grade fever, agitation, diaphoresis, and delirium tremens.

A patient has been feeling weak for 4 days with a rapid, irregular heart rate. The monitor shows atrial fibrillation with a rapid ventricular response. What is the priority nursing intervention? A. Performing carotid massage B. Preparing for elective cardioversion C. Administering adenosine IV D. Initiating an ordered amiodarone drip

D. Initiating an ordered amiodarone drip The patient is in atrial fibrillation, which has probably been going on for more than 48 hours. The American Heart Association does not recommend cardioversion until the patient has been anticoagulated. The appropriate intervention is to control the rate with a medication such as amiodarone while initiating anticoagulation. Elective cardioversion and adenosine IV would not be appropriate because cardioversion (electrical or chemical) would increase the risk of stroke. Carotid massage is not a nursing function and could cause an embolism.

A patient has a diastolic murmur located at the fifth intercostal space (ICS) midclavicular line (MCL). The nurse knows this is indicative of what disorder? A. Aortic regurgitation B. Tricuspid regurgitation C. Pulmonic stenosis D. Mitral stenosis

D. Mitral stenosis Mitral stenosis produces a diastolic murmur that is heard at the fifth intercostal space (ICS) midclavicular line (MCL). Tricuspid regurgitation and pulmonic stenosis are systolic murmurs. Aortic regurgitation is a diastolic murmur that is heard at the second ICS right sternal border.

The nurse is assessing a patient on complete bed rest. Which site should be checked for dependent edema? A. The arms B. The ankles C. The lower legs D. The sacrum

D. The sacrum The sacrum is the best place to assess the patient on bed rest for dependent edema. In the ambulatory patient, the ankles and the lower legs would not be appropriate. Edema may be present in the arms, but it would not be dependent edema.

A nurse has been having difficulty sleeping since the death of a patient who had a stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse's symptoms could be signs of what problem? A. Moral confusion B. Immoral distress C. Change fatigue D. Moral distress

D. Moral distress This scenario depicts moral distress. Although change fatigue could also cause some of the symptoms, that is not the case described here. Immoral distress and moral confusion are not applicable in this situation.

Despite appropriate interventions by the nurse, a teenage patient recovering from a closed-head injury continues to be intermittently restless and confused, crying out in pain. Diagnostics have been performed to rule out injury progression. What is the most appropriate complementary therapy for this patient? A. Mindfulness meditation B. Antipsychotics C. Benzodiazepines D. Music therapy

D. Music therapy The field of complementary therapies is evolving. The type of complementary therapy used depends on a patient's preferences, coping style, physical capabilities, and personality type. Patients and families enter health care setting knowing what methods best facilitate their bodies' own healing responses. In the case of a patient with a closed-head injury, music therapy would be most appropriate as a means of soothing the patient.

Pulse pressure is the difference between systolic pressure and diastolic pressure. What will happen to the patient's pulse pressure if the patient becomes volume depleted? A. Widen B. Increase C. Remain unchanged D. Narrow

D. Narrow A symptom of vasoconstriction is a narrowed pulse pressure. A widened pulse pressure is associated with vasodilation.

The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case? A. No. Documentation is not part of the duty of nurse. B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol. C. Yes. Failure to document always results in negligence. D. No. There were no damages associated with failure to document.

D. No. There were no damages associated with failure to document. To establish negligence, there must be a duty to the patient, the nurse must have breached that duty, the breach must cause harm to the patient, and the patient should therefore be compensated. Without damage, there is no charge. The nurse did violate hospital policy and could be subject to disciplinary actions. Failure to document on its own does not meet all the criteria to establish negligence, and documentation is part of the duty of the nurse.

The nurse is caring for a patient with a venous stasis ulcer of the right lateral malleolus. On performing the assessment, which finding would the nurse expect to note of the right pedal pulse? A. Weak or absent and asymmetric B. Weak or absent and symmetric C. Normal, strong, and asymmetric D. Normal, strong, and symmetric

D. Normal, strong, and symmetric Pulses in the presence of venous disease are normal, strong, and symmetric because pulses are an assessment of arterial patency. Arterial disease presents with pulses that are weak or absent. "Weak or absent and asymmetric" and "normal, strong, and asymmetric" are not accurate descriptions of either arterial or venous disease.

A patient is reported to have an ejection fraction of 30%. What is this finding most likely a sign of? A. Pulmonic valve regurgitation B. Ventricular dysrhythmia C. Coronary artery disease D. Poor ventricular function

D. Poor ventricular function The ejection fraction (EF) is the ratio of the stroke volume ejected from the left ventricle per beat to the volume of blood remaining in the left ventricle at the end of diastole. EF is expressed as a percentage, and a normal value is 50% or greater. An EF of less than 35% indicates poor ventricular function (as in cardiomyopathy), poor ventricular filling, obstruction to outflow (as in some valve stenosis conditions), or a combination of these conditions.

A trauma patient reports having nightmares and outbursts of anger, as well as feeling "up tight" all the time following a motor vehicle collision in which the patient's best friend was killed. The nurse suspects the patient may be experiencing which psychosocial issue? A. Hopelessness B. Spiritual distress C. Loss of control D. Posttraumatic stress disorder

D. Posttraumatic stress disorder The patient is experiencing posttraumatic stress disorder. After an exposure to a traumatic event, people may experience recall of the distressing event that produces an acute stress response. Nightmares and delusional memories, during which a trauma is re-experienced, provoke intense psychologic and physiologic distress. Cognitively, stress reactions lead to difficulty concentrating, poor executive function, and impaired decision making. The patient shows no evidence of hopelessness, spiritual distress, or loss of control.

A 25-year-old patient who has had an acute burn injury is exhibiting regressive behaviors, including childlike mannerisms such as whining and severe anxiety when a nurse does not remain at the bedside. The nurse recognizes that appropriate interventions for this patient include which action? A. Reprimanding the patient for inappropriate behaviors B. Allowing the behavior to continue as a normal reaction to injury C. Confronting the patient directly and asking why the behavior is occurring D. Setting limits in a mutually determined manner to allow the patient choices

D. Setting limits in a mutually determined manner to allow the patient choices Regression is an unconscious defense mechanism characterized by a retreat to behaviors characteristic of an earlier developmental level. Setting limits on these behaviors, encouraging independence and participation in self-care, counseling, and involving family members in establishing realistic goals are helpful strategies to assist a patient to diminish this manipulative behavior.

Which statement is true regarding noninvasive blood pressure measurement? A. A difference of 20 mm Hg between arms is an expected finding. B. The popliteal artery is the most common measurement location. C. Subclavian venous stenosis can be ruled out through measurement. D. The arm should be at the level of the heart during measurement.

D. The arm should be at the level of the heart during measurement. The most common peripheral locations for blood pressure monitoring are the bilateral brachial arteries. The pressure is measured in both arms to rule out subclavian arterial stenosis. Normally, the difference in pressure between the arms is less than 10 mm Hg. Correct positioning of the extremity being measured is essential; the arm or leg should be at the level of the heart.