Chapter 36: Cardiomyopathy & Valvular Heart Disease Evolve Practice Questions

5. What describes the SA node's ability to discharge an electrical impulse spontaneously? a. Excitability b. Contractility c. Conductivity d. Automaticity

✅d. Automaticity describes the ability to discharge an electrical impulse spontaneously. Excitability is a property of myocardial tissue that enables it to be depolarized by an impulse. Contractility is the ability of the chambers to respond mechanically to an impulse. Conductivity is the ability to transmit an impulse along a membrane.

13. Locate the following points or locations that are inspected and palpated on the chest wall. Angle of Louis Aortic area Erb's point Mitral area (apex) and point of maximal impulse (PMI) Pulmonic area

✔Correct Answers a. Angle of Louis; b. Aortic area; c. Mitral area (apex) and point of maximal impulse (PMI); d. Tricuspid area; e. Erb's point; f. Pulmonic area

3. A patient uses a mixed β-adrenergic blocking drug for treatment of migraine headaches. What effect may this drug have on BP and why?

✔Correct Answers 3. The drug will lower BP because of decreased stroke volume and decreased HR, both of which decrease CO.

6. What early manifestation(s) is the patient with primary hypertension likely to report? a. No symptoms b. Cardiac palpitations c. Dyspnea on exertion d. Dizziness and vertigo

✅ a. Hypertension is often asymptomatic, especially if it is mild or moderate, and has been called the silent killer. The absence of symptoms often leads to noncompliance with medical treatment and a lack of concern about the disease in patients. With severe hypertension, symptoms may include fatigue, palpitations, angina, dyspnea, and dizziness.

3. Which arteries are the major providers of coronary circulation (select all that apply)? a. Left marginal artery b. Right marginal artery c. Left circumflex artery d. Right coronary artery e. Posterior descending artery f. Left anterior descending artery

✔Correct Answers. c, d, f. The left circumflex and left anterior descending arteries branch from the left coronary artery. The left coronary artery and right coronary artery arise from the aorta to supply the atria, ventricles, and interventricular septum.

A 72-yr-old man with a history of aortic stenosis is admitted to the emergency department. He reports severe left-sided chest pressure radiating to the jaw. Which medication, if ordered by the health care provider, should the nurse question? A. Aspirin B. Oxygen C. Nitroglycerin D. Morphine sulfate

ANS: C Aspirin, oxygen, nitroglycerin, and morphine sulfate are all used to treat acute chest pain suspected to be caused by myocardial ischemia. However, nitroglycerin should be used cautiously or avoided in patients with aortic stenosis as a significant reduction in blood pressure may occur. Chest pain can worsen because of a decrease in blood pressure.

13. Dietary teaching that includes eating dietary sources of potassium is indicated for the hypertensive patient taking which drug? a. Enalapril b. Labetalol c. Spironolactone d. Hydrochlorothiazide

✅ d. Hydrochlorothiazide is a thiazide diuretic that causes sodium and potassium loss through the kidneys. High-potassium foods should be included in the diet, or potassium supplements may be used to prevent hypokalemia. Enalapril and spironolactone may cause hyperkalemia by inhibiting the action of aldosterone, and potassium supplements should not be used by patients taking these drugs. As a combined α/β-blocker, labetalol does not affect potassium levels

4. The ECG pattern of a patient with a regular HR reveals 20 small squares between each R-R interval. What is the patient's HR? _______bpm

✅. 1500 ÷ 20 = 75 bpm

9. Identify the significance of the following laboratory study results when found in patients with hypertension. List Significance of each Laboratory Studies Blood urea nitrogen: 48 mg/dL (17.1 mmol/L) Creatinine norm 0.6-1.: 4.3 mg/dL (380 mmol/L) Serum K+: 3.1 mEq/L (3.1 mmol/L) Serum uric acid: 9.2 mg/dL (547 mmol/L) Fasting blood glucose: 183 mg/dL (10.2 mmol/L) Low-density lipoproteins norm 70: 154 mg/dL (4.0 mmol/L)

(BUN) Elevated BUN and creatinine may indicate destruction of glomeruli and tubules of the kidney resulting from hypertension. k+ Serum potassium levels are decreased when hypertension is associated with hyperaldosteronism Uric acid mg/dL (547 mmol/L) An increased uric acid level may be caused by diuretics used to treat hypertension. Glucose Fasting glucose levels are elevated when hypertension is associated with glucose intolerance and insulin resistance. LDL/HDL An elevated LDL level indicates an increased risk for atherosclerotic changes in the patient with hypertension.

14. Indicate whether the following are characteristic of the first heart sound (S1) or the second heart sound (S2). _______ a. Soft lub sound _______ b. Sharp dub sound _______ c. Indicates beginning of systole _______ d. Indicates the onset of diastole _______ e. Loudest at pulmonic and aortic areas _______ f. Loudest at tricuspid and mitral areas

14. a. —->S1; b. —>S2; c. —S1; d. —->S2; e. —->S2; f. —->S1

What should the nurse teach the patient who has had a valve replacement with a biologic valve? A. Long-term anticoagulation therapy B. Antibiotic prophylaxis for dental care C. Exercise plan to increase cardiac tolerance D. β-Adrenergic blockers to control palpitations

ANS: B The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Long-term anticoagulation therapy is not used with biologic valve replacement unless the patient has atrial fibrillation. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? A. Regurgitant murmur at the mitral valve area B. Point of maximal impulse palpable in fourth intercostal space C. Heart rate of 94 beats/min and capillary refill time of 2 seconds D. Respiratory rate of 18 breaths/min and heart rate of 90 beats/min

ANS: A A regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits.

While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? A. Pulsus paradoxus B. Prolonged PR intervals C. Widened pulse pressure D. Clubbing of the fingers

ANS: A Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus greater than 10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis. Prolonged PR intervals occur with first-degree AV block. Widened pulse pressure occurs with valvular heart disease and increased intracranial pressure. Clubbing of fingers may occur in subacute forms of infective endocarditis and valvular heart disease.

The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include? A. Prompt recognition and treatment of streptococcal pharyngitis B. Avoiding respiratory infections in children born with heart defects C. Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis D. Requesting antibiotics before dental surgery for individuals with rheumatoid arthritis

ANS: A The nurse should emphasize the need for prompt and adequate treatment of streptococcal pharyngitis infection, which can lead to the complication of rheumatic fever.

A patient who has myocarditis now has fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What should collaborative care accomplish to improve cardiac output and quality of life? A. Decrease preload and afterload. B. Relieve left ventricular outflow obstruction. C. Improve diastolic filling and the underlying disease process. D. Improve ventricular filling by reducing ventricular contractility.

ANS: A The patient has developed dilated cardiomyopathy. To improve cardiac output and quality of life, drug, nutrition, and cardiac rehabilitation will be focused on controlling heart failure by decreasing preload and afterload. Relief of left ventricular outflow obstruction and improving ventricular filling by reducing ventricular contractility is done for hypertrophic cardiomyopathy. There are no specific treatments for restrictive cardiomyopathy, but interventions are aimed at improving diastolic filling and the underlying disease process.

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations? (Select all that apply.) A. Osler's nodes B. Janeway's lesions C. Splinter hemorrhages D. Subcutaneous nodules E. Erythema marginatum lesions

ANS: A, B, C Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.

The nurse provides discharge instructions for a 40-yr-old woman newly diagnosed with cardiomyopathy. Which statement indicates that further teaching is necessary? A. "I will avoid lifting heavy objects." B. "I can drink alcohol in moderation." C. "My family will need to take a CPR course." D. "I will reduce stress by learning guided imagery."

ANS: B Patients with cardiomyopathy should avoid alcohol consumption, especially in patients with alcohol-related dilated cardiomyopathy. Avoiding heavy lifting and stress, as well as family members learning CPR, are recommended teaching points.

A 25-yr-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. How should the nurse respond? A. "You will not feel well if you do not take the medicine and get over this infection." B. "Once you have been treated for a group A streptococcal infection, you will not get it again." C. "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." D. "You may not want to take the antibiotics for this infection, but you will be sorry if you do not."

ANS: C Rheumatic fever (RF) is not common because of effective use of antibiotics to treat streptococcal infections. Without treatment, RF can occur and lead to rheumatic heart disease, especially in young adults. Saying that the patient will not feel well or that the patient will be sorry if the antibiotics are not taken is threatening to the patient and inappropriate for the nurse to say. Patients may have reoccurring infection of group A streptococcus.

