Cardiac Imbalances and Shock

The nurse is caring for a patient with a diagnosis of first-degree heart block. The nurse anticipates that the patient's cardiac rhythm strip will reveal which of the following? Select all that apply. Select one or more: a. number of QRS complexes are half the number of P waves b. P wave rate is slower than the QRS rate c. QT segment is prolonged d. PR interval is prolonged e. PR interval is consistent

The correct answers are: PR interval is consistent, PR interval is prolonged

A client has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestations indicates to the nurse that reperfusion has been successful? Select all that apply Select one or more: a. Resolution of ST-segment depression b. Cessation of diaphoresis c. Sudden onset of pleuritic chest pain d. Onset of ventricular dysrhythmias

The correct answers are: Resolution of ST-segment depression (The nurse monitors for the following indications of clot lysis and artery reperfusion—cessation of chest pain, sudden onset of ventricular dysrhythmias, resolution of ST-segment depression, and a peak of markers of myocardial damage at 12 hours.), Cessation of diaphoresis (The nurse monitors for the following indications of clot lysis and artery reperfusion—cessation of chest pain, sudden onset of ventricular dysrhythmias, resolution of ST-segment depression, and a peak of markers of myocardial damage at 12 hours.), Onset of ventricular dysrhythmias

The client with ventricular tachycardia is unresponsive and has no pulse. What will the nurse do first? Select one: a. Carry out emergency cardioversion. b. Initiate CPR. c. Administer epinephrine. d. Defibrillate.

Feedback A client with pulseless VT should be defibrillated immediately. If the defibrillator is not available, the nurse should initiate CPR and then defibrillate as soon as possible. The correct answer is: Defibrillate.

A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes, with a heart rate of 35 beats/min on the monitor. What physical assessment parameter would be important to incorporate for this client? Select one: a. Pulmonary rales b. Acute hypertension c. Confusion or syncope d. Presence of a gallop rhythm

Feedback A heart rate of 40 beats/min or below, with widened QRS complexes, should alert the nurse to the possibility that the AV block is infranodal and a ventricular escape focus is pacing the ventricles. This could have hemodynamic consequences and the client is at risk of inadequate cerebral perfusion. The nurse should assess for lightheadedness, confusion, syncope, and seizure activity. The correct answer is: Confusion or syncope

Which assessment finding after a left-sided cardiac catheterization requires immediate intervention? Select one: a. Intake less than output b. Bruising at the insertion site c. Weak hand grasps and confusion d. Discomfort in the leg

Feedback A left-sided cardiac catheterization specifically increases the risk for a cerebrovascular accident (CVA). A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the client's fluid status. Neurologic changes would take priority. The correct answer is: Weak hand grasps and confusion

The client is experiencing sinus bradycardia with hypotension and dizziness. Which will the nurse administer? Select one: a. Atropine (Atropine) b. Digoxin (Lanoxin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor)

Feedback Atropine is a cholinergic antagonist that inhibits parasympathetic-induced hyperpolarization of the sinoatrial node. This inhibition results in an increased heart rate. The correct answer is: Atropine (Atropine)

Which client assessment takes priority prior to a cardiac catheterization? Select one: a. The level of anxiety b. The ability to move side to side c. Knowledge of the procedure d. Assessment for allergies to iodine and shellfish

Feedback Before the procedure, the nurse should ascertain if the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine-based. This allergy can cause a life-threatening reaction, so this is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and knowledge. The correct answer is: Assessment for allergies to iodine and shellfish

A nurse is caring for a client with chronic atrial fibrillation who is at risk for systemic emboli. Which drug should the nurse expect to administer to prevent this complication? Select one: a. Sotalol (Betapace) b. Heparin (Heparin) c. Atropine (Atropine) d. Lidocaine (Xylocaine)

Feedback Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. The correct answer is: Heparin (Heparin)

A client has just undergone a balloon valvuloplasty. For which complication of this procedure should the nurse monitor this client? Select one: a. Bleeding b. Acute tubular necrosis c. Short-term memory loss d. Pulmonary hypertension

Feedback Clients undergoing valvuloplasty are at higher risk of bleeding from the catheter insertion site. This is because of the use of a large-bore catheter for the arterial puncture needed to perform the procedure. The correct answer is: Bleeding

A client is preparing to be discharged home following mitral valve replacement. Which statement indicates that the client requires further education? Select one: a. "I won't be able to carry heavy loads for at least 6 months." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K." d. "I can use my electric razor to shave."

Feedback Clients who have defective or repaired valves are at high risk of endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk of endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics. The correct answer is: "I will have my teeth cleaned by the dentist in 2 weeks."

A client who is scheduled for echocardiography today asks why this test is being performed. How will the nurse respond? Select one: a. "This procedure is the best way to assess the structure of your heart noninvasively." b. "This procedure is to assess for abnormal electrical impulses from the sinoatrial node." c. "This procedure will evaluate the oxygen saturation in your blood." d. "This is the best way to evaluate the coronary arteries for any blockages that may be present."

Feedback Echocardiography is performed to assess the structure and function of the heart, especially the valves and wall motion. Coronary arteries are not assessed with echocardiography, and neither is the electrical conduction system. The correct answer is: "This procedure is the best way to assess the structure of your heart noninvasively."

The nurse has difficulty hearing heart sounds in a client with pericarditis. Which is the priority action of the nurse? Select one: a. Notify provider b. Assessing heart sounds with a Doppler c. Increasing the intravenous flow rate d. Administering oxygen by non-rebreather mask

Feedback Heart sounds that become muffled or more difficult to auscultate in a client with pericarditis may indicate the presence of tamponade, a medical emergency. The correct answer is: Notify provider

A client has returned from an angiography via the left femoral artery. Two hours after the procedure, the nurse notes that the left pedal pulse is weak. Which is the nurse's first action? Select one: a. Elevates the left leg and applies a sandbag to the entrance site b. Increases the flow rate of the intravenous fluids to 125 mL/hr c. Assesses the color and temperature of the left leg d. Documents the finding as left pedal pulse of +1/4

Feedback Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right and pulses should be compared with previous assessments, especially preprocedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. The correct answer is: Assesses the color and temperature of the left leg

A nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. Which is the nurse's first intervention based on these findings? Select one: a. Compares the results with previous readings b. Increases the IV fluid rate because these readings are low c. Immediately notifies the physician of the elevated pressures d. Documents the finding and continues to monitor

Feedback Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and 5 to 15 mm Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. The correct answer is: Compares the results with previous readings

Amiodorone is a class III agent used to treat cardiac arrhythmias. You recall that a class III agent: Select one: a. acts as a myocardial depressant by inhibiting sodium ion movement. b. prolongs the duration of the electrical stimulation on cells and the refractory time between electrical impulses. c. acts as a beta adrenergic agent. d. slows the rate of electrical conduction and prolongs the time interval between contractions.

Feedback RATIONALE: Class III agents slow the rate of electrical conduction and prolong the time interval between contractions. The correct answer is: slows the rate of electrical conduction and prolongs the time interval between contractions.

The client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. How will the nurse respond? Select one: a. "You are at greater risk for a heart attack, and the anticoagulants can reduce that risk." b. "Blood clots form more easily on artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg, making blood return to the heart much slower." d. "The surgery left a lot of small clots in your heart and lungs. The anticoagulants will slowly dissolve these."

Feedback Synthetic valve prostheses and scar tissue provide a surface on which platelets can aggregate easily and initiate the formation of blood clots. The correct answer is: "Blood clots form more easily on artificial replacement valves."

Which instructions are essential in a teaching plan for a client with hypertrophic cardiomyopathy (HCM)? Select one: a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have a maximum of two alcoholic drinks weekly."

Feedback The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur, because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM. The correct answer is: "You should report episodes of dizziness or fainting."

