Perfusion Prep-U

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? A. Elevate the legs periodically for at least an hour. B. Elevate the legs periodically for at least 15 to 20 minutes. C. Refrain from sexual activity for a week. D. Avoid foods with iodine.

B. Elevate the legs periodically for at least 15 to 20 minutes. The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? A. 7 B. 5 C. 1 D. 3

A. 7 Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect.

Increased secretion of renin in heart failure is caused by which event? A. Low cardiac output B. Increased renal blood flow C. Dysrhythmias D. Hypertension

A. Low cardiac output Low cardiac output reduces renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS). This system produces the vasoconstrictor angiotensin-ll and aldosterone, which increases sodium and water retention. Both of these actions attempt to increase renal perfusion. Hypertension and dysrhythmias do not activate RAAS.

How does the nurse describe the cardiac action potential to a new coworker? A. the cycle of depolarization and repolarization B. the time it takes from the firing of the sinoatrial (SA) node to the contraction of the ventricles C. the time between the contraction of the atria and the contraction of the ventricles D. the cycle of the firing of the atrioventricular (AV) node and the contraction of the myocardium

A. the cycle of depolarization and repolarization The action potential of the cardiac muscle cell consists of five phases: Phase 0 occurs when the cell reaches a point of stimulation. This is called depolarization. Phase 2, or the plateau stage, is a process called repolarization. Phase 4 is when spontaneous depolarization begins again. The action potential involves electrolytes and polarization and does not involve timing of the cardiac cycle.

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client? A. "It is important for you to do 30 minutes of exercise three times a week." B. "Take your blood pressure medications exactly as your doctor prescribed them." C. "You should decrease your intake of fried foods." D. "You need to sign up for the clinic's stop smoking program."

B. "Take your blood pressure medications exactly as your doctor prescribed them." Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.

A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? A. A client receiving oxygen therapy via Venturi mask B. A client experiencing hypothermia C. A client sitting in a chair after prolonged bed rest D. A client on a ventilator with PEEP

B. A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.

A client who is relatively healthy is seen in the clinic for a regular checkup. While there he tells the nurse that he is worried that he may develop a heart condition. When the nurse asks him why he is worried he tells her that his mother had aortic valve stenosis and is afraid that he might get it. He then asks to be tested for the disease. What should the nurse tell this client about diagnosing a valvular defect? A. An MRI, which is more expensive, can be helpful in this diagnosis. B. Valvular defects usually are detected through cardiac auscultation. C. Blood work can help to diagnose a valvular defect. D. An ECG can be done to rule out this disease.

B. Valvular defects usually are detected through cardiac auscultation. Although valvular heart disease can result from congenital defects, rheumatic heart disease, trauma and other causes, atrial stenosis is usually first diagnosed with auscultation of a loud systolic murmur or a single-split second heart sound. Other tests are not used initially.

The nurse admits an adult female client with a medical diagnosis of "rule out MI." The client is very frightened and expresses surprise that a woman would have heart problems. What response by the nurse will be most appropriate? A. "It takes longer for an electrical impulse to travel from the sinoatrial node to the atrioventricular node in a woman." B. "A woman's resting heart rate is lower than a man's." C. "A woman's heart is smaller and has smaller arteries that become occluded more easily." D. "The stroke volume from a woman's heart is lower than from a man's heart."

C. "A woman's heart is smaller and has smaller arteries that become occluded more easily." Because the coronary arteries of a woman are smaller, they become occluded from atherosclerosis more easily. The resting rate, stroke volume, and ejection fraction of a woman's heart are higher than those of a man. The electrical impulses from the sinoatrial node to the atrioventricular node are not different in the genders.

Which is not a likely origination point for cardiac dysrhythmias? A. atria B. atrioventricular node C. bundle of His D. ventricles

C. bundle of His Cardiac dysrhythmias may originate in the atria, atrioventricular node, or ventricles. They do not originate in the Bundle of His.

When educating a client about to undergo a pacemaker insertion, the nurse explains the normal phases of cardiac muscle tissue. During the repolarization phase, the nurse will stress that membranes must be repolarized before they can be re-excited. Within the cell, the nurse understands that: A. the influx of calcium is the primary stimulus for the repolarization of cardiac tissue. B. the cell membranes need to stay calm, resulting in muscle tissue becoming refractive. C. potassium channels open while sodium channels close, causing repolarization to the resting state. D. only the electrical activity within the heart will determine when repolarization occurs.

C. potassium channels open while sodium channels close, causing repolarization to the resting state. Repolarization is the phase during which the polarity of the resting membrane potential is re-established. This occurs with the closure of the sodium channels and opening of the potassium channels.

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? A. 20 B. 30 C. 40 D. 50

D. 50 Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process? A. Cushing's syndrome B. hyperthyroidism C. hypoparathyroidism D. Addison's disease

D. Addison's disease Intravenous hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with <--Addison's disease. Cushing's syndrome--> is associated with excessive amounts of glucocorticoids. Hyperthyroidism and hypoparathyroidism are not treated with hydrocortisone.

Which is a cerebrovascular manifestation of heart failure? A. Ascites B. Tachycardia C. Nocturia D. Dizziness

D. Dizziness Cerebrovascular manifestations of heart failure include dizziness, lightheadedness, confusion, restlessness, and anxiety. Tachycardia is a cardiovascular manifestation. Ascites is a gastrointestinal manifestation. Nocturia is a renal manifestation.

Infectious mononucleosis is a lymphoproliferative disorder caused by the Epstein-Barr virus (EBV) that is usually self-limiting and nonlethal. Which complication can arise during this mostly benign disease? A. Rupture of the lymph nodes B. Severe bacterial infections C. Peripheral nerve palsies D. Enlarged spleen

D. Enlarged spleen Hepatitis and splenomegaly are common manifestations of infectious mononucleosis and are thought to be immune mediated. Hepatitis is characterized by hepatomegaly, nausea, anorexia, and jaundice. Although discomforting, it usually is a benign condition that resolves without causing permanent liver damage. The spleen may be enlarged two to three times its normal size, but rupture of the spleen is an infrequent complication. Cranial nerve palsies, not peripheral nerve palsies, can occur. Lymph nodes do not rupture. Severe bacterial infections are complications of Kostmann syndrome.

Heart failure and circulatory shock are both conditions of circulatory system failure. Which statement regarding these conditions is correct? A. They have the same remediation. B. They have the same pathogenesis. C. They have the same etiology. D. They have the same compensatory mechanisms.

D. They have the same compensatory mechanisms. Heart failure and circulatory shock have common compensatory mechanisms that attempt to support cardiac output and tissue perfusion. They do not share common pathogenesis, causes, or remediation.

The nurse is assessing vital signs on a client who is 3 months status post myocardial infarction (MI). While the healthcare provider is examining the client, the client's spouse approaches the nurse and states "We are too afraid he will have another heart attack, so we just don't have sex anymore." What is the nurse's best response? A. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." B. "It is usually better to just give up sex after a heart attack." C. "Having an orgasm is very strenuous and your husband must be in excellent physical shape before attempting it." D. "The medications will prevent your husband from having an erection."

A. "The physiologic demands are greatest during orgasm and are equivalent to walking 3 to 4 miles per hour on a treadmill." The physiologic demands are greatest during orgasm. The level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. Sexuality is an important quality of life, so the healthcare provider will be determining when it is safe to have intercourse. Erectile dysfunction may be a side effect of beta-blockers, but other medications may be substituted.

Which is a characteristic of arterial insufficiency? A. Diminished or absent pulses B. Aching, cramping pain C. Superficial ulcer D. Pulses are present but may be difficult to palpate

A. Diminished or absent pulses A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

A client is in cardiogenic shock following a massive myocardial infarction. The client's family asks the nurse, "Why are the health care providers recommending dialysis since its the heart that is sick?" Which response by the nurse is most appropriate at this time? A. "It looks like your family member has had a blockage in the ureters for quite some time and the heart attack has made it more difficult for the blood to be filtered by the kidney." B. "When a person has a large heart attack and goes into shock due to heart failure, there is a decrease in renal perfusion which allows toxins to increase in the blood." C. "It looks like your loved one has been exposed to nephrotoxic drugs like a nonsteroidal anti-inflammatory drug (NSAID) prior to the heart attack." D. "When a person has such a large heart attack, the kidneys suffer by developing clots which interfere with urine production."

B. "When a person has a large heart attack and goes into shock due to heart failure, there is a decrease in renal perfusion which allows toxins to increase in the blood." Prerenal acute kidney injury (AKI) is characterized by a marked decrease in renal blood flow. It is reversible if the cause of the decreased renal blood flow can be identified and corrected before kidney damage occurs. Causes of prerenal AKI include heart failure and cardiogenic shock. This would call for temporary dialysis to filter the blood while the heart is healing. Intrarenal AKI is caused by acute tubular necrosis due to exposure to nephrotoxic drugs or prolonged ischemia. Postrenal AKI is caused by bilateral ureteral obstruction.

When reviewing diagnostic test results and physical assessment data for a client with a history of stage II hypertension, which of the following would be of most concern to the nurse? A. A heart rate (HR) of 62 beats/minute B. An ejection fraction of 40% C. Blood pressure of 146/80 D. Point of maximum impulse is located midclavicular at the 5th intercostal space

B. An ejection fraction of 40% This ejection fraction is below normal (normal is about 55% to 75%) and indicates a poor prognosis. This low ejection fraction is a result of the complications of long-standing hypertension.

The nurse observes a sudden dampening of the arterial waveform. What is the priority action by the nurse? A. Change the tubing. B. Assess the client's blood pressure. C. Flush the line. D. Contact the healthcare provider.

B. Assess the client's blood pressure. The priority action is to assess the client. A hypotensive crisis can look like dampened waveform and be life threatening if not treated appropriately. After the client is assessed, the healthcare provider can be contacted for additional interventions including a fluid challenge. Changing the tubing and flushing the line can be completed after the client is assessed.

The client with airway obstruction may experience perfusion of the lungs without ventilation due to what disorder? A. Pulmonary embolism B. Atelectasis C. Cardiogenic shock D. Abdominal aneurysm

B. Atelectasis Perfusion without ventilation is defined as a shunt. It occurs in conditions such as atelectasis in which there is airway obstruction. With dead air space there is ventilation without perfusion that occurs with conditions such as pulmonary embolism, which impairs blood flow to a part of the lung.

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? A. liver dysfunction B. organ damage C. unsteady gait D. weight loss

B. organ damage When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of A. myocardial infarction. B. pulmonary embolism. C. pneumonia. D. pulmonary edema.

B. pulmonary embolism. Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A 66-year-old client presents to the emergency department reporting severe headache and mild nausea for the past 6 hours. Upon assessment, the client's BP is 210/120 mm Hg. The client has a history of hypertension and takes 1.0 mg clonidine twice daily. Which question is most important for the nurse to ask the client next? A. "Are you having chest pain or shortness of breath?" B. "Did you take any medication for your headache?" C. "Have you taken your prescribed clonidine today?" D. "Do you have a dry mouth or nasal congestion?"

C. "Have you taken your prescribed clonidine today?" The nurse must ask whether the client has taken his prescribed clonidine. Clients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of clonidine is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire whether the client has taken the prescribed hypertension medication given the client's severely elevated BP.

The nurse is caring for a client with a history of sickle cell anemia. The nurse understands that this predisposes the client to which renal or urologic disorder? A. Neurogenic bladder B. Proteinuria C. Chronic kidney disease D. Kidney stone formation

C. Chronic kidney disease A history of sickle cell anemia predisposes the client to the development of chronic kidney disease. The other disorders are not associated with the development of sickle cell anemia.

A physician has ordered the measurement of a cardiac client's electrolyte levels as part of the client's morning blood work. Which statement best captures the importance of potassium in the normal electrical function of the client's heart? A. The impermeability of cardiac cell membranes to potassium allows for action potentials achieved by the flow of sodium ions. B. Potassium catalyzes the metabolism of ATP, producing the gradient that results in electrical stimulation. C. Potassium is central to establishing and maintaining the resting membrane potential of cardiac muscle cells. D. The reciprocal movement of one potassium ion for one sodium ion across the cell membrane results in the production of an action potential.

