Ch. 12 Practice Questions Cardiovascular Alterations

29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "My back is killing me!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

a. "My back is killing me!" RATIONALE: The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.

13. The patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

a. Coronary artery bypass graft surgery Rationale: Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%)

2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

c. Dyspnea and crackles Rationale: In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

MULTIPLE RESPONSE 6. The patient's husband tells the nurse, "We didn't think she was having a heart attack because the pain was in her neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel."

a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." RATIONALE: Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck.

MULTIPLE RESPONSE 5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture

a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture RATIONALE: All are potential complications of AMI.

MULTIPLE RESPONSE 1. The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply). a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) d. Ventricular assist device

a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) RATIONALE: This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump also may be warranted.

MULTIPLE RESPONSE 3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic.

a. Dysrhythmias are common occurrences. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. RATIONALE: Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

17. A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for: a. Erectile dysfunction b. Prostate enlargement c. Asthma d. Peripheral vascular disease

a. Erectile dysfunction Rationale: A history of the patient's use of sildenafil citrate (Viagra) or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies.

MULTIPLE RESPONSE 7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distention b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses

a. Jugular venous distention b. Peripheral edema RATIONALE: Rationale: Jugular venous distention, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure.

22. The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her: a. "It will be worth it to have him healthy, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then just let the children eat whatever they want."

b. "The low-cholesterol diet is one from which everyone can benefit." Rationale: Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease.

24. Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." RATIONALE: Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion.

28. The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse explains to her: a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." RATIONALE: Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

MULTIPLE RESPONSE 8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place

b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place RATIONALE: The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity.

25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

b. Atrial fibrillation or flutter RATIONALE: Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. Murmur c. S1 heart sound d. S3 heart sound

b. Murmur Rationale: The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

27. The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains: a. "The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems." b. "The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year." c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." d. "The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husband's symptoms."

c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." RATIONALE: A successful angioplasty procedure is one in which the stenosis is reduced to less than 50% of the vessel lumen diameter, although most clinicians aim for less than 20% final diameter stenosis.

21. The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains: a. "This is a result of a high-cholesterol diet and poor exercise habits." b. "The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac rehabilitation they will work with the patient to strengthen his heart through special exercises." c. "This is an inherited condition. You should give serious consideration to having family members screened for it." d. "This is a result of clot formation in the blood vessels in the heart. We will need to use medications to reduce the risk of further clotting."

c. "This is an inherited condition. You should give serious consideration to having family members screened for it." RATIONALE: Hypertrophic cardiomyopathy is a genetically inherited disease that affects the myocardial sarcomere.

20. The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. Dopamine b. Dobutamine c. Adenosine d. Atropine

c. Adenosine Rationale: If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed.

7. A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

c. Echocardiogram Rationale: Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

c. Myocardial remodeling Rationale: Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines, which causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

6. A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta-blockers d. Statins, bile acid, and nicotinic acid

c. Nitroglycerin, oxygen, and beta-blockers Rationale: Conservative intervention for the patient experiencing angina includes nitrates, beta-blockers, and oxygen.

MULTIPLE RESPONSE 4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave

c. Non-Q wave d. Q wave RATIONALE: AMI can be classified as Q wave or non-Q wave.

11. A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

c. Silent myocardial infarction Rationale: Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. These can occur with no presenting signs or symptoms. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients.

15. The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

c. contact the physician immediately and begin prepping the patient for surgery. Rationale: These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

d. Left main coronary artery RATIONALE: Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels at least 88% d. Maintain heart rate above 100 beats/min

a. Administer thrombolytic therapy unless contraindicated Rationale: Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Since interventional cardiology is not available, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

MULTIPLE RESPONSE 2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply). a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy

a. Administration of morphine b. Administration of nitroglycerin (NTG) d. Oxygen therapy RATIONALE: The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct.

4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. He is nauseous and diaphoretic, and his skin is dusky in color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

a. Emergent pacemaker insertion Rationale: The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

1. The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels Rationale: ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

12. A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED since he was hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse understands that? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

a. The patient is not a candidate for thrombolysis. Rationale: To be eligible for thrombolysis, the patient must be symptomatic for less than 6 hours.

19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

b. Left ventricular assist device (LVAD) Rationale: LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test

b. Transesophageal echocardiogram Rationale: In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns.

26. An essential aspect of teaching that may prevent recurrence of heart failure is: a. notifying the physician if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

b. compliance with diuretic therapy. RATIONALE: Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

c. Death of cardiac muscle from lack of oxygen (tissue necrosis). Rationale: Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches.

5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

c. Partial occlusion of a coronary artery with a thrombus Rationale: In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy.

14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

c. Radiofrequency catheter ablation Rationale: Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway.

8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

d. Statins Rationale: The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs