Craven Ch. 31: Cardiac Function

An electrocardiogram (ECG) uses 10 electrodes/leads to assess the heart's electrical activity from 12 different views. - True - False

- True

A nurse is teaching a client about the function of the heart. During the education session, the client asks the nurse, "Wow, what an incredible organ. Just how much blood does the heart pump out each minute?" Which response by the nurse would be most appropriate? - "About 2,000 gallons" - "About 5 quarts" - "Around 1 liter" - "Just about 10 gallons"

- "About 5 quarts" Explanation: The heart is a hollow, muscular pump that is a little larger than a fist. It is an amazing organ, pumping about 5 quarts of blood per minute. Each day, the average heart beats 100,000 times and pumps about 2,000 gallons of blood.

After teaching a client about nutritional measures to improve heart health, the nurse determines that the client requires additional education when he states: - "I can eat hot dogs, but I need to stay away from fast foods." - "I can eat foods that contain lots of whole grains." - "I should avoid foods that contain high amounts of sugar." - "If the food is high in total fat, I should not eat it."

- "I can eat hot dogs, but I need to stay away from fast foods." Explanation: A healthy diet low in fats, cholesterol, salt, and sugar and one that is high in fiber helps fight cardiovascular disease. Hot dogs are processed foods and are high in salt; along with convenience or fast foods, they should be avoided.

A client with angina is prescribed sublingual nitroglycerin. After teaching the client about this medication, the nurse determines that additional education is needed when the client states: - "I should carry the medicine with me at all times." - "I can store the medicine on my counter in a clear glass container." - "I should feel a tingling under my tongue when I use it." - "I need to check the expiration date so I refill the medicine on time."

- "I can store the medicine on my counter in a clear glass container." Explanation: In clients with a history of pain, nitroglycerin should always be available so that it can be quickly administered if chest pain occurs. Nitroglycerin breaks down over time and with exposure to light. It should tingle when placed under the tongue. The prescription should be refilled whenever it has passed the expiration date to ensure potency in case an emergency occurs.

A nurse is teaching a client with heart disease about exercising and signs of overexertion. The nurse determines that additional education is needed if the client states: - "I should stop exercising if my pulse is below my target zone." - "I need to call the doctor if it feels like my heart is racing." - "I need to start my routine with my warm-up exercises." - "I should wait at least an hour after eating before exercising."

- "I should stop exercising if my pulse is below my target zone." Explanation: For the client, the goal of the exercise program is to achieve the target heart rate. The client should stop exercising if his pulse rate exceeds his target zone. The client should call the physician if he feels that his pulse is racing, do warm-up exercises to prevent sudden demands on the heart, and wait at least an hour after eating to exercise.

A client asks the nurse, "I know my doctor told me why I'm taking this medication, but can you tell me again, why?" The client is prescribed a beta blocker. Which response by the nurse would be most appropriate? - "The medication is to help regulate your heart rhythm." - "The medication helps decrease your swelling." - "The medication will help to reduce your risk of forming a clot." - "The medication is used to help lower your blood pressure."

- "The medication is used to help lower your blood pressure." Explanation: Beta blockers are commonly prescribed to reduce blood pressure. Antiarrhythmics are used to regulate heart rhythm; diuretics are used to reduce swelling (edema); and anticoagulants are used to reduce the risk of clot formation.

The nurse is applying antiembolism stockings on a client. The client asks, "Why are you putting powder on my legs?" Which response by the nurse would be most appropriate? - "The powder helps to make sure your legs are dry for easier application." - "It helps to prevent any pressure areas from developing." - "The powder helps to ensure that the stockings fit properly." - "It helps to keep the legs warmer when wearing the stockings.

- "The powder helps to make sure your legs are dry for easier application." Explanation: Using powder on the legs helps to keep the skin dry, which eases the application. Powder does not prevent pressure or provide warmth. Measurement ensures that the stockings fit properly.

A client is scheduled for a cardiac catheterization. When explaining the purpose of this test to the client, which statement would be appropriate for the nurse to include in the education? - "The test is used to check how thick your heart muscle wall is." - "It helps to see how your heart responds to stress." - "The test can show any narrowing of the arteries in your heart." - "It helps identify any problems with electrical conduction in your heart."

- "The test can show any narrowing of the arteries in your heart." Explanation: Cardiac catheterization helps visualize the coronary arteries and identify possible narrowing of them. An echocardiogram can help to detect myocardial thickness and motion. Exercise testing assesses a person's response to cardiovascular stress. Electrophysiology determines if there are any problems with the electrical conduction in the heart.

A client is scheduled for echocardiography. When explaining this test to the client, which statement by the nurse would be most appropriate? - "They will use an x-ray to determine the size and shape of your heart." - "They will place electrodes on your chest and limbs to get a tracing of your heart's electrical activity." - "They will use an ultrasound device over your chest area to form patterns that will show how your heart is working." - "They will insert a catheter into a large blood vessel and thread it to the chambers of your heart."

- "They will use an ultrasound device over your chest area to form patterns that will show how your heart is working." Explanation: Echocardiography uses ultrasonic waves to produce echoes that form a pattern to evaluate the heart's function. Chest radiography uses x-rays to determine the size and shape of the heart. Electrocardiography involves the use of electrodes attached to the chest and limbs to evaluate cardiac electrical activity. A cardiac catheterization involves the insertion of a catheter into a large vein or artery, which is threaded to the heart's chambers.

A 60-year-old man has a 5-year diagnostic history of heart failure. He takes hydrochlorothiazide 25 mg daily to manage symptoms. He tells his nurse that he feels great, but sometimes notices some swelling in his ankles at the end of the day. What lab test would the nurse expect a health care provider to order to check for worsening heart failure? - B-type natriuretic peptide (BNP) - Troponin - CK-MB - Complete blood count (CBC)

- B-type natriuretic peptide (BNP) Explanation: The BNP is the only test specific to heart failure. Troponin and CK-MB are used to assess for ischemia and myocardial infarction. A CBC is often used as an assessment of a client's cardiovascular well-being but does not provide specific information about heart failure.

The nurse is reviewing the medical record of a client who has returned to the clinic for a follow-up visit. On several previous visits, the client's blood pressure readings were as follows: 124/80 mm Hg; 132/86 mm Hg; 130/88 mm Hg. The client's blood pressure today is 128/82 mm Hg. Which statement by the nurse best reflects appropriate education for this client? - "Your blood pressure is slightly elevated. This is known as prehypertension." - "Your blood pressure is normal. Keep up the good work!" - "Your blood pressure is moderately elevated. This is known as hypertension." - "Your blood pressure is significantly elevated. This is known as a hypertensive crisis."

- "Your blood pressure is slightly elevated. This is known as prehypertension." Explanation: The client's blood pressure readings fall within the prehypertension category, with a systolic blood pressure between 120 to 139 mm Hg and a diastolic blood pressure between 80 to 89 mm Hg. High blood pressure stage 1 readings fall between 140 to 159 mm Hg for systolic pressure and 90 to 99 mm Hg for diastolic pressure. High blood pressure stage 2 readings fall at systolic 160 mm Hg or higher and diastolic 100 mm Hg or higher. Hypertensive crisis is characterized by readings above 180 mm Hg systolic or 110 mm Hg diastolic.

A nurse has received certification in basic life support. The nurse would plan to be recertified in: - 1 year - 2 years - 3 years - 4 years

- 2 years Explanation: Recertification in basic life support is usually required every 2 years to keep skills updated.

The nurse is assessing the legs of a client and notes fairly normal contour with a 4-mm indentation when pressing on the shin and calf of each leg. How should the nurse interpret these findings? - trace edema - 1+ pitting edema - 2+ pitting edema - brawny edema

- 2+ pitting edema Explanation: With 2+ pitting edema, the legs are fairly normal contour and has deeper pit after pressing (4 mm) than trace or 1+ pitting edema. It lasts longer than 1+ pitting edema. It is not as severe as brawny edema.

A client who is wearing antiembolism stockings is being prepared for discharge. After teaching the client about the stockings, the nurse determines that the education was successful when the client states that she will remove the stockings for: - 10 minutes every 4 hours - 15 minutes every 6 hours - 30 minutes every 8 hours - 60 minutes every 12 hours

- 30 minutes every 8 hours Explanation: Antiembolism stockings are usually removed for 30 minutes once every 8 hours. When they are in place, the client's toes should remain warm, and the stockings should cause no obvious constriction or excoriation.

A nurse is providing care to several clients. Which client would the nurse determine as having the greatest risk for heart disease? - 35-year-old White female who smokes a pack of cigarettes per day - 68-year-old Black male with diabetes - 50-year-old Hispanic high-powered executive with gastric reflux - 53-year-old Asian female with anemia

- 68-year-old Black male with diabetes Explanation: Of the clients listed, the 68-year-old Black male with diabetes has three risk factors for heart disease: increased age, race, and diabetes. The 35-year-old female has smoking as a risk factor. The 50-year-old male has increasing age and stress as risk factors. The 53-year-old female is most likely postmenopausal and therefore, has gender as her only risk factor.

A nurse is providing care to a client with heart failure with a nursing diagnosis of Fluid Volume Excess. As part of the nursing plan of care, the nurse weighs the client every morning before breakfast. The client's weight yesterday was 75 kg. Which weight, if obtained today, would the nurse report to the health care provider? - 74.0 kg - 74.8 kg - 75.7 kg - 76.5 kg

- 76.5 kg Explanation: Weight should not vary by more than 1 kg per day for clients with fluid volume excess; thus, the nurse should notify the health care provider of a weight of 76.5 kg, which is 1.5 kg more than the previous day's indicated fluid retention.

A nurse is providing care to a client with chronic arterial disease of both lower extremities. The client is prescribed warm soaks to the lower left leg, from the knee to the ankle. To promote safety, the nurse ensures that the temperature of the compresses are within what range? - 90.0 to 94.5° F - 95.8 to 100.8° F - 100.2 to 102.5° F - 104.5 to 107.0° F

- 95.8 to 100.8° F Explanation: Chronically impaired perfusion of extremities can cause impaired perception of the sensation of heat. For this reason, the client with vascular disease is prone to burns. Exercise great care to avoid excessively hot soaks or compresses. Their temperature should not exceed 95.8° to 100.8°F (35.4° to 38.2°C).

A 35-year-old single woman was admitted to the unit status post a deep vein thrombosis (DVT). She is on a heparin drip and transitioning to enoxaparin sodium therapy. As a nurse prepares the client education, the nurse remembers that it is important to teach the client that what does not contribute to DVT formation? - Oral contraceptives - Alcohol use - Smoking - Pregnancy

- Alcohol use Explanation: Alcohol use has not been linked to increased risk of DVT formation.

The nurse is caring for several clients on the unit. Which client should the nurse prioritize interventions because of possible formation of thrombi? - An unconscious 29-year-old client who suffered a head injury in an accident - A 58-year-old client who underwent an emergent appendectomy - A 32-year-old client preparing for discharge after surgery for a fractured fibula - A 28-year-old client who is in traction for a fractured right femur

- An unconscious 29-year-old client who suffered a head injury in an accident Explanation: The immobile and unconscious client has the highest risk for developing a thrombi due to lack of movement and the nurse will need to ensure the client is provided proper care to help eliminate this potential risk. The other clients are also at risk but can be instructed to perform specific functions and exercise to help decrease their risk.

A nurse responds to a "code blue" in her health care facility. Which intervention should be performed first in this situation? - Assess the client. - Perform the ABCs of CPR. - Perform defibrillation. - Check the client's wish to be resuscitated.

- Assess the client. Explanation: The nurse should assess the client first, activate the emergency response system, check for client preference related to resuscitation, and perform the ABCs of CPR (airway, breathing, and circulation) followed by the 'D' of defibrillation to manage sudden cardiac death.

A nurse is preparing a presentation for a local community group about risk factors for coronary heart disease. Which would the nurse include as a nonmodifiable risk factor? Select all that apply. - Black race - Cigarette smoking - Physical inactivity - Diabetes - Gender

- Black race - Gender Explanation: Nonmodifiable risk factors include family history of heart disease, gender, increased age, and black race. Cigarette smoking, physical inactivity, and diabetes are modifiable risk factors.

The nurse is assessing a client's edematous lower extremities and notes the absence of pitting. The area appears shiny, warm, and moist; it is hard on palpation. The nurse documents this finding as which type of edema? - 2+ - 3+ - 4+ - Brawny

- Brawny Explanation: Brawny edema is characterized by fluid being no longer displaced secondary to excessive interstitial fluid accumulation. Pitting is absent and tissue palpation reveals firm or hard areas with skin surfaces appearing shiny, warm, and moist. Edema that is 2+ is characterized by a 4-mm depression with a fairly normal contour. Edema that is 3+ is characterized by a 6-mm depression that remains several seconds after pressing, with obvious skin swelling on inspection. Edema that is 4+ is characterized by a depression of 8 mm that remains for a prolonged time (possibly minutes) after pressing and frank swelling.

The nurse is preparing a diet plan for a client recently diagnosed with hypertension. Which item(s) should the nurse encourage the client to decrease in the diet plan? Select all that apply. - Breakfast cereal - Fried hamburger - Baked chicken - Homemade vegetable stew - Large soda

- Breakfast cereal - Fried hamburger - Large soda Explanation: A healthy diet low in fats, cholesterol, salt, and sugar and high in fiber helps fight cardiac disease. A diet high in total fat and saturated fat is also strongly associated with the risk of heart disease. Processed foods such as cereal can be high in sugar and sodium and should be limited. Foods purchased from convenience or fast-food venues often contain large amounts of sodium and sugar and should also be limited. Baked chicken and homemade vegetable stew are the safer choices.

A nurse is preparing an education plan about substances that increase blood pressure for a client with hypertension. Which of the following would the nurse most likely include? - Caffeine - Diuretics - Opioids - Cold remedies - Asthma medications

- Caffeine - Cold remedies - Asthma medications Explanation: Substances such as caffeine, cold remedies, and asthma medications can raise blood pressure. Diuretics decrease blood volume, which could lead to a decrease in blood pressure. Opioids can cause hypotension.

A nurse is educating a preoperative client on how to do leg exercises to prevent postoperative circulatory problems. Which exercises would the nurse most likely include? Select all that apply - Calf-pumping - Knee flexion and extension - Leg raising and lowering - Ankle flexion and extension - Hip rotation

- Calf-pumping - Knee flexion and extension - Leg raising and lowering Explanation: Leg exercises alternately contract and relax the muscles of the lower extremity. Contraction of these muscles helps promote the flow of blood back to the heart. Three separate leg movements can be encouraged. First, have the client perform calf-pumping exercises, which involve alternate dorsiflexion and plantar flexion of the feet. Second, have the client bend one knee, sliding the foot up as far as possible along the mattress and back again. The client should repeat this process with the other leg. Finally, have the client alternately raise and lower each straight leg off the mattress as far as comfort allows. Ankle flexion and extension and hip rotation are usually not included in preoperative education about leg exercises.

Students are reviewing information about cardiac output. They demonstrate an understanding of the concept when they state which of the following? - Blood pressure is a primary determinant of cardiac output. - Changes in metabolic demand can change cardiac output. - Cardiac output is a sole determinant of adequate tissue perfusion. - Coronary perfusion is unrelated to cardiac output.

- Changes in metabolic demand can change cardiac output. Explanation: Cardiac output is a function of heart rate and stroke volume, not blood pressure. An increase or decrease in either can change cardiac output. Tissue perfusion relies on several factors, one of which is adequate cardiac output. Adequate coronary perfusion is dependent on adequate cardiac output.

A nursing instructor is developing a class presentation about reasons people with cardiovascular problems seek medical care. Which of the following would the instructor include as the most common reason? - Hypertension - Chest pain - Lower extremity swelling - Persistent cough

- Chest pain Explanation: Although a person with cardiovascular dysfunction may have hypertension, lower extremity swelling, or cough, the onset of pain or discomfort in the chest is the most common reason people with cardiovascular dysfunction seek medical care.

During a home care visit, a nurse completes a physical assessment and suspects that the client is experiencing heart failure. What would lead the nurse to suspect this? - Flattened neck veins - Dependent edema - Pink skin - Clubbed fingers

- Dependent edema Explanation: Dependent edema and engorged neck veins suggest heart failure or inefficient pumping ability of the heart. Pink skin would be considered a normal finding. Engorged neck veins imply inefficient right-sided heart pumping. Clubbed fingers are associated with oxygenation problems resulting from respiratory or cardiovascular disease.

A nurse is working at a community health center. Other staff members are with other clients when a client in the waiting area suddenly collapses to the floor. Which action would the nurse do first? - Shout for help. - Determine unresponsiveness. - Call the emergency response operator. - Initiate CPR.

- Determine unresponsiveness. Explanation: If working alone in the home or community setting, the first step is to establish that the client is unresponsive and then call the emergency response operator. The nurse should also shout for help and initiate CPR after determining that the client has experienced a cardiac arrest.

A client is suspected of having a valvular disorder. Which test would the nurse most likely prepare the client for to help support the diagnosis? - Electrocardiogram - Echocardiogram - Stress ECG - Electrophysiology studies

- Echocardiogram Explanation: An echocardiogram would provide information about the function of the client's valves. An electrocardiogram identifies dysrhythmias and helps to determine the types and extent of heart damage from myocardial infarction. A stress ECG identifies cardiac abnormalities not seen on a resting ECG. Electrophysiology studies identify dysrhythmias and the effectiveness of antiarrhythmic treatment.

Which of the following is a noninvasive procedure assisting the nurse in cardiovascular care? - Electrocardiography - Pulmonary artery monitoring - Swan-Ganz catheterization - Cardiac output determination

- Electrocardiography Explanation: Noninvasive heart monitoring involves electrocardiography and cardiac monitoring. Invasive techniques, such as pulmonary artery monitoring, Swan-Ganz catheterization, cardiac output determination, and cardiac support via an intra-aortic balloon pump (IABP), typically are used by trained critical care personnel to provide additional monitoring and support.

The nurse is assessing a 54-year-old client with a history of alcohol use disorder, who presents with a strong odor of alcohol on the breath, slurred speech, and poor coordination. Which finding on the assessment will the nurse anticipate? - Elevated blood pressure - Slightly elevated temperature - No bowel sounds - Hyperactivity

- Elevated blood pressure Explanation: Excessive alcohol intake has been associated with hypertension, increased cardiovascular risk and cardiomyopathy. The other choices would be related to other causes for which the nurse would need to assess for as well, if noted.

After reviewing information about the structure of the heart, nursing students demonstrate understanding of the information when they identify which of the following as the part that attaches the heart to the diaphragm and sternal wall? - Septum - Endocardium - Myocardium - Epicardium

- Epicardium Explanation: The epicardium is a thin-walled sac that surrounds the heart and attaches it to the diaphragm and sternal wall of the thorax. The septum is the strong muscular wall that divides the heart into left and right halves. The endocardium is the innermost lining of the heart. The myocardium is the thick muscular layer that produces muscular contraction of the heart.

