Cardiovascular System EVOLVE
which statement by a client is consistent with a diagnosis of heart failure? "i see spots before my eyes" "i am tired at the end of the day" "i feel bloated when i eat a large meal" "i have trouble breathing when i climb a flight of stairs"
answer: "i have trouble breathing when i climb a flight of stairs" dyspnea on exertion occurs with heart failure because of the heart's inability to meet oxygen needs of the body. Seeing spots before one's eyes is not a symptom associated with heart failure. Fatigue at the end of the day is common for many people, whereas fatigue that occurs all day is a symptom of heart failure. Feeling bloated constantly would be a sign of fluid retention, not just after a large meal.
after an admission for ACS, a client is asked to notify the nursing staff before getting out of bed. after finding the client up walking alone in the hallways an hour later, which response by the nurse is best? "please go get back into your bed immediately" "it must be frustrating to lose your independence" "sometimes after ACS, people feel dizzy and fall" "the primary health care provider wants you to rest"
answer: "sometimes after ACS, people feel dizzy and fall" this response provides the client with the rationale for the activity restriction and is more likely to lead to client compliance. the response "please go get back into your bed immediately" is authoritarian and disrespectful to this adult client. in the response "it must be frustrating to lose your independence" the nurse is making an assumption about the client's emotional state and reason for walking. the response "the primary health care provider wants you to rest" offers no reason for the need for an activity restriction.
when teaching a client with HTN about a 2 gram sodium diet, which foods would the nurse instruct the client to avoid? select all that apply. canned chili ground beef fresh salmon luncheon meat cooked broccoli
answer: 1 and 4 canned chili is high in sodium and should be avoided. luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Although ground beef may be high in saturated fat, it is not high in sodium. fresh salmon is not high in sodium. Cooked, unprocessed broccoli does not have significant sodium levels.
When a client is diagnosed with left side congestive heart failure, which assessment findings would the nurse expect? Select all that apply. Dyspnea Crackles Frequent Cough Peripheral edema Jugular Distention
answer: 1, 2, 3 with left ventricular failure, increases in left ventricular volume and pressure lead to pulmonary congestion, causing dyspnea, lung crackles, and cough. Peripheral edema and jugular vein distention occurs when right sided heart failure causes increases in systemic venous pressure.
which diagnostic test is most important to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome? chest radiograph troponin T creatinine kinase MB (CK-MB) 12 lead electrocardiogram
answer: 12 lead EKG with ACS, EKG changes indicating myocardial injury and infaraction occur within minutes. beacuse treatment for ACS usually involves actions to restore blood flow to the myocardium as rapidly as possible, it is essential that the EKG be done and evaluated immediately. The other tests are also appropriate but will be done after the EKG. changes in the chest radiography will occur if there is cardiac enlargement, pericardial effusion, or HF secondary to myocardial infarction. Troponin T will increase with MI. CM-MB will increase with MI.
For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. weight loss unusual fatigue dependent edema nocturnal dyspnea increased urinary output
answer: 2,3,4 unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of orthopneic position, is a sign of left ventricular failure. Weight gain, not loss, occurs because of fluid retention. urinary output decreases, not increases, with heart failure because the sympathetic nervous system and the RAAS stimulate the retention of sodium and water in the kidneys.
when teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? select all that apply weight loss extreme fatigue coughing at night excessive urination difficulty breathing
answer: 2,3,5 fatigue is caused by lack of adequate oxygenation of body cells caused by a decreased cardiac output. as the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood tinged sputum to occur. dyspnea is associated with pulmonary congestion that occurs as fluid is retained by the kidneys. fluid retention, not diuresis occurs because of decreased circulation to the kidneys, resulting from decreased cardiac output.
which of these clients seen at a health fair will be most at risk for hypertension? 23 yr old white man 24 yr old white women 50 yr old Mexican American woman 62 yr old African American man
answer: 62 yr old African American man African Americans have the highest risk for hypertension; before the age of 45, men are at a higher risk than women.
which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? select all that apply. weight inactivity cholesterol tobacco use homocysteine
answer: ALL Modifiable risk factors are those a person can change. Modifiable risk factors for cardiovascular disease include maintaining a healthy weight, getting regular physical activity, keeping cholesterol levels within normal limits, refraining from using tobacco, and monitoring homocysteine levels to make sure they are within the normal range.
to determine if whether a client is experiencing ACS, which component of the EKG would the nurse analyze? P wave PR interval QRS complex ST segment
answer: ST segment elevation or depression of the ST segment is indicative of ACS because of changes in cardiac electrical activity that occurs with ischemia and injury. P wave changes are not used to diagnose ACS. Changes in P wave are not used to diagnose ACS. Changes in the QRS complex do not occur with ACS. Changes in the PR interval are not diagnostic of ACS.
which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? select all that apply. fatigue orthopnea pitting edema dry hacking cough 4 pound weight gain
answer: all signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.
how can the nurse describe heart failure to a patient? a cardiac condition caused by inadequate circulating blood volume an acute state in which the pulmonary circulation pressure decreases an inability of the heart to pump blood in proportion to metabolic needs a chronic state in which the systolic blood pressure drops below 90
answer: an inability of the heart to pump blood in proportion to metabolic needs as the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents the tissues from receiving adequate oxygen and nutrients, and it will result in the heart's inability to pump blood in proportion ti metabolic needs. HF is related to an increase not decreased or inadequate, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The BP may be decreased in HF, but a systolic BP below 90 can occur in healthy clients or be caused by many other diagnoses.
when an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first? interview the client for health history assess the client's heart and lung sounds monitor the client's peripheral pulse quality obtain the client's blood specimen for electrolytes
answer: assess the client's heart and lung sounds the nurse's first assessments would focus on detection of signs and symptoms of severely decreased cardiac output, such as tachycardia and lung crackles, which would require rapid action to correct. The health history interview is done after vitals and breath sounds are obtained and the client is stabilized. Although peripheral pulse quality would decrease in heart failure, this is not a life threatening finding. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.
when admitting a client with acute coronary syndrome to the telemetry unit after catheterization and percutaneous intervention, which action would the nurse take first? attach the cardiac monitor auscultate the heart sounds check the intravenous fluid rate assess alertness and orientation
answer: attach the cardiac monitor because of fatal dysryhmias may occur in the first hours after the myocardial infarction, cardiac monitoring is a priority. the nurse will also do auscultation of the heart, but changes in heart sounds are not expected with ACS and PCI. checking the intravenous line for patency and correct infusion rate is also important but would be done after establishing cardiac monitoring. neuro status would also be assess, but changes in neuro status are not expected after PCI, which does not require general anesthesia.
which parameter would the nurse assess in client with right sided heart failure ? select all that apply. fluid volume lung sounds mental status respiratory rate peripheral pulses
answer: fluid volume JVD, edema, ascites and weight gain would be expected in a client with right sided heart failure. Therefore, the nurse would assess fluid volume. crackles when auscultating lung sounds, restlessness and confusion caused by impaired oxygenation, increased, shallow RR, and peripheral pulses is associated with left sided HF.
when a client with ACS is admitted to the coronary intensive care unit, which topic is a priority to include in teaching? symptoms of worsening heart failure use of daily low dose aspirin after discharge need to report any chest discomfort to the nurses importance of starting a walking and exercise program
answer: need to report any chest discomfort to the nurses the priority teaching for a client who is experiencing an acute event is content that is immediately useful, such as the need to report any symptoms of cardiac ischemia immediately so that they can be treated. Although clients with ACS may develop heart failure, this client does not currently have this diagnosis and does not need teaching about this problem. Daily low dose aspirin likely to be prescribed, but this would be taught closer to the time of discharge. initially, clients with ACS have restricted activity, although the nurse will teach about the need for gradually increase exercise at the time of discharge.
when a client with history of hypertension that is usually successfully treated with medications that had blood pressure of 160/100 during a clinic appointment, which action would the nurse take next? teach the client about the need for a low sodium diet ask the client when blood pressure meds were taken last question the client about symptoms such as a headache or chest pain call for an ambulance o transport the client to the emergency department
answer: question the client about symptoms such as a headache or chest pain the nurse's initial action would be to determine if the client is having acute complications such as a stroke or ACS. the client may need teaching about sodium reduction, but more assessment is needed before the nurse implements teaching. Failure to take BP meds is a common reason that clients have a sudden increase in BP, but is more important to determine if the client is having complications caused by the elevated blood pressure. If the client is having symptoms of stroke or ACS, an ambulance would be called for transport to the hospital, but an elevated blood pressure alone is not an indicator of a need for emergency services.
which dietary choice reflects the recommendations for the Dietary Approaches to Stop Hypertension (DASH) diet? select all that apply. salami pickles salmon french fries canned soup
answer: salmon the DASH diet includes fruit, veggies, low fat/fat free foods, fish, poultry, and reduced sugar. Salmon is a meal choice that aligns with the recommendations. Salami is a processed meat that is high in fat. pickles are high in sodium. french fries are high in fat and starch. Canned soups are high in sodium.
which lab value will be the most important for the nurse to determine whether a client with chest pain as ACS? troponin T c-reactive protein LDL b-type natriuretic protein
answer: troponin T cardiac troponins are released into circulation within hrs of myocardial injury or infarction, and elevation in troponin levels helps determine that the client is experiencing ACS. the other 3 values will also be monitored but are not markers for ACS or acute myocardial infarction. c-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease. elevated LDL is a risk factor for atherosclerosis and CAD. elevated BNP is diagnostic for heart failure.
to avoid complications in a client who has developed severe bone marrow damage after receiving chemotherapy for cancer, which actions by the nurse are appropriate? select all that apply. monitor for signs of alopecia encourage an increase in fluids wash hands before entering the client's room advise use of a soft toothbrush for oral hygiene report an elevation in temperature immediately teach the client to avoid eating raw fruits or veggies
bone arrow depression causes neutropenia; it is essential to prevent infection in this client through hand washing before touching the client or client's belongings. thrombocytopenia occurs with chemotherapy-induced bone marrow depression; using a soft toothbrush helps prevent bleeding gums. any temperature elevation in a client with neutropenia must be reported because it may be a sign of infection. although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. increasing fluids will neither reverse bine marrow supression nor stimulate hematopoiesis. clients who have neutropenia may eat raw fruits and veggies after washing off soil that may contain disease causing microbes