Chapter 20
An older adult client newly diagnosed with systolic hypertension asks her health care provider why this happens. Which response is most accurate?
"With age, your arteries lose their elasticity and are replaced with collagen, which makes your arteries stiffer." Systolic blood pressure rises almost linearly between 30 and 84 years of age, whereas diastolic pressure rises until 50 years of age and then levels off or decreases. This rise in systolic pressure is thought to be related to increased stiffness of the large arteries. With aging, the elastin fibers in the walls of the arteries are gradually replaced by collagen fibers that render the vessels stiffer and less compliant.
A client with persistent primary hypertension remains apathetic about having high blood pressure, stating, "I do not feel sick, and it does not seem to be causing me any problems that I can tell." How would the nurse best respond to this client's statement?
"You may not sense any problems, but it really increases your risk of heart disease and stroke." Hypertension is a highly significant risk factor for heart disease and stroke. It would be inappropriate to promote monitoring without promoting lifestyle modifications or other interventions to lower the client's blood pressure, or teaching the client about the deleterious effects of hypertension. It is likely unproductive to simply characterize the client's hypertension as demonstrating that the client does not "take care" of himself. Hypertension is not a risk factor for the development of diabetes mellitus.
The nurse suspects a client has stage 2 systolic hypertension. What systolic pressure would confirm the nurse's suspicion?
140 mm Hg or higher Explanation: Classification of blood pressure in adults defines a systolic pressure of 140 mm Hg or higher as stage 2 hypertension. Stage 1 hypertension has a systolic pressure between 130 and 139 mm Hg. Systolic blood pressure between 120 and 129 mm Hg is classified as elevated and 119 mm Hg or lower is classified as normal.
The nurse knows that the main objective of the management of hypertension is to achieve a sustainable level of blood pressure below:
140/90 The main objective of hypertension management is to achieve a pressure of 140/90, although persons with renal disease or diabetes are advised to aim for 130/80 or lower. Persons with blood pressure between 140/90 and 120/80 are considered to be prehypertensive and should be monitored at regular intervals to detect any rise in pressure.
Which assessment finding would be suggestive of cardiac tamponade?
A 20 mm Hg drop in systolic blood pressure during respiration Explanation: A key diagnostic finding in cardiac tamponade is pulsus paradoxus, or an exaggeration of the normal variation in the systolic blood pressure, commonly defined as a 10 mm Hg or more fall in the systolic blood pressure, which occurs with inspiration. Worsening blood gases, chest secretions, and chest pain are not symptoms specific to cardiac tamponade. The client's ECG would not be normal.
Which client would the nurse recognize as needing to be assessed for orthostatic hypotension?
An 80-year-old client who has experienced two falls while attempting to ambulate to the bathroom Explanation: Dizziness, blurred vision, palpitations, and syncope (i.e., fainting) are characteristic signs and symptoms of orthostatic hypotension, and both predispose an individual to falls; this is especially the case among older adults. Headaches, edema, diabetes, and vision changes are not associated with orthostatic hypotension.
Following several weeks of increasing fatigue and a subsequent diagnostic workup, a client has been diagnosed with mitral valve regurgitation. Failure of this heart valve would have which hemodynamic consequences?
Backflow from the left ventricle to left atrium The mitral valve separates the left ventricle from the left atrium; failure of this valve would cause backflow from the former to the latter during systole. Valve function does not directly affect cardiac contractility.
A client is immobilized following a hip injury. The client has developed lower leg discoloration with edema, pain, and tenderness in the midcalf area. How should the nurse document these clinical findings?
Deep vein thrombosis Explanation: Venous insufficiency with deep vein thrombus formation is characterized by pain, swelling [edema], and deep muscle tenderness. Fever, general malaise, and elevated white blood cell count and erythrocyte sedimentation rate are accompanying indications of inflammation. Swelling may vary from minimal to maximal. Immobility raises the risk for thrombus formation. The skin is intact, so venous stasis ulcerations are not present. Distended torturous veins (varicosity manifestations) are not present with deep vein thrombosis.
About a week after dental cleaning and root canal, a client has developed an infection of the thin, three-layered membrane that lines the heart and covers the valves. What is this client's most likely diagnosis?
Endocarditis Explaination The endocardium is a thin, three-layered membrane that lines the heart and covers the valves; infection of this part of the heart is consequently referred to as endocarditis. Pericarditis represents an inflammatory process of the pericardium. Myocarditis is the inflammation of the myocardium. Vasculitis is the inflammation of the blood vessels.
Chronic stable angina, associated with inadequate blood flow to meet the metabolic demands of the myocardium, is caused by:
Fixed coronary obstruction Chronic stable angina is caused by fixed coronary obstruction that produces an imbalance between coronary blood flow and the metabolic demands of the myocardium. Endothelial relaxing factors relax the smooth muscle in the vessel wall and allow increased blood flow; treatment for chronic stable angina is with a vasodilating agent, such as nitroglycerine, that relaxes the vessels and enhances coronary blood flow. Intermittent vessel vasospasms, in conjunction with coronary artery stenosis, cause the vasospastic type of angina. Increased formation of collateral vessels is a compensatory response that allows adequate blood circulation to tissues distal to an obstruction.
A 50-year-old man is having routine blood work done as part of his yearly physical. The doctor informs him that his good cholesterol is low. To which form of cholesterol is the doctor referring?
HDL HDL is known as the "good" cholesterol because it transports cholesterol back to the liver for metabolism. LDL, VLDL, and IDL transport cholesterol to the tissues.
The health care provider is teaching a client about modifiable risk factors for atherosclerosis. The most appropriate information to provide would be:
Hypertension The major risk factors that can be modified by a change in health care behaviors include cigarette smoking, obesity, hypertension, hyperlipidemia and elevated LDL cholesterol, and diabetes mellitus, all of which are traditional cardiovascular risk factors. The other options are nonmodifiable risk factors for atherosclerosis.
The nurse is counseling a client regarding a high cholesterol level. The nurse teaches the client that which lipoprotein is the main carrier of cholesterol?
LDL LDL is the main carrier of cholesterol. HDL is 50 percent protein; VLDL carries a large amount of triglycerides. IDLs are fragments of VLDLs after the triglycerides are removed and can be recycled to form VLDLs or converted to LDLs.
A nursing instructor is explaining the role of vascular smooth muscle cells in relation to increases in systemic circulation. During discussion, which neurotransmitter is primarily responsible for contraction of the entire muscle cell layer, thus resulting in decreased vessel lumen radius?
Norepinephrine Explanation: Nerve cells and circulating hormones are responsible for vasoconstriction of the vessel walls. Because they do not enter the tunica media of the blood vessel, the nerves do not synapse directly on the smooth muscle cells. Instead, they release the neurotransmitter norepinephrine, which diffuses into the media and acts on the nearby smooth muscle cells; this results in contraction of the entire muscle cell layer and thus reduces the radius of the vessel lumen. This increases the systemic circulation.
Which lipoprotein is the main carrier of cholesterol?
Low-density lipoprotein (LDL) Although all of the lipoproteins contain cholesterol and triglycerides, LDL is the main carrier of cholesterol.
A client has just been diagnosed with hypercholesterolemia and is asking what treatment will be needed. About which topics should the nurse educate the client? Select all that apply.
Smoking cessation Dietary measures to reduce LDL levels Weight reduction if overweight The management of hypercholesterolemia focuses on dietary and therapeutic lifestyle changes; when these are unsuccessful, pharmacologic treatment may be necessary. Therapeutic lifestyle changes include an increased emphasis on physical activity, dietary measures to reduce LDL levels, smoking cessation, and weight reduction for people who are overweight. Increased intake of fats and sodium would cause weight gain and hypertension and result in a negative consequence.
Which serum biomarker is highly specific for myocardial tissue?
Troponin The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.
Which serum biomarker is highly specific for myocardial tissue?
Troponin Explanation: The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.
A client is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as:
Valvular regurgitation Explanation: When cardiac valves such as the aortic or mitral fail to close properly, blood does not efficiently exit from the left ventricle. This condition is valvular regurgitation. Valvular stenosis is a narrowing of the lumen of the valve. Pericardial effusion, an accumulation of fluid in the pericardial sac, causes obstructive shock, as it impedes ventricular filling. Infective endocarditis could trigger septic shock.