Which patients are most at risk for developing endocarditis? (Select all that apply.) A. Older woman with histoplasmosis B. Man with reports of chest pain and dyspnea C. Man who is homeless with history of IV drug use D. Patient with end-stage renal disease on peritoneal dialysis E. Adolescent with exertional palpitations and clubbing of fingers F. Female with peripheral intravenous site for medication administration

ANS: C, D Intravenous drug use, especially if reusing or sharing needles are at risk of developing sepsis. In addition, risk for infection is increased in the elderly, homeless, and those with chronic illness. Peritoneal dialysis requires strict sterile technique to prevent peritonitis. Chest pain, shortness of breath, and palpitations may be signs of endocarditis. Clubbing of the fingers indicates long-term hypoxia. Central venous catheters, not peripheral, increase risk to for infective endocarditis. Patients with fungal infections, such as histoplasmosis and candida, are at risk for pericarditis.

A 55-yr-old female patient develops acute pericarditis after a myocardial infarction. Which assessment finding indicates a possible complication? A. Presence of a pericardial friction rub B. Distant and muffled apical heart sounds C. Increased chest pain with deep breathing D. Decreased blood pressure with tachycardia

ANS: D Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms include narrowed pulse pressure, tachypnea, tachycardia, a decreased cardiac output, and decreased blood pressure. The other symptoms are consistent with acute pericarditis.

On admission to the emergency department, a patient with cardiomyopathy has an ejection fraction of 10%. On assessment, the nurse notes bilateral crackles and shortness of breath. Which additional assessment finding would most indicate patient decline? A. Increased heart rate B. Increased blood pressure C. Decreased respiratory rate D. Decreased level of consciousness

ANS: D Decreased level of consciousness indicates a lack of perfusion, hypoxia, or both. A patient with an ejection fraction of 10% indicates very low cardiac output. Bilateral crackles and shortness of breath are consistent with decompensating heart failure. The nurse would expect an increase in heart rate, blood pressure, and respiratory rate in response to the low ejection fraction. When blood pressure drops, the nurse would be aware of potential shock.

The patient with pericarditis is reporting chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? A. Corticosteroids B. Morphine sulfate C. Proton pump inhibitor D. Nonsteroidal antiinflammatory drugs

ANS: D Nonsteroidal antiinflammatory drugs (NSAIDs) control pain and inflammation. Corticosteroids are reserved for patients already taking corticosteroids for autoimmune conditions and those who do not respond to NSAIDs. Morphine is not necessary. Proton pump inhibitors are used to decrease stomach acid to avoid the risk of gastrointestinal bleeding from the NSAIDs.

The nurse is caring for a patient who received a mechanical aortic valve replacement 2 years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/µL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? A. Assess the vital signs. B. Start intravenous fluids. C. Monitor for signs of bleeding. D. Contact the health care provider.

ANS: D Patients with mechanical valve replacement are placed on anticoagulants and should be in a therapeutic INR range of 2.5 to 3.5. Administration of Coumadin (Warfarin) prolongs clotting time and prevents clot formation on the valve. The low INR would require a call to the health care provider for an order increase the medication dose. Vital signs would be unchanged related to the low INR. Intravenous fluids are not indicated. The patient is at risk of forming clots, not bleeding.

An 80-yr-old patient with uncontrolled type 1 diabetes is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? A. Aortic valve replacement B. Have a pacemaker inserted C. Open commissurotomy (valvulotomy) procedure D. Percutaneous transluminal balloon valvuloplasty (PTBV) procedure

ANS: D The PTBV procedure is best for this older adult patient who is a poor surgery candidate related to the uncontrolled type 1 diabetes. Aortic valve replacement would probably not be tolerated well by this patient, although it may be done if the PTBV fails and the diabetes is controlled in the future. Open commissurotomy procedure is used for mitral stenosis. The patient is not a candidate for a pacemaker.

Which of the following medications are used for the initial treatment of a client with acute ST-segment elevation myocardial infarction (select all that apply)? A. Statin B. Nitroglycerin C. Morphine D. Loop diuretic E. Oxycodone

Correct Answers: B. Nitroglycerin C. Morphine Initial treatment measure in acute ST-elevation MI (STEMI) include the following, which can be remembered by the mnemonic "MONA": • M - morphine • O - oxygen • N - nitroglycerin • A - aspirin The ultimate goal of treatment is to relieve the arterial blockage and restore perfusion to the heart, preventing loss of heart muscle. This can be achieved by use of a thrombolytic drug, such as TPA, or by coronary angioplasty in the cardiac catheterization laboratory. Nursing interventions include obtaining a 12-lead EKG and placing the client on a continuous bedside cardiac monitor; administration of oxygen by nasal cannula as prescribed; establishing IV access and administering IV medications; monitoring the respiratory system; assisting the client to maintain strict bed rest; collecting blood specimens to send for evaluation of cardiac isoenzymes; and administration of morphine, aspirin, and nitroglycerin. Other medications used in the treatment of clients with STEMI include heparin, clopidogrel for clients who cannot take aspirin, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), beta blockers, calcium channel blockers, and statins. Incorrect Answers: A. Statins should be initiated within 24 hours of admission. D. Loop diuretics are used in the treatment of congestive heart failure, not STEMI. E. Morphine is used in myocardial infarction, not oxycodone. Morphine is an analgesic and vasodilator. If morphine can not be used, then fentanyl is used. Vital Concept: The goal of care when a client presents with acute myocardial infarction, particularly STEMI, is relief of the obstruction in the coronary artery, to prevent loss of heart muscle. Initial care of a client with acute myocardial infarction includes administration of oxygen, aspirin, nitroglycerin, and morphine.

A nurse is preparing to give furosemide (Lasix) to a client with heart failure. The nurse knows that it causes which of the following side effects? (Select all that apply.) A. Dry mouth B. Hearing loss C. Weight gain D. Migraine headaches E. Hypercalcemia

Correct Answers: A. Dry mouth B. Hearing loss Furosemide is a diuretic medication given to eliminate excess fluid when it accumulates in the body due to health conditions that include heart failure and ascites. Lasix can cause changes in electrolyte levels, particularly when it is taken incorrectly, so the nurse should assess for signs such as dry mouth, numbness and tingling of the extremities, fainting, or jaundice. Vital Concept: Furosemide is a loop diuretic. It blocks reabsorption of sodium and water in the kidney. Side effects include dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis. hemolytic anemia, leukopenia, thrombocytopenia, muscle cramps, paresthesia, and tinnitus/hearing loss. GI side effects include anorexia, constipation, diarrhea, dry mouth, dyspepsia, elevated liver enzymes, nausea, vomiting and pancreatitis.

A nurse is caring for a 16-year-old client with congestive heart failure (CHF) due to valvular defect. Bumex (bumetanide) is prescribed. Baseline vital signs are assessed prior to the administration. The nurse should perform which of the following assessments to monitor for side effects or negative effects during treatment of this client? (Select all that apply.) A. Record output after 4 hours B. Monitor for postural hypotension C. Observe for ototoxicity D. Observe for hypertension E. Observe for loss of consciousness

Correct Answers: B. Monitor for postural hypotension C. Observe for ototoxicity Bumex (bumetanide) is a loop diuretic that blocks the reabsorption of sodium and water in the tubules of the kidneys. It is usually prescribed for clients with CHF to reduce the amount of excessive fluid in the body. It is more potent than furosemide (Lasix) in its diuretic effect. The common side effects of Bumex include hypokalemia, postural hypotension, ototoxicity, nephrotoxicity, headache, and loss of appetite. Incorrect Answers: A. Urine output should be recorded beginning as soon as the drug is given. D. Hypertension is not a side effect of bumetanide. The nurse will monitor for hypotension. E. Loss of consciousness is not a side effect of bumetanide. Vital Concept: Bumetanide is used to treat edema due to heart failure, hepatic disease, or renal impairment. Postural hypotension, ototoxicity, and renal toxicity are some of the side effects from taking this drug, and should be monitored and observed by the nurse. Other side effects include Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and photosensitivity; pruritis, rash; hyperglycemia, hyperuricemia; dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, and metabolic alkalosi

6. Which serum lipid elevation, along with high LDL, is strongly associated with CAD? a. Apolipoproteins b. Fasting triglycerides c. Total serum cholesterol d. High-density lipoprotein (HDL)

✅ b. High fasting triglyceride levels are associated with cardiovascular disease and diabetes. Apolipoproteins are found in varying amounts on the HDLs and activate enzyme or receptor sites that promote removal of fat from plasma, which is protective. The apolipoprotein A and apolipoprotein B ratio must be done to predict CAD. High total serum cholesterol must be calculated with HDL for a ratio over time to determine an increased risk of CAD. High HDLs are associated with a lower risk of CAD.

9. What should the nurse reading the monitor strip call a rhythm with a regular PR interval but a blocked QRS complex? a. Asystole b. Atrial fibrillation c. First-degree AV block d. Type II second-degree AV block

✅ d. In type II second-degree AV block, a P wave is nonconducted without progressive PR interval lengthening. It is usually from a block in a bundle branch, occurs in a ratio of 2 P waves-to-1 QRS complex, 3:1, and so on. Asystole is absence of ventricular activity. Atrial fibrillation has a chaotic P wave. First-degree AV block is a prolonged AV conduction time, so the PR interval is prolonged.

A nurse is caring for a client who has gout. Which of the following findings should the nurse identify as risk factors for this disease? (Select all that apply.) A. Diuretic use B. Obesity C. Deep sleep deprivation D. Episodes of depression E. Cardiovascular disease

The use of diuretics is a risk factor for gout. Obesity is a risk factor for gout. Cardiovascular disease is a risk factor for gout. Incorrect Answers: C. Deep sleep deprivation is a manifestation of fibromyalgia and is not a risk factor for gout. D. Depression is a manifestation of systemic lupus erythematosus (SLE) and is not a risk factor for gout. Vital Concept: Gout, or hyper uricemia, is a systemic disorder that causes inflammation arthritis in joints and other body tissues. The nurse should recognize that precipitating risk factors include obesity, use of diuretics or chemotherapy, and cardiovascular diseases.

10. A 42-year-old man has been diagnosed with primary hypertension with an average BP of 162/92 mm Hg on 3 consecutive clinic visits. What are 4 priority lifestyle modifications that should be explored in the initial treatment of the patient? i. ii. iii. iv.

a. Dietary modifications to increase fruits, vegetables, fat-free milk, whole grains, fish, poultry, beans, seeds, and nuts; and restrict sodium, cholesterol, and saturated fat; maintain intake of potassium, calcium, vitamin D, and omega-3 fatty acids; and promote weight reduction if overweight b. Daily moderate-intensity physical activity for at least 30 minutes on most days of the week c. Cessation of tobacco use (if a user) d. Moderation or cessation of alcohol intake Usually medications, monitoring BP at home, and psychosocial risk factors must also be addressed.

8. The nurse plans close monitoring for the patient during electrophysiologic study (EPS) because this study a. requires the use of dyes that irritate the myocardium. b. causes myocardial ischemia, resulting in dysrhythmias. c. involves the use of anticoagulants to prevent thrombus and embolism. d. induces dysrhythmias that may require cardioversion or defibrillation to correct.

✅ d. (EPS) involves electrical stimulation to various areas of the atrium and ventricle to determine the inducibility of dysrhythmias and often induces ventricular tachycardia or ventricular fibrillation. The patient may have "near-death" experiences and requires emotional support if this occurs. Dye and anticoagulants are used for coronary angiograms.

3. A patient with a regular heart rate (HR) has 4 QRS complexes between every 3-second marker on the ECG paper. Calculate the patient's HR. _______bpm

✅ 4 (beats per 3 seconds) + 4 = 8 beats per 6 seconds × 10 = 80 bpm

9. During a routine health examination, a 48-year-old patient is found to have a total cholesterol level of 224 mg/dL (5.8 mmol/L) and an LDL level of 140 mg/dL (3.6 mmol/L). What does the nurse teach the patient based on the Therapeutic Lifestyle Changes diet (select all that apply)? a. Use fat-free milk. b. Abstain from alcohol use. c. Reduce red meat in the diet. d. Eliminate intake of simple sugars. e. Avoid foods prepared with egg yolks.

✅ a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize reduction in saturated fat and cholesterol intake. Whole milk products, red meats, and eggs as well as butter, stick margarine, lard, and solid shortening should be reduced or eliminated from diets. If triglyceride levels are high, alcohol and simple sugars should be reduced. 10. b. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD.

15. A patient with no history of heart disease has a rhythm strip that shows an occasional distorted P wave followed by normal AV and ventricular conduction. About what should the nurse question the patient? a. The use of caffeine b. The use of sedatives c. Any aerobic training d. Holding of breath during exertion

✅ a. A distorted P wave with normal conduction of the impulse through the ventricles is characteristic of a PAC. In a normal heart, this dysrhythmia is frequently associated with emotional stress or the use of caffeine, tobacco, or alcohol. Sedatives rarely slow the heart rate (HR). Aerobic conditioning and holding of breath during exertion (Valsalva maneuver) often cause bradycardia, but the P wave is not distorted.

16. A patient's rhythm strip indicates a normal HR and rhythm with normal P waves and QRS complexes, but the PR interval is 0.26 second. What is the most appropriate action by the nurse? a. Continue to assess the patient. b. Administer atropine per protocol. c. Prepare the patient for synchronized cardioversion. d. Prepare the patient for placement of a temporary pacemaker.

✅ a. A rhythm pattern that is normal except for a prolonged PR interval is characteristic of a first-degree heart block. First-degree heart blocks are not treated but are observed for progression to higher degrees of heart block. Atropine is administered for bradycardia. Synchronized cardioversion is used for atrial fibrillation with a rapid ventricular response or PSVT. Pacemakers are used for higher-degree heart blocks.

3. After obtaining patient histories, which patient does the nurse identify as having the highest risk for CAD? a. A white man, age 54 years, who is a smoker and has a stressful lifestyle b. A white woman, age 75 years, with a BP of 172/100 mm Hg and who is physically inactive c. An Asian woman, age 45 years, with a cholesterol level of 240 mg/dL and a BP of 130/74 mm Hg d. An obese Hispanic man, age 65 years, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm Hg

✅ b. This white woman has 1 unmodifiable risk factor (age) and 2 major modifiable risk factors (hypertension and physical inactivity). Her gender risk is as high as a man's because she is 75 years of age. The white man has 1 unmodifiable risk factor (gender), 1 major modifiable risk factor (smoking), and 1 contributing modifiable risk factor (stressful lifestyle). The Asian woman has only 1 major modifiable risk factor (hyperlipidemia), and Asians in the United States have fewer myocardial infarctions (MIs) than do whites. The Hispanic man has an unmodifiable risk factor related to age and 1 major modifiable risk factor (obesity). Hispanics have slightly lower rates of CAD than non-Hispanic whites or blacks.

7. What causes most organ damage in hypertension? a. Increased fluid pressure exerted against organ tissue b. Atherosclerotic changes in vessels that supply the organs c. Erosion and thinning of blood vessels in organs from constant pressure d. Increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces

✅ b. Elevated BP causes endothelial damage, which causes the inner lining of arterioles to become thickened and stiffened and affects coronary circulation, cerebral circulation, peripheral vessels, and renal and retinal blood vessels. The narrowed vessels lead to ischemia and ultimately to damage of these organs.

19. Collaboration: The unit is very busy and short staffed. What could the RN delegate to the unlicensed assistive personnel (UAP)? a. Administer antihypertensive medications to stable patients. b. Obtain orthostatic BP readings for older patients. c. Check BP readings for the patient receiving IV sodium nitroprusside. d. Teach about home BP monitoring and use of automatic BP monitoring equipment.

✅ b. The UAP may check postural changes in BP as directed. The LPN may administer antihypertensive medications to stable patients. The RN must monitor the patient receiving IV sodium nitroprusside, as the patient is in a hypertensive crisis. The RN must also do the teaching related to home BP monitoring.

8. The patient who is being admitted has had a history of uncontrolled hypertension. High SVR is most likely to cause damage to which organ? a. Brain b. Heart c. Retina d. Kidney

✅ b. The increased systemic vascular resistance (SVR) of hypertension directly increases the workload of the heart, and heart failure occurs when the heart can no longer pump effectively against the increased resistance. The heart may be indirectly damaged by atherosclerotic changes in the blood vessels, as are the brain, retina, and kidney.

25. The use of radiofrequency catheter ablation therapy to "burn" areas of the cardiac conduction system is indicated for the treatment of? a. sinus arrest. b. heart blocks. c. tachydysrhythmias. d. premature ventricular beats.

✅ c. Catheter ablation therapy uses radiofrequency energy to ablate or "burn" accessory pathways or ectopic sites in the atria, AV node, or ventricles that cause tachydysrhythmias. It is not used for sinus arrest, heart blocks, or premature ventricular beats.

20. In the patient experiencing ventricular fibrillation (VF), what is the rationale for using defibrillation? a. Enhance repolarization and relaxation of ventricular myocardial cells b. Provide an electrical impulse that stimulates normal myocardial contractions c. Depolarize the cells of the myocardium to allow the SA node to resume pacemaker function d. Deliver an electrical impulse to the heart at the time of ventricular contraction to convert the heart to a sinus rhythm

✅ c. The intent of defibrillation is to apply an electrical current to the heart that will depolarize the cells of the myocardium so that subsequent repolarization of the cells will allow the SA node to resume the role of pacemaker. An artificial pacemaker provides an electrical impulse that stimulates normal myocardial contractions. Synchronized cardioversion involves delivery of a shock that is programmed to occur during the QRS complex of the ECG, but this cannot be done during ventricular fibrillation because there is no normal ventricular contraction or QRS complex.

15. A 38-year-old man is treated for hypertension with triamterene and hydrochlorothiazide and metoprolol (Lopressor). Four months after his last clinic visit, his BP returns to pretreatment levels, and he admits he has not been taking his medication regularly. What is the nurse's best response to this patient? a. "Try always to take your medication when you carry out another daily routine so that you do not forget to take it." b. "You probably would not need to take medications for hypertension if you would exercise more and stop smoking." c. "The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems in this area?" d. "You need to remember that hypertension can be only controlled with medication, not cured, and you must always take your medication."

✅ c. Sexual dysfunction, which can occur with many of the antihypertensive drugs, including thiazide and potassium-sparing diuretics and β-adrenergic blockers, can be a major reason that a male patient does not adhere to his treatment regimen. It is helpful for the nurse to raise the subject because sexual problems may be easier for the patient to discuss and handle once it has been explained that the drug may be the source of the problem.

2. What accurately describes the PR interval (select all that apply)? a. 0.16 seconds b. < 0.12 seconds c. 0.06 to 0.12 seconds d. 0.12 to 0.20 seconds e. Time of depolarization and repolarization of ventricles f. Measured from beginning of P wave to beginning of QRS complex

✅ d, f. The expected PR interval is 0.12 to 0.20 seconds and is measured from the beginning of the P wave to the beginning of the QRS complex. The T wave is 0.16 seconds, the QRS interval is < 0.12 seconds, the P wave is 0.06 to 0.12 seconds, and the QT interval is the time of depolarization and repolarization of the ventricles.

14. A patient with an acute MI has sinus tachycardia of 126 bpm. The nurse recognizes that if this dysrhythmia is not treated, what is the worst thing the patient is likely to experience? a. Hypertension b. Escape rhythms c. Ventricular tachycardia d. An increase in infarct size

✅ d. Although many factors can cause a sinus tachycardia, in the patient who has had an acute myocardial infarction (MI), tachycardia increases myocardial oxygen need in a heart that already has impaired circulation and may lead to increasing angina and further ischemia and necrosis.

21. What action is included in the nurse's responsibilities in preparing to administer defibrillation? a. Applying gel pads to the patient's chest b. Setting the defibrillator to deliver 50 joules c. Setting the defibrillator to a synchronized mode d. Sedating the patient with midazolam before defibrillation

✅. a. In preparation for defibrillation the nurse should apply conductive materials (e.g., saline pads, electrode gel, defibrillator gel pads) to the patient's chest to decrease electrical impedance and prevent burns. For defibrillation, the initial shock is 120 to 200 joules with biphasic defibrillators, 360 joules with monophasic, and the synchronizer switch used for cardioversion must be turned off. Be sure all staff are clear of the patient and bed before defibrillating. Sedatives may be used before cardioversion if the patient is conscious, but the patient in ventricular fibrillation is unconscious.

24: A patient on the telemetry unit goes into VF and is unresponsive. Following initiation of the emergency call system (Code Blue), what is the next priority for the nurse in caring for this patient? a. Begin CPR. b. Get the crash cart. c. Administer amiodarone IV. d. Defibrillate with 360 joules

✅. a. Until the defibrillator is available, the patient needs CPR. Defibrillation is needed as soon as possible, so someone should bring the crash cart to the room. Amiodarone is an antidysrhythmic that is part of the advanced cardiac life support (ACLS) protocol for ventricular fibrillation. Defibrillation would be with 360 joules for monophasic defibrillators and 120 to 200 joules for biphasic defibrillators.

22. While providing discharge instructions to the patient who has had an implantable cardioverter-defibrillator (ICD) inserted, the nurse teaches the patient that if the ICD fires, it is important that he or she should do what? a. Lie down. b. Call the cardiologist. c. Push the reset button on the pulse generator. d. Immediately take his or her antidysrhythmic medication.

✅. b. If the implanted cardioverter-defibrillator delivers a shock, the patient has experienced a lethal dysrhythmia and needs to notify the cardiologist. The patient will want to lie down to allow recovery from the dysrhythmia. In the event that the patient loses consciousness or there is repetitive firing, a call should be placed to the emergency response system (ERS) by anyone who finds the patient.

17. In the patient with a dysrhythmia, which assessment indicates decreased cardiac output (CO)? a. Hypertension and bradycardia b. Chest pain and decreased mentation c. Abdominal distention and hepatomegaly d. Bounding pulses and a ventricular heave

✅. b. Symptoms of decreased cardiac output (CO) related to dysrhythmias include a sudden drop in BP and symptoms of hypoxemia, such as decreased mentation, chest pain, and dyspnea. Peripheral pulses are weak and the HR may be increased or decreased, depending on the type of dysrhythmia present.

10. To which patients should the nurse teach the Therapeutic Lifestyle Changes diet to reduce the risk of CAD? a. Patients who have had an MI b. All patients to reduce CAD risk c. Those with 2 or more risk factors for CAD d. Those with a cholesterol level > 200 mg/dL (5.2 mmol/L)

✅. b. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD.

23. A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, what should the nurse include when teaching the patient? a. Avoid cooking with microwave ovens. b. Avoid standing near antitheft devices in doorways. c. Use mild analgesics to control the chest spasms caused by the pacing current. d. Start lifting the arm above the shoulder right away to prevent a "frozen shoulder."

✅. b. The patient should avoid standing near antitheft devices in doorways of department stores and libraries but walking through them at normal pace is fine. High-output electrical generators or large magnets, such as those used in MRI, can reprogram pacemakers and should be avoided unless the pacemaker is MRI safe. Microwave ovens pose no problems to pacemaker function, but the affected arm should not be raised above the shoulder until approved by cardiologist. The pacing current of an implanted pacemaker is not felt by the patient, but an external transcutaneous pacemaker may cause uncomfortable chest muscle contractions.

12. A patient with an acute myocardial infarction (MI) develops the following ECG pattern: atrial rate of 82 bpm and regular; ventricular rate of 46 bpm and regular; P wave and QRS complex are normal but there is no relationship between the P wave and the QRS complex. What dysrhythmia does the nurse identify this as and what treatment is expected? a. Sinus bradycardia treated with atropine b. Third-degree heart block treated with a pacemaker c. Atrial fibrillation treated with electrical cardioversion d. Type I second-degree AV block treated with observation

✅. b. Third-degree or complete heart block is recognized with the atrial and ventricular dissociation and treated with a pacemaker. Sinus bradycardia does not have atrial and ventricular dissociation. Atrial fibrillation does not have normal P waves, as they are stimulated by ectopic foci. In type I second-degree AV heart block, the PR interval gradually lengthens and a QRS complex is dropped. Then the cycle begins again.

14. Priority Decision: A patient with stage 2 hypertension who is taking chlorothiazide (Diuril) and lisinopril (Zestril) has prazosin (Minipress) added to the medication regimen. What is most important for the nurse to teach the patient to do? a. Weigh every morning to monitor for fluid retention. b. Change position slowly and avoid prolonged standing. c. Use sugarless gum or candy to help relieve dry mouth. d. Take the pulse daily to note any slowing of the heart rate.

✅. b. Chlorothiazide is a thiazide diuretic that causes orthostatic hypotension. Prazosin is an α-adrenergic blocker that causes dilation of arterioles and veins and causes orthostatic hypotension. The patient may feel dizzy, weak, and faint when assuming an upright position after sitting or lying down and should be taught to change positions slowly, avoid standing for long periods, do leg exercises to increase venous return, and lie or sit down when dizziness occurs. Direct-acting vasodilators often cause fluid retention; dry mouth may occur with diuretic use, and centrally acting α- and β-blockers may cause bradycardia.

18. : A patient with an acute MI is having multifocal PVCs and couplets. He is alert and has a BP reading of 118/78 mm Hg with an irregular pulse of 86 bpm. What is the priority nursing action at this time? a. Continue to assess the patient. b. Ask the patient to perform Valsalva maneuver. c. Prepare to administer antidysrhythmic drugs per protocol. d. Be prepared to administer cardiopulmonary resuscitation (CPR).

✅. c. Multifocal PVCs in a patient with an MI indicate significant ventricular irritability that may lead to ventricular tachycardia or ventricular fibrillation. Preparing to administer antidysrhythmics, such as β-adrenergic blockers, procainamide, amiodarone, or lidocaine, is the priority to control the dysrhythmias. Valsalva maneuver may be used to treat PSVT. The nurse must always be ready to perform cardiopulmonary resuscitation (CPR), but drugs may prevent this need.

26. A patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit for observation and diagnosis. While the patient has continuous ECG monitoring, what finding would most concern the nurse? a. Occasional PVCs b. QRS complex change c. ST segment elevation d. A PR interval of 0.18 second

✅. c. ST segment elevation indicates injury or infarction of an area of the heart. A widened QRS occurs with second-degree AV block, type II and antidysrhythmic drugs. Occasional PVCs may be normal or may be the result of electrolyte imbalance or hypoxia. They require continued observation. A PR interval of 0.18 second is within normal range.

11. Patient-Centered Care: A 62-year-old woman smokes a pack of cigarettes per day and has a BP 138/88 mm Hg. She has no symptoms of CAD, but a recent LDL level was 154 mg/dL (3.98 mmol/L). Based on these findings, the nurse would expect that which treatment plan would be used first for this patient? a. Diet and drug therapy b. Exercise instruction only c. Diet therapy and smoking cessation d. Drug therapy and smoking cessation

✅. c. Without the total serum cholesterol and HDL results, diet therapy and smoking cessation are indicated for this patient without CAD who has prehypertension and an LDL level ≥ 130 mg/dL. When the patient's LDL level is 75 to 189 mg/dL with a 10-year risk for cardiovascular disease (CVD) of 7.5% or above, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benefit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment.

5. A patient diagnosed with secondary hypertension asks why it is called secondary and not primary. What is the best explanation for the nurse to provide? a. Has a more gradual onset than primary hypertension b. Does not cause the target organ damage that occurs with primary hypertension c. Has a specific cause, such as renal disease, that often can be treated by medicine or surgery d. Is caused by age-related changes in BP regulatory mechanisms in people over 65 years of age

✅. c. Secondary hypertension has an underlying cause that will be treated, in contrast to primary or essential hypertension, which has no single known cause. Isolated systolic hypertension occurs when the systolic BP (SBP) is consistently equal to or over 130 mm Hg and the diastolic BP (DBP) is consistently equal to or over at 80 mm Hg.

27. A 54-year-old patient who has no structural heart disease has an episode of syncope. A head-up tilt-test is performed to rule out cardioneurogenic syncope. The nurse explains to the patient that if cardioneurogenic syncope is the problem, the patient will experience what? a. No change in HR or BP b. Palpitations and dizziness c. Tachydysrhythmias and chest pain d. Marked bradycardia and hypotension

✅. d. One of the most common causes of syncope is cardioneurogenic syncope, or "vasovagal" syncope. In this type of syncope, there is accentuated adrenergic activity in the upright position, with intense activation of cardiopulmonary receptors resulting in marked bradycardia and hypotension, cerebral hypoperfusion, and syncope. Normally testing with the head-up tilt-test causes activation of the renin-angiotensin- aldosterone system and compensation to increase CO and maintain BP when blood pools in the extremities.

10. After defibrillation, the advanced cardiac life support (ACLS) nurse says that the patient has pulseless electrical activity (PEA). What is most important for the nurse to understand about this rhythm? a. The HR is 40 to 60 bpm. b. Hypoxemia and hypervolemia are common with PEA. c. There is dissociated activity of the ventricle and atrium. d. There is electrical activity with no mechanical response.

✅. d. Pulseless electrical activity (PEA) occurs when there is electrical activity on the ECG but no mechanical activity on assessment and therefore no pulse. PEA is the most common dysrhythmia seen after defibrillation and may be caused by hypovolemia, hypoxia, metabolic acidosis, altered potassium level, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, and trauma. Dissociated atria and ventricles is a third-degree AV block.

28. The patient is brought to the emergency department with acute coronary syndrome (ACS). What changes should the nurse expect to see on the ECG if only myocardial injury has occurred? a. Absent P wave b. A wide QT interval c. Tall, peaked T wave d. ST-segment elevation

✅. d. ST segment elevation is seen in myocardial injury. An absent or buried P wave can occur with PVCs, ventricular tachycardia, or ventricular fibrillation. A wide pathologic QT interval affects repolarization and is caused by drugs and electrolyte imbalances. Tall, peaked T waves may be seen with electrolyte imbalance.

12. The patient asks the nurse about valsartan (Diovan), the new medication prescribed for blood pressure. What is the best explanation the nurse can use to explain the action of this medication? a. Prevents the conversion of angiotensin I to angiotensin II b. Acts directly on smooth muscle of arterioles to cause vasodilation c. Decreases extracellular fluid volume by increasing Na+ and Cl− excretion with water d. Vasodilation, prevents the action of angiotensin II, and promotes increased salt and water excretion

✅. d. Valsartan (Diovan) is an angiotensin II receptor blocker (ARB). ARBs prevent the action of angiotensin II, produce vasodilation, and increase salt and water excretion. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II. Direct vasodilators act directly on smooth muscle of arterioles to cause vasodilation. Thiazide diuretics decrease extracellular fluid volume by increasing Na+ and Cl− excretion with water.

16. A 78-year-old patient is admitted with a BP of 180/98 mm Hg. Which age-related physical changes may contribute to this patient's hypertension (select all that apply)? a. Decreased renal function b. Increased baroreceptor reflexes c. Increased peripheral vascular resistance d. Increased adrenergic receptor sensitivity e. Increased collagen and stiffness of the myocardium f. Loss of elasticity in large arteries from arteriosclerosis

✅a, c, e, f. The age-related changes that contribute to hypertension include decreased renal function, increased peripheral vascular resistance, increased collagen and stiffness of the myocardium, and decreased elasticity in large arteries from arteriosclerosis. The baroreceptor reflexes are blunted. The adrenergic receptor sensitivity and renin response are both decreased with aging.

17. What should the nurse emphasize when teaching a patient who is newly prescribed clonidine (Catapres)? a. The drug should never be stopped abruptly. b. The drug should be taken early in the day to prevent nocturia. c. The first dose should be taken when the patient is in bed for the night. d. Because aspirin will decrease the drug's effectiveness, Tylenol should be used instead

✅a. Centrally acting α-adrenergic blockers may cause severe rebound hypertension if the drugs are abruptly discontinued, and patients should be taught about this effect because many are not consistently compliant with drug therapy. Diuretics should be taken early in the day to prevent nocturia. The profound orthostatic hypotension that occurs with first-dose peripheral acting α-adrenergic blockers can be prevented by taking the initial dose at bedtime. Aspirin use may decrease the effectiveness of ACE inhibitors.

22. A patient has a BP of 222/148 mm Hg and confusion, nausea, and vomiting. Which goal should the nurse try to achieve by titrating medications? a. Decrease the mean arterial pressure (MAP) to 129 mm Hg b. Lower the BP to the patient's normal within the second to third hour c. Decrease the SBP to 160 mm Hg and the DBP to 100 mm Hg as quickly as possible d. Reduce the SBP to 158 mm Hg and the DBP to 90 mm Hg within the first 2 hours

✅a. Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure (MAP) by no more than 20% to 25% in the first hour, with further gradual reduction over the next 24 hours. In this case, the MAP is 222 + 2(148)/3 = 172, so decreasing it by 25% equals 129. Lowering the BP too far or too fast may cause a stroke, myocardial infarction (MI), or renal failure. Only when the patient has an aortic dissection, angina, or signs of an ischemic stroke does the SBP have to be lowered to 100 to 120 mm Hg or less as quickly as possible.

5. Which characteristics are associated with LDLs (select all that apply)? a. Increases with exercise b. Contains the most cholesterol c. Has an affinity for arterial walls d. Carries lipids away from arteries to liver e. High levels correlate most closely with CAD f. The higher the level, the lower the risk for CAD

✅b, c, e. LDLs contain more cholesterol than the other lipoproteins, have an attraction for arterial walls, and correlate most closely with increased incidence of atherosclerosis and CAD. HDLs increase with exercise and carry lipids away from arteries to the liver for metabolism. A high HDL level is associated with a lower risk of CAD.

13. Myocardial ischemia occurs because of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)? a. Hypovolemia or anemia b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension f. Sympathetic nervous system stimulation by drugs, emotions, or exertion

✅b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.

16. Which characteristics describe unstable angina (select all that apply)? a. Usually precipitated by exertion b. New-onset angina with minimal exertion c. Occurs only when the person is recumbent d. Characterized by increased duration or severity e. Usually occurs in response to coronary artery spasm

✅b, d. Unstable angina is new-onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity. Chronic stable angina is usually precipitated by exertion. Angina decubitus occurs when the person is recumbent. Prinzmetal's angina is often caused by a coronary artery spasm.

8. The nurse is encouraging a sedentary patient with major risks for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will directly contribute to reducing which risk factors? a. Diabetes and hypertension b. Hyperlipidemia and obesity c. Increased serum lipids and stressful lifestyle d. Hypertension and increased serum homocysteine

✅b. Increased exercise without an increase in caloric intake will result in weight loss, reducing the risk associated with obesity. Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk. Exercise may indirectly reduce the risk of CAD by controlling hypertension, promoting glucose metabolism in diabetes, and reducing stress. While high blood levels of homocysteine are linked to an increased risk for CAD, reducing homocysteine levels has not been shown to reduce the risk of heart disease.

6. What describes the refractory phase? a. Abnormal electrical impulses b. Period in which heart tissue cannot be stimulated c. Areas of the heart do not repolarize at the same rate because of depressed conduction d. Sodium migrates rapidly into the cell, so it is positive compared to the outside of the cell

✅b. Refractory phase is the period in which heart tissue cannot be stimulated. Ectopic foci produce abnormal electrical impulses. Reentrant excitation causing premature beats may occur when areas of the heart do not repolarize simultaneously with depressed conduction. Depolarization of cardiac cells occurs when sodium migrates rapidly into the cell.

7. The laboratory tests for 4 patients show the following results. Which patient should the nurse teach first about preventing CAD because the patient is at the greatest risk for CAD even without other risk factors? a. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL b. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL c. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL

✅d. All the results are abnormal. The patient in option "c" is close to being at risk; if this patient is a woman, the HDL is too low and the other results are at or near the cut off for being normal. The other patients' results are at acceptable levels.

2. What accurately describes the pathophysiology of CAD? a. Partial or total occlusion of the coronary artery occurs during the stage of raised fibrous plaque. b. Endothelial changes may be caused by chemical irritants, such as hyperlipidemia or by tobacco use. c. Collateral circulation in the coronary circulation is more likely to be present in the young patient with CAD. d. The leading theory of atherogenesis proposes that infection and fatty dietary intake are the basic underlying causes of atherosclerosis.

✅b. The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development and resulting atheromas is related to endothelial injury and inflammation, which can be the result of tobacco use, hyperlipidemia, hypertension, toxins, diabetes, high homocysteine levels, and infection causing a local inflammatory response in the inner lining of the vessel walls. Partial or total occlusion occurs in the complicated lesion stage. Extra collateral circulation occurs in the presence of chronic ischemia. Therefore it is more likely to occur in an older patient.

13. Which rhythm abnormality has an increased risk of ventricular tachycardia and ventricular fibrillation? a. PAC b. Premature ventricular contraction (PVC) on the T wave c. Accelerated idioventricular rhythm d. PVC couplet

✅b. When premature ventricular contraction (PVC) falls on the T wave of the preceding beat, R-on-T phenomenon occurs. Because the ventricle Is depolarizing and there is increased excitability of cardiac cells, there is an increased risk of ventricular tachycardia or ventricular fibrillation. The other options do not increase this risk.

12. What are manifestations of acute coronary syndrome (ACS) (select all that apply)? a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI)

✅c, d, e. Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS.

15. What types of angina can occur in the absence of CAD (select all that apply)? a. Silent ischemia b. Nocturnal angina c. Prinzmetal's angina d. Microvascular angina e. Chronic stable angina

✅c, d. Prinzmetal's angina and microvascular angina may occur in the absence of CAD but with arterial spasm in Prinzmetal's angina or abnormalities of the coronary microcirculation. Silent ischemia is prevalent in persons with diabetes and contributes to asymptomatic myocardial ischemia. Nocturnal angina occurs only at night. Chronic stable angina refers to chest pain that occurs with the same pattern of onset, duration, and intensity intermittently over a long period of time.

1. What accurately describes electrocardiographic (ECG) monitoring? a. Depolarization of the cells in the ventricles produces the T wave on the ECG. b. An abnormal cardiac impulse that arises in the atria, ventricles, or atrioventricular (AV) junction can create a premature beat that is known as "an artifact." c. Lead placement for V1 includes 1 lead each for right arm, right leg, left arm, and left leg with the fifth lead on the fourth intercostal space to the right of the sternal border. d. If the sinoatrial (SA) node fails to discharge an impulse or discharges very slowly, a secondary pacemaker in the AV node is able to discharge at a rate of 30 to 40 times per minute.

✅c. The V1 leads are placed toward each limb and centrally at the fourth intercostal space to the right of the sternal border. Depolarization of the ventricular cells produces the QRS interval on the electrocardiogram (ECG). The T wave is produced by repolarization of the ventricular cells. Abnormal cardiac impulses from the atria, ventricles, or atrioventricular (AV) junction create ectopic beats. Artifacts are seen with leads or electrodes that are not secure, with muscle activity or electrical interference. The rate produced by the AV node pacing in a junctional escape rhythm is 40 to 60 bpm. If the His-Purkinje system is blocked, the heart rate is 20 to 40 bpm.

11. The nurse is evaluating the telemetry ECG rhythm strip. How should the nurse document the distorted P wave causing an irregular rhythm? a. Atrial flutter b. Sinus bradycardia c. Premature atrial contraction (PAC) d. Paroxysmal supraventricular tachycardia (PSVT)

✅c. The premature atrial contraction (PAC) has a distorted P wave that may feel like a skipped beat to the patient. Atrial flutter is an atrial tachydysrhythmia with recurring, regular, saw-toothed flutter waves from the same focus in the right or possibly left atrium. Sinus bradycardia has a regular heart rate <100 bpm. Paroxysmal supraventricular tachycardia (PSVT) starts in an ectopic focus above the bundle of His and may be triggered by PAC. If seen, the P wave may have an abnormal shape and has a spontaneous start and termination with a rate of 150 to 220 bpm.

11. What is the primary BP effect of β-adrenergic blockers, such as atenolol (Tenormin)? a. Vasodilation of arterioles by blocking movement of calcium into cells b. Decrease Na+ and water reabsorption by blocking the effect of aldosterone c. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys d. Vasodilation caused by inhibiting sympathetic outflow from the central nervous system (CNS)

✅c. Cardioselective β-adrenergic blockers decrease CO, reduce sympathetic vasoconstrictor tone, and decrease renin secretion by kidneys. Calcium channel blockers reduce BP by causing blocked movement of calcium into cells, which causes vasodilation of arterioles. Spironolactone blocks the effect of aldosterone. Central adrenergic antagonists, such as clonidine (Catapres) inhibit sympathetic outflow from the central nervous system (CNS).

20. Which manifestation is an indication that a patient is having hypertensive emergency? a. Symptoms of a stroke with an elevated BP b. A systolic BP (SBP) > 180 mm Hg and a diastolic BP (DBP) > 110 mm Hg c. A sudden rise in BP accompanied by neurologic impairment d. A severe elevation of BP that occurs over several days or weeks

✅c. Hypertensive emergency, a type of hypertensive crisis, is a situation in which a patient's BP is severely elevated with evidence of acute target organ disease (e.g., cerebrovascular, cardiovascular, renal, or retinal). The neurologic manifestations are often similar to the presentation of a stroke but do not show the focal or lateralizing symptoms of stroke. Hypertensive crises are defined by the degree of organ damage and how rapidly the BP rises, not by specific BP measurements. A hypertensive urgency is a less severe crisis, in which a patient's BP becomes severely elevated over hours or days but there is no evidence of target organ damage.

4. : What should the nurse emphasize when teaching women about the risks and incidence of CAD? a. Smoking is not as significant a risk factor for CAD in women as it is in men. b. Women seek treatment sooner than do men when they have symptoms ofCAD. c. Estrogen replacement therapy in postmenopausal women decreases the risk for CAD. d. CAD is the leading cause of death in women, with a higher mortality rate after myocardial infarction (MI) than in men.

✅d. CAD is the number-one killer of American women, and women have a much higher mortality rate within 1 year following MI than do men. Smoking carries specific problems for women because smoking has been linked to a decrease in natural estrogen levels and to early menopause, and it has been identified as the most powerful contributor to CAD in women under the age of 50 years. Fewer women than men present with classic manifestations, and women delay seeking care longer than men. Estrogen replacement does not always reduce the risk for CAD, even though natural estrogen lowers low-density lipoprotein (LDL) and raises high-density lipoprotein (HDL) cholesterol.

7. The patient's PR interval comprises 6 small boxes on the ECG graph. What does the nurse determine that this indicates? a. A normal finding b. A problem with ventricular depolarization c. A disturbance in the repolarization of the atria d. A problem with conduction from the SA node to the ventricular cells

✅d. The normal PR interval is 0.12 to 0.20 seconds and reflects the time taken for the impulse to spread through the atria, AV node and bundle of His, the bundle branches, and Purkinje fibers. A PR interval of 6 small boxes is 0.24 second and indicates that the conduction of the impulse from the atria to the Purkinje fibers is delayed.

18. What is included in the correct technique for BP measurements? a. Always take the BP in both arms. b. Position the patient supine for all readings. c. Place the cuff loosely around the upper arm. d. Take readings at least 2 times at least 1 minute apart.

✅d. Correct technique in measuring BP includes taking and averaging 2 or more readings at least 1 minute apart. Initially BP measurements should be taken in both arms to detect any differences. If there is a difference, the arm with the higher reading should be used for all subsequent BP readings. The patient may be supine or sitting. The important points are that the arm being used is at the heart level and the cuff needs to fit snugly.

21. Which drugs are most commonly used to treat hypertensive crises? a. Labetalol and bumetanide (Bumex) b. Esmolol (Brevibloc) and captopril (Captopril) c. Enalaprilat (Vasotec) and minoxidil (Minoxidil) d. Fenoldopam (Corlopam) and sodium nitroprusside (Nitropress)

✅d. Hypertensive crises are treated with IV administration of antihypertensive drugs, including the vasodilators sodium nitroprusside, fenoldopam, and nicardipine; adrenergic blockers, such as labetalol, esmolol, and phentolamine; the ACE inhibitor enalaprilat; the calcium channel blocker clevidipine; nitroglycerin for myocardial ischemia; hydralazine with other medications; and oral captopril. Sodium nitroprusside is the most effective parenteral drug for hypertensive emergencies.

23. What does the nursing responsibility in the management of the patient with hypertensive urgency include? a. Monitoring hourly urine output for drug effectiveness b. Titrating IV drug dosages based on BP and HR measurements every 2 to 3 minutes c. Providing continuous electrocardiographic (ECG) monitoring to detect side effects of the drugs d. Instructing the patient to follow up with a health care provider within 24 hours after outpatient treatment

✅d. Hypertensive urgencies are often treated with oral drugs on an outpatient basis, but it is important for the patient to be seen by a HCP within 24 hours to evaluate the effectiveness of the treatment. Hourly urine measurements, titration of IV drugs, and Electrocardiogram (ECG) monitoring are indicated for hypertensive emergencies

A client with heart failure is scheduled for echocardiography. Which of the following compensatory mechanisms occur during heart failure as a result of decreased cardiac output? (Select all that apply) A. Sodium retention is inhibited B. Decreased urination C. Blood flow to periphery is increased D. Catecholamines are released E. Diarrhea occurs F. Seizures occur

✔ Correct Answers: B. Decreased urination D. Catecholamines are released The compensatory mechanisms that occur in response to poor perfusion from heart failure are complex. The neuroendocrine response results in stimulation of the sympathetic nervous system to release catecholamines to maintain cardiac output. The release of catecholamines brings about homeostatic changes in the heart rate, blood pressure, vascular resistance and venous return. The renin-angiotensin aldosterone system is also activated, resulting in salt and water retention by the kidneys, and decreased urine output. Eventually atrial natriuretic peptide and brain natriuretic peptide are released due to ventricular stretch, causing diuresis, vasodilation, and increased sodium excretion. Blood flow is also redistributed to vital organs by peripheral vasoconstriction, which causes decreased perfusion of skin and muscles. Diarrhea and seizures are not compensatory factors during heart failure. Vital Concept: Heart failure refers to failure of the heart to pump sufficient blood to meet tissue needs for oxygen and nutrients. Systolic dysfunction refers to heart failure caused by a problem with contraction of the heart. Diastolic dysfunction refers to dysfunctional filling of the ventricles. Heart failure may result in pulmonary or systemic congestion. It a progressive, chronic condition managed with lifestyle changes and medications, including diuretics, in order to prevent episodes of acute decompensation.

A nurse at a hemodialysis center is caring for a client who has a new order for erythropoietin (Epogen) to be administered subcutaneously. Which of the following side effects should the nurse advise the client to report to the healthcare provider? A. Anuria B. Pruritus C. Nausea D D. Severe headache

✔Correct Answer: D. Severe headache Erythropoietin (EPO) is a hormone made in the kidney and is necessary for maturation of red blood cells. It is used to treat anemia associated with chronic renal failure and due to cancer and treatment with toxic chemotherapeutic drugs. Hypertension and related headaches occur in 15% of individuals with the administration of erythropoietin. A headache may progress to seizures or encephalopathy. Increased blood pressure occurs less frequently with subcutaneous administration compared to intravenous administration of EPO. Hypertension can be relieved with dialysis or, in individuals who are not on dialysis, with a diuretic. Incorrect Answers: A. Anuria is a urine output of less than 50 mL/day and is expected in a client on hemodialysis. B. Pruritus is associated with end-stage renal disease. C. Nausea is a side effect that is expected with the initiation of EPO therapy. Vital Concept: Erythropoeitin is a hormone produced in the kidney that promotes maturation of red blood cells. In clients with anemia due to chemotherapy or chronic renal failure, supplementation may be necessary. Significant adverse effects include hypertension with headache, seizure, and even encephalopathy

23. A male patient has a total cholesterol level of 200 mg/dL (5.172 mmol/L) and an HDL of 32 mg/dL (0.83 mmol/L). Based on these findings, which patient has the highest cardiac risk? a. The man, because his HDL is lower b. The woman, because her HDL is higher c. The woman, because her cholesterol is higher d. The man, because his cholesterol-to-HDL ratio is higher

✔Correct Answers a, c. Copeptin is detected immediately with acute coronary syndrome (ACS) and increased levels of cardiac troponin T (cTnT) are detected within hours. Increased CK-MM is most commonly associated with skeletal muscle injury. Increased b-type natriuretic peptide (BNP) is a marker for heart failure. Increased C-reactive protein (CRP) occurs with acute inflammation as in atherosclerosis. Increased lipoprotein-associated phospholipase A2 (Lp-PLA2) indicates increased risk for CAD.

18. A patient is scheduled for exercise nuclear imaging stress testing. The nurse explains to the patient that this test involves? a. IV administration of a radioisotope at the maximum heart rate during exercise to identify the heart's response to physical stress. b. placement of electrodes inside the right-sided heart chambers through a vein to record the electrical activity of the heart directly. c. exercising on a treadmill or stationary bicycle with continuous ECG monitoring to detect ischemic changes in the heart during exercise. d. placement of a small transducer in 4 positions on the chest to record the direction and flow of blood through the heart by the reflection of sound waves.

✔Correct Answers a. In an exercise nuclear imaging scan, a radioisotope is injected at the maximum heart rate on a bicycle or treadmill and used to evaluate blood flow in different parts of the heart. Insertion of electrodes into the heart chambers via the venous system to record intracardiac electrical activity is an electrophysiology study. Simply monitoring electrocardiogram (ECG) activity during exercise is an exercise stress test, and an echocardiogram uses transducers to bounce sound waves off of the heart.

15. What sounds can be auscultated in a patient with cardiac valve problems (select all that apply)? a. Arterial bruit b. Heart murmurs c. Pulsus alternans d. Third heart sound (S3) e. Pericardial friction rub f. Fourth heart sound (S4)

✔Correct Answers b, d, f. The heart murmurs are produced by turbulent blood flow across diseased heart valves, S3 is heard with mitral valve regurgitation, and S4 is heard with aortic stenosis. Arterial bruits are from turbulent peripheral blood flow. Pulsus alternans, seen in heart failure, is a variation in the strength of each pulse when palpated. Pericardial friction rub is the sound heard with pericarditis.