The nurse enters the client's room to assist the client to the bathroom and notes the client is having difficulty getting out of a chair to stand and has slurred speech. Which action(s) should the nurse prioritize? - Evaluate the client's face - Ask the client about any vision changes - Check the arms for weakness - Obtain the client's vital signs - Use a wheelchair to take client to bathroom

- Evaluate the client's face - Ask the client about any vision changes - Check the arms for weakness Explanation: A tool nurses can use to recognize stroke symptoms is BE-FAST (Balance, Eyes, Face, Arms, Speech, Time test). With this tool, the nurse assesses balance (gait changes), eyes (vision changes, blurred or double vision or loss of vision field), facial drooping, arm weakness, speech changes, and time (when symptoms began and time to call 911). Obtaining the client's vital signs is not the priority at this moment. It would be inappropriate to go ahead and take the client to the bathroom with a wheelchair especially if the client is currently having a stroke. The client needs appropriate emergency care to prevent his or her death.

The nurse performs a health risk assessment for a 50-year-old male client who reports eating fast food several times per week including soft drinks and very little water and no regular exercise program. Assessment reveals a body mass index of 32, blood pressure of 150/94 mm Hg, total cholesterol of 258 mg/dL (6.68 mmol/L), high density lipids of 32 mg/dL (0.83 mmol/L), and non-high density lipids of 226 mg/dL (5.85 mmol/L). The nurse plans a health improvement program for the client that includes which strategy(ies)? Select all that apply. - Exercise at least 30 minutes 5 times per week - Eat at least 5 servings of fruit and/or vegetables each day - Decrease fast food to one time per week - Eat at least 8 oz of red meat for protein each day - Drink at least 4 to 6 glasses of water per day

- Exercise at least 30 minutes 5 times per week - Eat at least 5 servings of fruit and/or vegetables each day - Decrease fast food to one time per week - Drink at least 4 to 6 glasses of water per day Explanation: The health improvement program strategy to help the client modify risk factors for cardiovascular disease includes exercising at least 30 minutes 5 times per week, eating at least 5 servings of fruit and/or vegetables each day, decreasing fast food to one time per week, and drinking at least 4 to 6 glasses of water per day. While high in protein and iron, red meat would not be recommended for a client trying to reduce body mass, weight, and cholesterol.

A client with cardiovascular dysfunction is prescribed a diuretic. Which nursing diagnosis would most likely apply? - Fluid Volume Excess - Activity Intolerance - Decreased Cardiac Output - Pain

- Fluid Volume Excess Explanation: Although Activity Intolerance, Decreased Cardiac Output, and Pain may be appropriate nursing diagnoses for a client with cardiovascular dysfunction, the use of a diuretic indicates Fluid Volume Excess. A diuretic reduces edema and fluid volume by increasing urinary output.

Nursing students are preparing a presentation for a health fair about the effects of cigarette smoking on cardiovascular health. Which of the following would the nurses include? Select all that apply. - Decreased heart rate - Increased blood pressure - Enhanced atherosclerosis - Vasodilation - Limited blood oxygen-carrying capacity

- Increased blood pressure - Enhanced atherosclerosis - Limited blood oxygen-carrying capacity Explanation: Cigarette smoking increases the heart rate, increases the blood pressure, constricts arterioles, and may cause irregular cardiac rhythm. It enhances the atherosclerotic process and is a major cause of peripheral vascular disease. Smoking also limits the blood's oxygen-carrying capacity by displacing oxygen with carbon monoxide.

Which statements about bedside cardiac monitoring are true? Select all that apply. It provides continuous observation of the heart's electrical activity. - It focuses on the detection of clinically significant dysrhythmias. - It is used for clients who have conduction disorders. - It is used to monitor clients who are at risk for developing life-threatening dysrhythmias. - It is used to identify early changes in level of consciousness. - It is used to decrease the number of direct care staff.

- It focuses on the detection of clinically significant dysrhythmias. - It is used for clients who have conduction disorders. - It is used to monitor clients who are at risk for developing life-threatening dysrhythmias.

A nurse is preparing to apply a sequential compression device to a client's lower extremities. Before applying the sleeves, which would be least appropriate for the nurse to apply to the client's legs? - Antiembolism stockings - Ace wraps - Stockinette wraps - Knee-high cotton socks

- Knee-high cotton socks Explanation: Before applying a sequential compression device, the nurse would apply antiembolism stockings or Stockinette or ace wraps to the client's legs to decrease the risk of diaphoresis and irritation under the plastic sleeves, and to provide extra support. Knee-high cotton socks would be inappropriate to use because they would not provide extra support.

The nurse is conducting an assessment on a 57-year-old male who presents to the emergency department with reports of chest discomfort, blacking-out, swollen and sore ankles, shortness of breath when lies down, and blood pressure 138/92 mm Hg. Which action should the nurse prioritize? - Obtain 12-lead electrocardiogram (ECG) - Ask about pain level - Complete a comprehensive assessment - Attach blood pressure monitor

- Obtain 12-lead electrocardiogram (ECG) Explanation: Some subjective reports associated with chest pain related to cardiovascular dysfunction can include blackouts, swelling of hands and ankles, shortness of breath, and difficulty lying flat. The pain may be close to 10. The blood pressure reading may indicate the client has hypertension.

A nurse is forming an education plan for a client who is being discharged from the nursing unit after cardiac catheterization. Which diagnosis and intervention are most appropriate for this client? - Knowledge Deficient: Risk for altered perfusion secondary to re-occlusion - Knowledge Deficient: Altered urinary output related to catheterization - Knowledge Deficient: Impaired mobility related to lying flat for 8 hours - Knowledge Deficient: Risk for ineffective breathing pattern related to incisional pain

- Knowledge Deficient: Risk for altered perfusion secondary to re-occlusion Explanation: Urinary output should not be changed from a cardiac catheterization. The incision for this procedure may require 8 hours of lying flat, but mobility returns to baseline before discharge home. The risk for ineffective breathing pattern would not be due to incisional pain, which would be in the groin or elbow. Educating the client to be aware for the safety issue of chest pain resulting from the newly opened coronary arteries becoming re-occluded and blocking blood flow to the heart is the highest priority focus.

The nurse provides care for a client newly diagnosed with heart failure. Which information does the nurse include in teaching the client to maintain a healthy lifestyle while living with heart failure? Select all that apply. - Low-sodium diet - Weight management - Monthly blood glucose levels - Cardiac rehabilitation exercise/activity plan - Monitoring new or worsening signs or symptoms of heart failure

- Low-sodium diet - Weight management - Cardiac rehabilitation exercise/activity plan - Monitoring new or worsening signs or symptoms of heart failure Explanation: The nurse includes a low-sodium diet, weight management, cardiac rehabilitation activity and exercise program, and monitoring any new or worsening symptoms of heart failure in the education program to help the client newly diagnosed with heart failure maintain a healthy lifestyle. Monthly blood glucose monitoring is not indicated.

Nurses are preparing a class presentation on the differences in cardiovascular function between men and women. Which of the following would the nurses include in the discussion? Select all that apply. - Women's blood vessels are generally larger than men's blood vessels. - Male heart size is typically larger than female heart size. - Women typically develop hypertension later in life than men do. - The risk of death after a heart attack is significantly higher for women than for men. - Menopause has little demonstrated effect on cardiovascular events.

- Male heart size is typically larger than female heart size. - Women typically develop hypertension later in life than men do. - The risk of death after a heart attack is significantly higher for women than for men. Explanation: Women generally have a smaller stature than men and therefore have smaller hearts and smaller blood vessels. Women also develop hypertension and cardiovascular disease later in life than men. There is a demonstrated link between the onset of menopause and cardiovascular events. A woman's risk for developing diabetes following a heart attack is three times higher than that of a man, and death following a heart attack is 50% higher in women than men.

Antiembolism stockings are ordered for a client. To ensure proper fit, which action by the nurse would be most appropriate? - Measure from heel to groin and around the calf and thigh. - Compare the client's height to the size guide on the package. - Obtain the client's weight and add 1/2 inch for every ten pounds above 120 lbs. - Estimate the size based on the client's shoe size.

- Measure from heel to groin and around the calf and thigh. Explanation: The nurse should measure for proper fit before first application by measuring length (heel to groin) and width (calf and thigh) and comparing to manufacturer's printed material to ensure proper fit. Using height, weight, or shoe size would be inappropriate.

A client is brought to the emergency department with a suspected myocardial infarction. Which laboratory test would the nurse expect the physician to order to confirm the suspected myocardial infarction? - B-type natriuretic peptide - Blood urea nitrogen - Creatinine - Myoglobin - Creatine kinase-MB - Troponin

- Myoglobin - Creatine kinase-MB - Troponin Explanation: Serum levels of specific biomarkers (e.g., myoglobin, creatine kinase-MB [CK-MB], and troponin) are drawn and assessed to confirm a suspected myocardial infarction. B-type natriuretic peptide (BNP) is a diagnostic lab value that is specifically used to diagnose heart failure. Blood urea nitrogen and creatinine are laboratory tests that evaluate kidney function.

A client is suspected of having an acute stroke. The nurse applies evidence-based guidelines and assesses the severity of the stroke using: - FAST - NIH Stroke Scale - Glasgow Coma Scale - Echocardiography

- NIH Stroke Scale Explanation: The National Institutes of Health Stroke Scale (Lyden et al., 2009) is an evidenced-based tool used to standardize the evaluation of neurologic deficits in the acute stroke client. It also provides a baseline to compare subsequent assessments. A tool nurses use to recognize stroke symptoms that can also be used to educate clients is the Face Arm Speech Time (FAST). However, this tool does not assess stroke severity. The Glasgow Coma Scale is used to assess neurologic function, not specific to stroke. Echocardiography is a diagnostic test used to evaluate heart size and thickness, valve function and cardiac output.

The nurse is assessing a client who comes to the urgent care clinic with the general report, "I just do not feel good." Which action should the nurse prioritize when noting the client's blood pressure is 198/130 mm Hg? - Notify the health care provider immediately - Recheck the blood pressure after 5 minutes - Attach a blood pressure monitor to the client - Document reading in the medical record

- Notify the health care provider immediately Explanation: A blood pressure reading of higher than 180 systolic and/or higher than 120 diastolic indicates a hypertensive crises and requires emergency care. The other choices will also be completed but it is important to let the health care know immediately so emergent care can be initiated.

A client is at risk for thrombus formation following surgery. Which action should the nurse take to assess for this risk? - Auscultate the lungs - Observe the legs for redness - Measure the blood pressure - Measure the pulse at the carotid artery

- Observe the legs for redness Explanation: Thrombi can form in any blood vessel, but they are most likely to form in the deep veins of the legs. The nurse should report any redness or reports of pain or swelling in the legs. A clot can form in the legs and travel from the legs to the lungs and cause pulmonary embolism. Auscultating the lungs, measuring blood pressure, and obtaining a client's pulse are important assessment criteria for postsurgical clients but would not indicate a thrombus in the lower extremities.

A client is scheduled for surgery. The nurse is teaching the client how to perform leg exercises. The nurse determines that the education was successful when the client demonstrates which action while performing calf pumping exercises? Select all that apply. - Points toes of both feet toward the foot of the bed - Relaxes and pulls toes toward chin - Makes circles with both ankles, one direction then the other - Flexes knees with feet flat on the bed - Slides feet forward as far as possible then back to a flexed knee position

- Points toes of both feet toward the foot of the bed - Relaxes and pulls toes toward chin - Makes circles with both ankles, one direction then the other Explanation: Calf pumping exercises involve these steps: pointing toes of both feet toward the foot of the bed; relaxing then pulling toes toward the chin. Flexing the knees with the feet flat on the bed and then sliding the feet forward as far as possible reflects knee flexion and extension exercises.

Upon entering a client's room, the client tells the nurse, "I'm having some really strong pain in my chest." The nurse intervenes immediately, placing the client in which position? - Supine - Sitting - Flat with legs raised 20 to 30 degrees - Standing upright

- Sitting Explanation: The nurse should make the client comfortable in a sitting position. A supine position inhibits full chest expansion and limits gas exchange in the lung, so this position should be avoided. Since the heart works harder in the supine position than in the upright position, the supine position is not recommended. The hypotensive client is positioned with legs elevated 20 to 30 degrees.

When describing the normal cardiac cycle, which of the following would a nursing instructor describe as occurring during systole? - Heart muscle relaxes. - Impulse is generated. - Ventricles eject blood. - Chambers fill with blood.

- Ventricles eject blood. Explanation: The cardiac cycle begins with the generation of an impulse in the SA node. This impulse spreads throughout the heart, which then causes the muscle contraction and pumping motion. With each contraction during systole, the ventricles eject blood. During the diastole, the heart muscle relaxes and the chambers fill with blood.

Which initial cardiac rhythm is most frequently found in clients who experience sudden cardiac arrest? - Ventricular fibrillation - Ventricular tachycardia - Wolff-Parkinson-White pattern - Third-degree heart block

- Ventricular fibrillation Explanation: This action will increase hematoma formation and prolong bleeding.

A nurse is developing a plan of care for a man with metabolic syndrome. Which of the following would the nurse expect to find? - Triglyceride level of 130 mg/dL - HDL level of 45 mg/dL - Waist circumference of 44 inches - Blood pressure of 128/80 mm Hg

- Waist circumference of 44 inches Explanation: Metabolic syndrome is characterized by a waist circumference greater than 40 inches in men, triglyceride levels over 150 mg/dL, HDL levels less than 40 mg/dL for men, blood pressure greater than 130/85, and a fasting glucose greater than 110 mg/dL.

A client comes to the emergency department with an acute stroke. The nurse is assessing the severity of the stroke using the NIH Stroke Scale. Which area would the nurse assess? Select all that apply. - Vital signs - Wakefulness - Vision - Movement - Sensation - Language - Speech

- Wakefulness - Vision - Movement - Sensation - Language - Speech Explanation: The National Institutes of Health Stroke Scale (Lyden et al., 2009) is an evidenced-based tool used to standardize the evaluation of neurologic deficits in the acute stroke client. It also provides a baseline to compare subsequent assessments. It is the most widely used instrument available for clinical assessment in stroke clients. Five areas of client function — wakefulness (level of consciousness), vision, movement, sensation, and language and speech— are evaluated and scored.

A nurse is talking with a group of young and middle-aged adults about reducing the risk of cardiovascular disease. The nurse recommends that the group consume which type(s) of foods in small amounts to help reduce cardiovascular disease? Select all that apply. - cruciferous vegetables - canned foods - fried foods - whole grains - lobster

- canned foods - fried foods - lobster Explanation: A healthy diet low in fats, cholesterol, salt, and sugar—and high in fiber—helps fight cardiovascular disease; conversely, a diet high in total fat and saturated fat is strongly associated with the risk of heart disease. The fiber in cruciferous vegetables and whole grains are important elements of cardiovascular health, and a diet high in fiber has been linked to heart health because it helps reduce blood cholesterol. Canned foods tend to be high in sodium. Lobster and fried foods are high in saturated fat.

A nurse is evaluating a client's blood pressure. On the past several visits to the clinic, the client's blood pressure readings were 134/76 mm Hg, 128/70 mm Hg and 130/72 mm Hg. Today, the client's blood pressure is 136/78 mm Hg. The nurse would classify this as: - normal. - elevated blood pressure - high blood pressure stage 1. - high high blood pressure stage 2.

- elevated blood pressure Explanation: The client's blood pressure readings fall within the category of elevated blood pressure (BP), defined as 120-139 mm Hg systolic and less than 80 mm Hg diastolic. Normal ranges are below 120/80 mm Hg. High BP stage 1 is characterized by readings of 130-139 mm Hg systolic or 80-89 mm Hg diastolic. High BP stage 2 is characterized by readings of 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic.

A client with cardiovascular disease says to the nurse, "I know that exercise is good for me, but how exactly does it help?" Which of the following would the nurse include when responding to the client? Select all that apply. - improved heart pumping efficiency - increased platelet stickiness - raising of HDL cholesterol - reduced triglyceride levels - reduced heart pumping

- improved heart pumping efficiency - raising of HDL cholesterol - reduced triglyceride levels Explanation: Engaging in regular exercise improves the heart's pumping ability and efficiency, increases blood circulation (which prevents thrombi formation by decreasing platelet stickiness), raises the "good" (HDL) cholesterol level, and reduces triglyceride levels.

A nurse is a guest speaker at a smoking cessation class being held at a local community center. When describing the effects of cigarette smoking to the class, which effect would the nurse most likely include? Select all that apply. - decreased heart rate - increased blood pressure - arteriolar dilation - irregularities in heart rhythm - enhanced atherosclerosis

- increased blood pressure - irregularities in heart rhythm - enhanced atherosclerosis Explanation: Cigarette smoking is extremely harmful and has caused more deaths from cardiovascular disease than lung cancer or chronic obstructive pulmonary disease (COPD). It increases the heart rate and BP, constricts arterioles, and may cause an irregular cardiac rhythm. It enhances the process of atherosclerosis and is the major cause of peripheral vascular disease. Smoking also limits the blood's oxygen-carrying capacity by displacing oxygen with carbon monoxide.

What contributes to health disparities with relation to blood pressure? Select all that apply. - less access to fresh foods in urban, poor neighborhoods - high intake of salty or fried foods - sedentary lifestyle secondary to unsafe outdoor space - working 40 hours per week

- less access to fresh foods in urban, poor neighborhoods - high intake of salty or fried foods - sedentary lifestyle secondary to unsafe outdoor space Explanation: The incidence of risk factors of high blood pressure increases in low-income families due to diets that are focused on fried or salty foods and more individuals living a sedentary lifestyle.

A nurse is assigned to care for a client with a terminal cardiovascular illness. When developing the client's plan of care, which outcome would the nurse identify as most realistic for this client? - maintenance of adequate comfort - adaptation to living with limitations - acceptance of changes in lifestyle - recovery from the cardiovascular problem

- maintenance of adequate comfort Explanation: The realistic outcome for a client with terminal cardiovascular disease is maintenance of adequate comfort and acceptance of impending death. Realistic outcomes for the client with chronic cardiovascular disease focus on helping the client to live within limitations imposed by the disease and to improve acceptance of changes in lifestyle and self-concept. Outcomes pertinent to the client who is admitted with an acute problem focus on recovery from the cardiovascular problem without residual complications.

A nurse is providing care to a client with high blood pressure who is at risk for decreased cerebral tissue perfusion. The nurse would be alert for: - slowed speech. - orientation to time. - appropriate responses. - ability to follow directions.

- slowed speech. Explanation: The nurse should look for slowed speech in the client, which indicates decreased tissue perfusion and decreased blood flow to the brain. Cognition is often the first indicator of decreased perfusion to be assessed because it is readily apparent in the nurse's first interactions with the client. People with normal cerebral perfusion usually speak in a normal cadence; they answer questions quickly and appropriately and are oriented to person, place, and time. They are able to follow directions.