C. Potassium is central to establishing and maintaining the resting membrane potential of cardiac muscle cells. The selective permeability of cell membranes to potassium, and its near-impermeability to sodium ions, produces the resting membrane potential of cardiac cells. Potassium does not catalyze the metabolism of ATP, and sodium and potassium ions do not move across the cell membrane in a 1:1 ratio.

Assessment of an older adult client reveals bilateral pitting edema of the client's feet and ankles; difficult to palpate pedal pulses; breath sounds clear on auscultation; oxygen saturation level of 93% (0.93); and vital signs normal. What is this client's most likely health problem? A. cor pulmonale B. pericarditis C. right-sided heart failure D. cardiogenic shock

C. right-sided heart failure A major effect of right-sided heart failure is the development of peripheral edema. A client who is in shock would not have stable vital signs. Cor pulmonale would be accompanied by manifestations of lung disease. Pericarditis is an inflammation of the pericardium exhibited by fever, precordial pain, dyspnea, and palpitations.

Which is an age-related change of the hepatobiliary system? A. Decreased prevalence of gallstones B. Enlarged liver C. Increased drug clearance capability D. Decreased blood flow

D. Decreased blood flow Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in the size and weight of the liver.

The nurse takes a client's blood pressure in the primary care provider's office. The last three times the client has been in the office it has been high. What structure in the eye is this adverse effect of hypertension most likely to affect? A. Iris B. Ciliary body C. Lens D. Retina

D. Retina The adverse effect of hypertension most likely will affect the retina of the eye. The lens is affected with a cataract. The iris and ciliary body are not impacted.

The cardiologist just informed a client that he has a reentry circuit in the electrical conduction system in his heart. This dysrhythmia is called Wolff-Parkinson-White (WPW) syndrome. After the physician has left the room, the client asks the nurse to explain this. Which statement most accurately describes what is happening? A. "There is an extra, abnormal electrical pathway in the heart that leads to impulses traveling around the heart very quickly, in a circular pattern, causing the heart to beat too fast." B. "You must have a large clot in one of your arteries that supply oxygenated blood to the special conduction cells in your heart." C. "For some reason, your electrical system is not on full charge so they will have to put in new leads and a pacemaker to make it work better." D. "This means that the SA node (which is the beginning of your heart's electrical system) has been damaged and is no longer functioning normal."

A. "There is an extra, abnormal electrical pathway in the heart that leads to impulses traveling around the heart very quickly, in a circular pattern, causing the heart to beat too fast." There are several forms of reentry. The first is anatomic reentry. It involves an anatomic obstacle around which the circulating current must pass and results in an excitation wave that travels in a set pathway. Dysrhythmias that arise as a result of anatomic reentry are paroxysmal supraventricular tachycardias, as seen in WPW syndrome, atrial fibrillation, atrial flutter, etc. Sinus node dysrhythmias and sick sinus syndrome result in the SA node being damaged. A large clot in one of the arteries can result in dysrhythmias caused by MI. A third-degree block or ventricular standstill, for example, would result in new leads and a pacemaker for this client.

A young nurse working on a cardiac floor who is working with a nursing student informs the student that there are numerous ways to evaluate coronary blood flow. Which does she identify as the most frequently used cardiovascular diagnostic procedure? A. 12-lead ECG B. Cardiac catherization C. Cardiac CT D. Stress test

A. 12-lead ECG Electrocardiography or the 12-lead ECG is the most frequently used cardiovascular diagnostic procedure. The others are also used in evaluating blood flow and myocardial perfusion, but not as frequently.

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take? A. Administer the prescribed enoxaparin (Lovenox). B. Monitor partial thromboplastin (PTT) time. C. Encourage a diet high in vitamin K. D. Have the client limit physical activity.

A. Administer the prescribed enoxaparin (Lovenox). Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? A. An irregular apical pulse B. Pitting edema of the legs C. Dry mucous membranes D. Frequent urination

A. An irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? A. Apply antiembolism stockings B. Instruct about exercise, as prescribed C. Apply cold packs D. Instruct about using client-controlled analgesia, if prescribed

A. Apply antiembolism stockings Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.

Which cardiac drug classification decreases sympathetic outflow to the heart and is the is the cornerstone of therapy for catecholaminergic polymorphic ventricular tachycardia (CPVT)? A. Beta-adrenergic blockers B. Sodium channel blockers C. Calcium channel blockers D. Potassium blockers

A. Beta-adrenergic blockers Antiarrhythmic drugs act by modifying disordered formation and conduction of impulses that induce cardiac muscle contraction. Beta-adrenergic blocking drugs decrease sympathetic outflow to the heart. Antiadrenergic treatment with beta-blockers is the cornerstone of therapy for CPVT. The remaining options act by blocking specific electrolytes, thus altering electrical impulses affecting the heart.