A young adult presents with a fever, symptoms of heart failure, and a murmur. Which additional data will the nurse obtain? Select one: a. Family history of coronary artery disease b. Recent travel to third-world countries c. Whether the client is responsible for cleaning pet litter boxes d. History of any systemic infection or dental work within the past month

Feedback The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. The correct answer is: History of any systemic infection or dental work within the past month

A client in the hyperdynamic phase of septic shock has been admitted to the intensive care unit. For which complication will the nurse be alert for as shock progresses from the hyperdynamic to the hypodynamic phase? Select one: a. Acute respiratory distress syndrome b. Acute bowel obstruction c. Ventricular tachycardia d. Seizure activity

Feedback The correct answer is: Acute respiratory distress syndrome As septic shock progresses to the hypodynamic phase, acute respiratory distress syndrome (ARDS), a potentially fatal complication, can develop. There will be decreased perfusion to the bowel, but a bowel obstruction is usually seen.

A client admitted to the coronary care unit with a myocardial infarction begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats/min, and cold, clammy skin. Which is the nurse's best action prior to notifying the physician? Select one: a. Administering oxygen b. Increasing the IV flow rate c. Placing the client in supine position d. Preparing the client for emergency echocardiography

Feedback The correct answer is: Administering oxygen The nurse recognizes these manifestations as impending cardiogenic shock. Oxygen is needed to prevent further deterioration. The physician or health care provider is notified immediately so that efforts can be made to reverse this condition, because it has a mortality rate of 65% to 100%.

Which of these manifestations would indicate to the nurse that the patient who has aortic stenosis is experiencing myocardial oxygen deficiency? Select one: a. Jugular vein distention b. Sacral edema c. Angina d. Pericardial friction rub

Feedback The correct answer is: Angina

Which of the following is most appropriate for the client receiving sodium nitroprusside? Select one: a. Assessing for chest pain b. Assessing blood pressure every 15 minutes c. Monitoring urinary output every 30 minutes d. Observing the client's extremities for color and perfusion

Feedback The correct answer is: Assessing blood pressure every 15 minutes The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and increase shock.

For which complication will the nurse monitor in the immediate post-procedure period in the client with peripheral arterial disease who has just undergone laser-assisted angioplasty? Select one: a. Hypertensive crisis b. Bleeding c. Aspiration d. Chest pain

Feedback The correct answer is: Bleeding

The nurse monitors for which complication in the client who had PTCA 1 hour ago? Select one: a. Hypertensive crisis b. Hyperkalemia c. Infection d. Bleeding

Feedback The correct answer is: Bleeding In the first few postprocedure hours, the nurse monitors for complications, such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias.

Which statement describes why heart failure occurs as a complication of aortic stenosis? Select one: a. Cardiac workload is decreased from increased cardiac output. b. Cardiac workload is decreased from reduced cardiac output c. Cardiac workload is increased from reduced cardiac output. d. Cardiac workload is increased from increased cardiac output.

Feedback The correct answer is: Cardiac workload is increased from reduced cardiac output.

For which manifestations will the nurse monitor when caring for the client with distributive shock resulting from an anaphylactic event? Select one: a. Increased heart rate and blood pressure b. Increased blood pressure and cardiac output c. Decreased blood pressure and respiratory rate d. Decreased blood pressure and edema

Feedback The correct answer is: Decreased blood pressure and edema Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak.

n caring for the client who has suffered a myocardial infarction, the nurse correlates which hemodynamic parameters with cardiogenic shock? Select one: a. Decreased cardiac output and decreased MAP b. Increased cardiac output and increased afterload c. Increased cardiac output and increased MAP d. Decreased cardiac output and increased MAP

Feedback The correct answer is: Decreased cardiac output and decreased MAP Myocardial infarction (MI) is a major cause of direct pump failure. With MI, cardiac output and MAP are decreased and afterload is increased.

For which clinical manifestations of myocardial infarction should the nurse monitor in the older adult? Select one: a. Pain on inspiration b. Posterior wall chest pain c. Disorientation or confusion d. Numbness and tingling of the arm

Feedback The correct answer is: Disorientation or confusion In older adults (younger than 80 years), disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations could also be related to the myocardial infarction. However, the nurse is more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

The client post-coronary artery bypass graft (CABG) has a serum potassium level of 4.5 mEq/L. What is the nurse's best action? Select one: a. Notify the physician. b. Document the finding as the only action. c. Decrease the IV solution flow rate. d. Administer potassium replacement as ordered.

Feedback The correct answer is: Document the finding as the only action. The client who is postoperative from a CABG is at risk of hypokalemia from hemodilution, nasogastric suction, or diuretic therapy. Therefore, the potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. This value is at the desired level for this client. The finding requires documentation only.

The client's urinary output is normal, whereas the respiratory rate and heart rate are slightly elevated from baseline. The nurse correlates these findings to which stage of shock? Select one: a. Early b. Compensatory c. Intermediate d. Refractory

Feedback The correct answer is: Early An increase in heart and respiratory rates (heart rate first) from the client's baseline or a slight increase in diastolic blood pressure may be the only objective manifestations of early shock.

While monitoring a patient with cardiomyopathy, the nurse recognizes that the manifestations of cardiomyopathy are similar to those of which of these conditions? Select one: a. Angina b. Myocardial infarction c. Pericarditis d. Heart failure

Feedback The correct answer is: Heart failure

Which medication(s) will the nurse administer to a client in the hyperdynamic phase of septic shock? Select one: a. Heparin b. Vitamin K c. Corticosteroids d. Clotting factors, platelets, and plasma

Feedback The correct answer is: Heparin During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors.

In monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride drip, the nurse recognizes which parameter as the desired response to this drug? Select one: a. Hypotension b. Tachycardia c. Increased cardiac output d. Decreased mean arterial pressure

Feedback The correct answer is: Increased cardiac output. Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation.

The nurse monitors for which responses as indicative of improvement in the client receiving dobutamine for management of heart failure following an acute MI? Select one: a. Decreased heart rate, increased pulse quality b. Decreased heart rate, decreased pulse quality c. Increased heart rate, increased pulse quality d. Increased heart rate, decreased pulse quality `

Feedback The correct answer is: Increased heart rate, increased pulse quality Dobutamine is a positive inotropic agent that works by stimulating beta-adrenergic receptor sites. The result of this stimulation is an increase in the rate and force of the myocardial contraction

A client admitted with septic shock develops tachycardia and an increase of 20 mm Hg in systolic blood pressure. Which pathophysiologic factors of hyperdynamic shock are responsible for these clinical manifestations? Select one: a. Inflammatory reaction of circulating endotoxins b. Vasoconstriction resulting in tissue hypoxia c. Reductions in hematocrit and hemoglobin d. Platelet aggregation

Feedback The correct answer is: Inflammatory reaction of circulating endotoxins Circulating endotoxins interact with white blood cells and blood vessel walls to trigger inflammatory reactions. Some endotoxins exert a direct effect on the heart, causing an initial increase in cardiac output and resulting in tachycardia, with normal to elevated systolic blood pressure. In hyperdynamic shock, vasodilation is present. Reductions in hematocrit and hemoglobin levels are seen late in septic shock accompanying hemorrhage. Platelet aggregation can cause microthrombus formation, leading to disseminated intravascular coagulation (DIC).

The nurse prioritizes which assessment in the older client who has had CABG surgery? Select one: a. Skin assessment b. Otoscopic assessment c. Mental status assessment d. Gastrointestinal assessment

Feedback The correct answer is: Mental status assessmentssessment of mental status is important, because older adults are more likely to experience transient neurologic deficits as compared with younger adults

A patient with suspected paroxysmal supraventricular tachycardia (PSVT) has received 6 mg of adenosine (Adenocard) by rapid IV push, followed by 20 mL of normal saline. Suddenly the cardiac monitor indicates asystole. The nurse should: Select one: a. Initiate emergency procedures because the patient has received an overdose of adenosine. b. Check the patient's level of consciousness and lead placement c. Initiate emergency procedures because the patient is in cardiac arrest. d. Monitor the patient because a brief period of asystole is common after this drug is given.

Feedback The correct answer is: Monitor the patient because a brief period of asystole is common after this drug is given.

The nurse notes that the mediastinal tubes of a client who is 6 hours postoperative after undergoing CABG are not draining. Which action would be indicated at this time? Select one: a. Replacing the tubing b. Notifying the physician c. Irrigating the tubing with normal saline d. Documenting the finding

Feedback The correct answer is: Notifying the physician The sudden cessation of mediastinal drainage could result in cardiac tamponade from the accumulation of blood around the heart. It would require immediate notification of the surgeon.

A client who has returned to the unit after arterial revascularization states that pain similar to that before the procedure is felt in the affected limb. Which is the nurse's best action? Select one: a. Elevating the extremity b. Notifying the surgeon c. Placing a warm blanket on the operative limb d. Administering pain medication

Feedback The correct answer is: Notifying the surgeon

The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate to the nurse that the client should not yet be advanced to the next level? Select one: a. Facial flushing b. Onset of chest pain c. Heart rate increase of 10 beats/min at completion of ambulation d. Systolic blood pressure increase of 10 mm Hg at completion of ambulation

Feedback The correct answer is: Onset of chest pain Chest pain on ambulation indicates poor tolerance to activity and is an indication that the heart is not ready for progression.

When assessing a client who just returned from an abdominal aortic aneurysm repair, which assessment finding requires immediate intervention? Select one: a. Absent bowel sounds in all quadrants b. Blood pressure of 104/72 and pulse of 96 c. Urine output to 60 mL/hr d. Severe abdominal pain and distention

Feedback The correct answer is: Severe abdominal pain and distention

The nurse assesses for modifiable risk factors in the client with coronary artery disease. Which intervention is the priority to assist the client in decreasing the risk for coronary artery disease? Select one: a. Age b. Gender c. Smoking d. Family history

Feedback The correct answer is: Smoking Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (age, gender, family history). The nurse needs to encourage the client to stop smoking, because this is a proven risk factor for coronary artery disease development.

In monitoring the client recovering from aortofemoral bypass surgery, which clinical manifestations are consistent with compartment syndrome? Select one: a. Increased pulse amplitude and warmth below surgical site b. Swelling, pain, and tension of affected limb c. Elevated temperature and diaphoresis d. Loss of sensation and pallor proximal to surgical site

Feedback The correct answer is: Swelling, pain, and tension of affected limb

A client who had a stroke 1 month ago presents with an acute MI. The nurse recognizes which statement as correct regarding the administration of thrombolytic therapy to this client? Select one: a. The stroke has no bearing to administration of this therapy b. The stroke is a relative contraindication to administration of this therapy c. The stroke is an absolute contraindication for administration of this therapy d. Administration of this medication will cause an Increased risk for an extension of the current MI

Feedback The correct answer is: The stroke is an absolute contraindication for administration of this therapy Recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy.

A nurse is caring for a client admitted with community-acquired pneumonia. Which white blood cell (WBC) count and differential are associated with an increased risk for septic shock? Select one: a. Total WBC count 10,000/mm3 and neutrophil count 7000/mm3 b. Total WBC count 17,000/mm3 and neutrophil count 15,000/mm3 c. Total WBC count 3,000/mm3 and neutrophil count 2,000/mm3 d. Total WBC count 3,000/mm3 and neutrophil count 400/mm3

Feedback The correct answer is: Total WBC count 3,000/mm3 and neutrophil count 400/mm3This total white blood cell count is lower than normal (leukopenia), with a profound decrease (left shift) of mature neutrophils. This greatly increases the risk for the client to develop sepsis.

The nurse monitors for which clinical manifestation of poor organ perfusion in the client with left ventricular failure secondary to a myocardial infarction? Select one: a. Headache b. Hypertension c. Urine output of less than 30 mL/hr d. Heart rate of 55 to 60 beats/min

Feedback The correct answer is: Urine output of less than 30 mL/hr The nurse should remain alert for signs of poor organ perfusion that are the result of decreased cardiac output. When the kidneys are not well perfused, urine output drops to less than 30 mL/hr. Other signs include changes in mental status, cool, clammy extremities with decreased or absent pulses, fatigue, and recurrent chest pain.

Before a patient receives metoprolol (Lopressor) for tachycardia, the nurse should ask the patient about a history of which of the following? Select one: a. bronchospasms b. seizure c. peripheral vascular disease d. myasthenia gravis

Feedback The correct answer is: bronchospasms

The client has all the following clinical manifestations. Which assessment findings alerts the nurse to the probability of septic shock? Select all that apply. Select one or more: a. Oozing of blood at the IV site b. Anxiety and confusion c. Hypotension d. Pale clammy skin

Feedback The correct answers are: Anxiety and confusion, Oozing of blood at the IV site

he nurse correlates which clinical manifestations with the early stages of hypovolemic shock? (Select all that apply.) Select one or more: a. Elevated heart rate b. Elevated systolic blood pressure c. Elevated diastolic blood pressure d. Decreased respiratory rate e. Decreased pulse rate f. Decreased body temperature

Feedback The correct answers are: Elevated heart rate, Elevated diastolic blood pressure Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock.

What is/are the priority nursing diagnosis(es) for a client admitted with a diagnosis of a large acute anterior wall myocardial infarction?Select all that apply Select one or more: a. Potential for Decreased Tissue Integrity b. Potential for Sensory Perception Alteration c. Potential for Impaired Tissue Perfusion d. Potential for Decreased Cardiac Output

Feedback The correct answers are: Potential for Impaired Tissue Perfusion, Potential for Decreased Cardiac OutputIn the client experiencing acute myocardial infarction, a decrease in pumping effectiveness of cardiac muscle results in a decreased cardiac output. In the client experiencing acute myocardial infarction, a decrease in pumping effectiveness of cardiac muscle results in a decreased cardiac output.In the client experiencing acute myocardial infarction, a decrease in pumping effectiveness of cardiac muscle results in a decreased cardiac output.

Which of the following are characteristics of mechanical valves used for cardiac valve replacement? Select all that apply. Select one or more: a. They do not require lifelong anticoagulant therapy. b. They are durable. c. They create turbulent blood flow. d. They require donors. e. They may be preferred if anticoagulation is a concern.

Feedback The correct answers are: They are durable., They create turbulent blood flow.

What clinical manifestation alerts the nurse to the possibility that the client's mitral stenosis has progressed? Select one: a. The client's oxygen saturation is 92%. b. The client has dyspnea on exertion. c. The client has a systolic crescendo-decrescendo murmur. d. The client experiences a loss of strength in the upper extremities.

Feedback The development of dyspnea on exertion occurs as the mitral valvular orifice narrows and pressure in the lungs increases. The correct answer is: The client has dyspnea on exertion.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops increased lower back pain radiating to the groin. Which is the nurse's interpretation of this information? Select one: a. The client is experiencing normal sensations associated with this condition. b. The aneurysm has become obstructed. c. The client is experiencing inflammation of the aneurysm. d. The aneurysm may be undergoing expansion.

Feedback When an aneurysm is expanding or preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm. The correct answer is: The aneurysm may be undergoing expansion.

The nurse is caring for a newly admitted patient with a diagnosis of restrictive cardiomyopathy. When planning this patient's care, which of the following would be the most appropriate nursing diagnosis? Select one: a. Fear related to new onset symptoms b. Activity intolerance related to decreased cardiac output c. Hopelessness related to lack of cure and debilitating symptoms d. Deficient knowledge related to medication regime

Feedback Your answer is correct. All patients with cardiomyopathy have some decrease in their cardiac output and corresponding activity intolerance. The experiences of fear, hopelessness or deficient knowledge are patient specific and need to evaluated on an individual basis. Any or all of these may be present but more data would be needed to determine whether the other nursing diagnoses apply. Utilizing Maslow's hierarchy one would address physiologic before psychological issues. The correct answer is: Activity intolerance related to decreased cardiac output

A patient asks, "What is a dissecting aneurysm?" Which of these responses by the nurse is correct? Select one: a. "A communication between an artery and a vein." b. "A separation of the inner layer of the arterial wall." c. "An outpouching of one side of the arterial wall." d. "An enlargement of the entire circumference of the artery."

eedback The correct answer is: "A separation of the inner layer of the arterial wall."