Cardiovascular System

The nurse is assessing a client who had a stroke and underwent a carotid endarterectomy. The client is now experiencing motor deficits and communication problems. Which of the following findings requires immediate follow-up? 1. Slurred speech and inability to write clearly 2. Drowsiness and difficulty in dressing 3. Weak cough and difficulty walking 4. Increased pulse and decreased blood pressure

4 Increased pulse and decreased blood pressure may indicate hemorrhage, which is a complication of the surgery. The other options are related to findings of the stroke.

A nurse is caring for a client with a confirmed diagnosis of myocardial infarction. Which finding requires the nurse's immediate action? 1. Lightheadedness 2. Shortness of breath 3. Periorbital edema 4. Lethargy

1 Heart rhythms that are too fast or too slow may cause a transient drop in cardiac output during the arrhythmia. Inadequate cardiac output compromises blood flow to the brain causing lightheadedness, near syncope or unresponsiveness, which are the most concerning findings in the client with an arrhythmia. These findings should be reported immediately after a verification of the cardiac status through assessment cardiac rhythm and for other signs of poor cardiac output such as chest discomfort, shortness of breath or hypotension.

The client is admitted to the hospital with a diagnosis of right -sided heart failure. Which of the following findings would the nurse expect? (Select all that apply.) 1. Anorexia and nausea 2. Orthopnea 3. Cough 4. Ascites 5. Dependent edema

1, 4, 5 The classic findings of right-sided heart failure arise from blood backing up into the systemic circulation, resulting in abdominal organ engorgement and dependent edema. The nurse would expect to find orthopnea and cough with left-sided heart failure.

A client does not understand why she has been diagnosed with high blood pressure. What should the nurse say to her? 1. "It sounds like you are skeptical of the provider's diagnosis. Would you like to talk more about it?" 2. "Hypertension is diagnosed by taking the average of three or more blood pressure readings, two minutes apart, at each of three or more visits after an initial screening visit" 3. "Hypertension is diagnosed by taking average of five or more blood pressure readings, two minutes apart, at each of five or more visits after an initial screening visit" 4. "Your blood pressure is 160/90 today and a normal adult blood pressure should be 120/80"

2 Hypertension is diagnosed by taking the average of three or more blood pressure readings, two minutes apart, at each of three or more visits after an initial screening visit.Assuming that the client is skeptical of the diagnosis is not proper therapeutic communication. Although a blood pressure reading of 160/90 is high, additional screening would need to take place. High blood pressure can be caused by a variety of situations such as pain or stress.

A client is being seen in the emergency department for a myocardial infarction (MI). The client mentions that she stopped taking the metoprolol (Lopressor) five days ago because she was feeling better. Which of the following nursing diagnoses takes priority for this client? 1. Anxiety 2. Ineffective tissue perfusion; cardiopulmonary 3. Acute pain 4. Ineffective therapeutic regimen management

2 MI results from prolonged myocardial ischemia, caused by reduced blood flow through the coronary arteries. Therefore, the priority nursing diagnosis for this client is ineffective tissue perfusion (cardiopulmonary). The other choices are true and important considerations but are not the initial priority. Remember, nothing else matters if the tissues are not receiving oxygen.

The nurse is admitting a 72-year-old with a diagnosis of right-sided heart failure. What finding should the nurse anticipate when assessing the client? 1. Bibasilar crackles 2. Pleural effusion 3. Jugular vein distension 4. Decreased urine output

3 Signs of right-sided heart failure include jugular vein distention at 35-45 degrees or higher elevation of the head of the bed, fatigue, nausea, vomiting, sacral edema and bilateral feet and/or ankle edema.

The nurse assesses a cardiac client and observes that he has the classic triad of symptoms. Which of the following nursing actions should take priority? 1. Call a rapid response and monitor for a pneumothorax 2. Call a rapid response and elevate the bed to 45 degrees 3. Call a rapid response and anticipate a pericardiocentesis 4. Call a rapid response and provide emotional support

3 The nurse's first priority action is to call for a rapid response and prepare for an emergency pericardiocentesis. The nurse will monitor for a pneumothorax post-pericadiocentesis, and elevate the bed post-pericardiocentesis. Emotional support is important, however being ready for the pericardiocentesis is a life-saving intervention.

A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client's blood pressure has a trend of increased readings. Which action should the nurse take first? 1. Check the client's deep tendon reflexes 2. Check the protein level in urine 3. Have the client turn to the left side 4. Take the temperature

3 The priority action in this situation is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every four hours or more often if indicated, but no data in the stem supports a check of temperature. The deep tendon reflexes are checked as needed especially when magnesium drips are being infused.

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: 1. Is pale and oddly shaped 2. Is deep with even edges 3. Is granulated 4. Is brown and leathery

4 A venous stasis leg ulcer is brown in color with a leather like look and feel. The ulcer is an open wound with irregular borders.

Mitral Valve Insufficiency (Regurgitation)

Occurs when a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during ventricular systole. To handle the back flow, the atrium enlarges. The left ventricle also enlarges, in part to make up for its lower cardiac output.

Aortic Insufficiency (Regurgitation)

Occurs when blood flows back into the left ventricle during diastole, overloading the ventricle and causing it to hypertrophy. Extra blood also overloads the left atrium and, eventually, the pulmonary system.

Aortic Stenosis

Occurs when the aortic valve becomes narrowed, causing poor cardiac output and increasing left heart pressures.

Mitral Valve Stenosis

Occurs when the mitral valve thickens and gets narrower, blocking blood flow from the left atrium to the left ventricle.

Pulmonary Valve Insufficiency (Regurgitation)

Occurs when the pulmonary valve fails to close, so that blood flows back into the right ventricle.

Pulmonary Stenosis

The narrowing of the pulmonic valve between the right ventricle and pulmonary artery, which obstructs right ventricular outflow leading to right ventricular hypertrophy and right heart failure.

Tricuspid Stenosis

The narrowing of the tricuspid valve between the right atrium and right ventricle.

Tricuspid Valve Insufficiency (Regurgitation)

The tricuspid valve does not close properly during ventricular systole, allowing blood to leak from the right ventricle back into the right atrium.