A physician is working with a 30-year-old male client with Down syndrome who has been admitted to hospital with a diagnosis of acute leukemia. Which physical assessment finding would the physician be more likely to find in an examination of this client than other clients without Down syndrome? A. Congenital heart defects B. Decreased visual acuity C. Hepatomegaly D. Diabetes mellitus

A. Congenital heart defects Congenital heart defects are associated with Down syndrome. Hepatomegaly, visual disturbances, and diabetes are not associated.

The nurse is evaluating a client's peripheral neurovascular status. Which would the nurse report to the health care provider as a circulatory indicator of peripheral neurovascular dysfunction? A. Cool skin B. Paralysis C. Paresthesia D. Weakness

A. Cool skin Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation.

A morbidly obese client asks the nurse if medications are available to assist with weight loss. The nurse knows that the client would not be a candidate for phentermine if the following is part of the client's health history: A. Coronary artery disease B. Use of lithium C. Peptic ulcer disease D. Diabetes

A. Coronary artery disease Phentermine, which requires a prescription, stimulates central noradrenergic receptors, causing appetite suppression. It may increase blood pressure and should not be taken by people with a history of heart disease, uncontrolled hypertension, hyperthyroidism, or glaucoma.

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response? A. Document the findings and continue to monitor the client B. Check the security of all connections and increase the milliamperage C. Reposition the extremity and turn the client to left side D. Obtain a 12-lead ECG and a portable chest x-ray

A. Document the findings and continue to monitor the client Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the client. Repositioning the client, placing the client on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

A pregnant woman contacts her physician because she has developed sudden, severe pain and swelling in her left lower leg. The physician explains to her that her past medical includes an inherited defect in factor V Leiden, which predisposes her to the development of: A. Excessive clotting B. Abnormal bleeding C. Platelet disorders D. Thrombocytopenia

A. Excessive clotting Factor V Leiden is an inherited clotting disorder. The normal factor V gene is replaced by the factor V Leiden gene, which is harder for normal anticoagulants to inactivate. The inability to inactivate factor V Leiden predisposes a person to developing blood clots, and the prothrombic situation that occurs with pregnancy increases the risk of thrombosis.

The angiogenesis process, which allows tumors to develop new blood vessels, is triggered and regulated by tumor-secreted: A. Growth factors B. Attachment factors C. Procoagulants D. Proteolytic enzymes

A. Growth factors Many tumors secrete growth factors, which trigger and regulate the angiogenesis process. Tumor cells express various cell surface attachment factors, for anchoring. Tumor cells secrete proteolytic enzymes to degrade the basement membrane and migrate into surrounding tissue. Cancer cells may produce procoagulant materials that affect clotting mechanisms.

The health care provider is teaching a client about modifiable risk factors for atherosclerosis. The most appropriate information to provide would be: A. Hypertension B. 55 years of age C. Being male D. Family history of heart disease

A. Hypertension The major risk factors that can be modified by a change in health care behaviors include cigarette smoking, obesity, hypertension, hyperlipidemia and elevated LDL cholesterol, and diabetes mellitus, all of which are traditional cardiovascular risk factors. The other options are nonmodifiable risk factors for atherosclerosis.

What will the nurse assess as the end result of activation of the renin-angiotensin-aldosterone system? A. Increased blood pressure B. Increased heart rate C. Increased respiratory rate D. Increased urination

A. Increased blood pressure Stimulation of the sympathetic nervous system activates the renin-angiotensin-aldosterone system, which mediates an increase in vascular tone and renal retention of sodium and water. This causes an increase in blood pressure. The other assessment findings would not be the end result of activation of this system.

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? A. Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit B. Fatigue related to decreased hemoglobin and hematocrit C. Risk for falls related to complaints of dizziness D. