cardiac

Which statement would lead the nurse to determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle?

"I already have my airline ticket, so I will not miss my meeting tomorrow." Explanation: Leaving the hospital and immediately flying to a meeting indicate poor judgment by the client and little understanding of what she needs to change regarding her lifestyle. The other statements show that the client understands some of the changes she needs to make to decrease her stress and lead a healthier lifestyle.

In what position should a nurse place the head of the bed to obtain the most accurate reading of jugular vein distensio

30 degrees Explanation: The nurse should measure jugular vein distention with the head of the bed elevated between 15 and 30 degrees. This position allows the nurse to obtain the vertical distance between the sternal angle and the point of highest pulsation. The nurse can't observe increased pressure when the client is supine or when the head of the bed is at 120 degrees because the point that marks the pressure level is above the jaw and, therefore, not visible. In high Fowler's position, the veins are barely discernible above the clavicle.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority?

Assessing troponin 1 levels Explanation: Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority

The nurse is assigned to a client in the ICU. During the initial assessment, the nurse notes jugular vein distention and recognizes that the plan of care will follow which disorder?

Heart failure Explanation: Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump. Jugular vein distention is not a symptom of abdominal aortic aneurysm or pneumothorax. If severe enough, an MI can progress to heart failure, but an MI alone does not cause jugular vein distention.

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

History of aortic valve replacement Explanation: 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

Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:

Place a large bore IV. Explanation: The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An IV should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with severe nausea and vomiting to decompress the stomach

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?

Rheumatic fever Explanation: 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.

A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed?

Withhold the medication and notify the physician immediately. Explanation: The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, he cannot give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent

Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit?

keeping the door closed to provide privacy Explanation: Keeping the client's door closed is likely to contribute to feelings of isolation and sensory deprivation. Such activities as watching television, visiting with a relative, and reading a newspaper help prevent sensory deprivation and yet do not require physical effort

A client with Raynaud's phenomenon is considering having a sympathectomy. This nurse should tell the client that the surgery is performed:

when all other treatment alternatives have failed. Explanation: Sympathectomy is scheduled only after other treatment alternatives have been explored and have failed. Medication and stress management are beneficial strategies to prevent advancement of the disease process. If the disease is controlled by medication, there is no reason for surgery