Which type of blood vessel cells in the tunica media layer produce vasoconstriction and/or dilation of blood vessels?
Vascular smooth muscle cells (SMCs) Explanation: Vascular SMCs, which form the predominant cellular layer in the tunica media, produce vasoconstriction and/or dilation of blood vessels.
A nurse is teaching a client with newly diagnosed dilated cardiomyopathy (DCM) about associated treatments. The nurse determines that the knowledge is understood when the client correctly matches which drug category to the primary action of decreasing preload by suppressing renal reabsorption of sodium and increasing salt and water excretion?
diuretics The treatment of DCM is directed toward relieving the symptoms of heart failure and reducing the work of the heart. Diuretics, such as the thiazides, loop diuretics, and the aldosterone antagonist (potassium-sparing) diuretics, lower blood pressure initially by decreasing vascular volume (by suppressing renal reabsorption of sodium and increasing salt and water excretion), thereby decreasing preload and cardiac output. Although ACE inhibitors also lower the reabsorption of sodium and water by reducing the amount of circulating levels of aldosterone (through reducing the conversion of angiotensin 1 to angiotension 2), they also prevent vasoconstriction, so the effects on sodium and water retention is not this class of drug's only or primary effect. Calcium channel blockers prevent vasoconstriction as thier primary mechanism of actions, and beta-blockers primarily reduce cardiac output by reducing heart rate and contractility.
Cardiac tamponade and pericardial effusion can be life-threatening when the pericardial sac _______ and ______ the heart.
fills rapidly; compresses Explanation: Rapid accumulation of effusion fluid or blood in the pericardial sac causes cardiac tamponade, resulting in compression of the heart. This leads to cardiac standstill or failure. Pericardial sac thickening due to inflammation can restrict the heart, rather than allow stretching. Rupture of the sac is pathologic, resulting in heart expansion. A friction rub sound (rubbing between the inflamed pericardial surfaces) is characteristic of acute pericarditis. Constrictive pericarditis causes scar tissue formation that contracts and interferes with filling.
The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be:
improving quality of life by relieving symptoms. A primary treatment goal for a client with CHF is to improve the quality of life through symptom management. CHF will not be cured, and maintaining a higher oxygen level will assist with dyspnea associated with CHF. A stent is not an option for treatment of CHF.
The physician's order states, "Calculate the pulse pressure of the client's B/P." The blood pressure reading is as follows: systolic pressure of 146 mm Hg and a diastolic pressure of 82 mm Hg. The pulse pressure would be:
64 mm Hg The difference between the systolic and diastolic pressure is called the pulse pressure (approximately 40 mm Hg). The pulse pressure is calculated by deducting the diastolic pressure (82) from the systolic pressure (146). The difference is the pulse pressure.
The nurse is providing education for a client diagnosed with essential hypertension. The nurse will state that the cause of this disorder is:
Unknown Essential or primary hypertension has no identifiable cause, although there are many risk factors. The other options are causes of secondary hypertension, for which a cause can be identified and often treated.
Coronary artery bypass grafting (CABG) is a treatment modality for which disorder of cardiac function?
Atherosclerosis and unstable angina Coronary artery bypass grafting (CABG) may be the treatment of choice for people with significant coronary artery disease (CAD) who do not respond to medical treatment and who are not suitable candidates for percutaneous coronary intervention. CABG does not address valve disorders, pericardial effusion, or cardiomyopathies.
Which lipid results on four clients will the nurse recognize as having the greatest risk for cardiovascular disease?
LDL cholesterol 205 mg/dL (5.31 mmol/L), HDL 40 mg/dL (1.04 mmol/L), and triglyceride level 150 mg/dL (1.69 mmol/L) Diagnosis of hyperlipidemia depends on a person's complete lipid profile (total cholesterol, LDL, HDL, and triglyceride levels) after an overnight fast. One person may have a favorable lipid profile with a HDL of 110 mg/dL, a triglyceride level of 175 mg/dL, and an LDL of 130 mg/dL, whereas another person with a HDL of 40 mg/dL, a triglyceride level of 150 mg/dL, and LDL cholesterol of 205 mg/dL would be at much greater risk for cardiovascular disease.