8. Which effects result from sympathetic nervous system stimulation of β- adrenergic receptors (select all that apply)? a. Vasoconstriction b. Increased heart rate c. Decreased heart rate d. Increased rate of impulse conduction e. Decreased rate of impulse conduction f. Increased force of cardiac contraction

✔Correct Answers b, d, f. The sympathetic nervous system increases the heart rate, the speed of impulse conduction through the atrioventricular (AV) node, and the force of atrial and ventricular contractions via the β-adrenergic receptors.

17. Which finding is associated with a blue color around the lips and conjunctiva? a. Finger clubbing b. Central cyanosis c. Peripheral cyanosis d. Delayed capillary filling time

✔Correct Answers b. Central cyanosis is evident with a blue tinge in the lips, conjunctiva, or tongue. Finger clubbing results from endocarditis, congenital defects, or prolonged O2 deficiency. Peripheral cyanosis is evident with blue-tinged extremities or in the nose and ears. Decreased capillary refill may be seen in reduced capillary perfusion or anemia.

20. Which method is used to evaluate the ECG responses to normal activity over a period of 1 or 2 days? a. Serial ECGs b. Holter monitoring c. 6-minute walk test d. Event monitor or loop recorder

✔Correct Answers b. Holter monitoring involves placing electrodes on the chest attached to a recorder that will record ECG rhythm for 24 to 48 hours while the patient engages in normal activities of daily living (ADLs). The recording is later analyzed for dysrhythmias. Serial ECGs are frequent but not continuous ECGs. The 6-minute walk test measures the distance walked in 6 minutes to determine response to treatments and functional capacity for ADLs. An event monitor or loop recorder is used to record infrequent rhythm disturbances when the patient activates the recording with symptom occurrence.

16. The nursing student is seeking assistance in hearing the patient's abnormal heart sounds. What should the nurse tell the student to do for a more effective assessment? a. Use the diaphragm of the stethoscope with the patient prone. b. Use the diaphragm of the stethoscope with the patient supine. c. Use the bell of the stethoscope with the patient leaning forward. d. Use the bell of the stethoscope with the patient on the right side.

✔Correct Answers c. The bell of the stethoscope will enable better hearing of the low- pitched extra heart sounds. Having the patient lean forward best enables hearing the aortic and pulmonic areas; having the patient on the left side will enhance the mitral area sounds; both of these positions bring the heart closer to the chest wall. Having the patient supine or prone will not improve the auscultation.

22. A female patient has a total cholesterol level of 232 mg/dL: (6.0 mmol/L) and a high-density lipoprotein (HDL) of 65 mg/dL (1.68 mmol/L). A male patient has a total cholesterol level of 200 mg/dL (5.172 mmol/L) and an HDL of 32 mg/dL (0.83 mmol/L). Based on these findings, which patient has the highest cardiac risk? a. The man, because his HDL is lower b. The woman, because her HDL is higher c. The woman, because her cholesterol is higher d. The man, because his cholesterol-to-HDL ratio is higher

✔Correct Answers d. A risk assessment for CAD is determined by comparing the total cholesterol to high-density lipoprotein (HDL), and a ratio can be calculated by dividing the total cholesterol level by the HDL level. The ratio provides more information than either value alone, and an increased ratio indicates an increased risk. The female patient has a ratio of 3.57, which is average risk, compared with the male patient's ratio of 6.25, which is increased risk

4. What are nonmodifiable risk factors for primary hypertension (select all that apply)? a. Age b. Obesity c. Gender d. Ethnicity e. Genetic link

✔Correct Answers. a, c, d, e. Hypertension progresses with increasing age. It is more prevalent in men before early middle age and above the age of 64 years in women. Blacks have a higher incidence of hypertension than do whites. Children and siblings of patients with hypertension should be screened and taught about healthy lifestyles.

21. When caring for a patient after a cardiac catheterization with coronary angiography, which finding should be of most concern to the nurse? a. Swelling at the catheter insertion site b. Development of raised wheals on the patient's trunk c. Absence of pulses distal to the catheter insertion site d. Patient pain at the insertion site at 4 on a scale of 0 to 10

✔Correct Answers. c. An absence of pulses distal to the catheter insertion site indicates that clotting is occluding blood flow to the extremity and is an emergency that requires immediate medical attention. Some swelling and pain at the site are expected, but the site is also monitored for bleeding, and a pressure dressing or compression device may be applied. Hives may occur as a result of iodine sensitivity and will require treatment but the priority is the lack of pulses.

12. When palpating the patient's popliteal pulse, the nurse feels a vibration at the site. How should the nurse record this finding? a. Thready, weak pulse b. Bruit at the artery site c. Bounding pulse volume d. Thrill of the popliteal artery

✔Correct Answers. d. A palpable vibration of a blood vessel is called a thrill and usually indicates a narrowed or bulging vessel wall. A weak, thready pulse has little pressure and is difficult to palpate. A bruit is an abnormal buzzing or humming sound that may be auscultated over diseased blood vessels, and a bounding pulse is an extra full, hard pulse that may occur with atherosclerosis or hypervolemia.

19. Priority Decision: The nurse caring for a patient immediately following a transesophageal echocardiogram (TEE) should consider which action to be the highest priority? a. Monitor the ECG. b. Monitor pulse oximetry. c. Assess vital signs (BP, HR, RR, temperature). d. Maintain NPO status until gag reflex has returned.

✔Correct Answers. d. All actions will be done but to perform a transesophageal echocardiogram (TEE). The throat must be numbed. Until sensation returns, as evidenced by the gag reflex, the patient is at risk of aspiration, so this action has the highest priority (priority related to airway—airway, breathing and circulation [ABCs]).

10. What is a significant finding in the health history of a patient during an assessment of the cardiovascular system? a. Metastatic cancer b. Calcium supplementation c. Frequent viral pharyngitis d. Frequent use of recreational drugs

✔Correct Answers. d. Recreational or abused drugs, especially stimulants, such as cocaine and methamphetamine, are a growing cause of dysrhythmias and problems associated with tachycardia. IV injection of abused drugs is a risk factor for inflammatory and infectious conditions of the heart. Although calcium is involved in the contraction of muscles, calcium supplementation is not a significant factor in heart disease, nor is metastatic cancer. Streptococcal, but not viral, pharyngitis is a risk factor for rheumatic heart disease

A nurse should withhold which of the following prescribed medications pending a discussion with the healthcare provider? (select all that apply)? A. Dilantin for a client who has gingival hyperplasia B. An order for administration of a third dose of trimethoprim-sulfamethoxazole (Bactrim) for a client who has developed a rash C. Unfractionated heparin for a client with a platelet count of 40,000/mm^3 D. Unfractionated heparin for a client with deep vein thrombosis who has an aPTT (activated partial thromboplastin time) of 65 seconds E. Furosemide 80 mg IV for a client with a serum potassium level of 4.0 mEq/L Check Answer Perfect! Close Explanation

✔Correct Answers: B. An order for administration of a third dose of trimethoprim-sulfamethoxazole (Bactrim) for a client who has developed a rash C. Unfractionated heparin for a client with a platelet count of 40,000/mm^3 Trimethoprim-sulfamethoxazole (Bactrim) is associated with a risk of severe dermatological reactions, including toxic epidermal necrolysis and Stevens-Johnson syndrome, which result in erythema, formation of bullae, blistering, exfoliation, and separation of the epidermal layer of the skin. These skin reactions can result in death. Use of trimethoprim-sulfamethoxazole should be discontinued at the initial sign of a rash. Unfractionated intravenous heparin is associated with heparin-induced thrombocytopenia, which ranges from a mild decrease in platelets to a severe form with a drop in the platelet count of more than 50% of baseline. If the severe form (known as type II HIT) occurs, heparin must be discontinued. Incorrect Answers: A. Gingival hyperplasia is a known effect of long-term phenytoin use. Risk is reduced by good dental hygiene while on phenytoin therapy. D. Unfractionated heparin is a natural anticoagulant that is monitored by use of activated partial thromboplastin time. Therapeutic levels depend on the control level in the laboratory but range from 1.5-2.5x the normal range. This can range from 45-85 seconds, depending on the control. E. Although loop diuretics can result in hypokalemia, this is a normal potassium level (3.5-5.0 mEq/L). Vital Concept: Nurses are legally responsible for their actions when administering medicatIon, whether or not there is a written order. If a nurse administers a medication with an incorrect dosage written on the prescription, the nurse and healthcare provider are both held responsible. The nurse should question any unreasonable prescriptions and should not administer the medication until the prescription is adequately clarified.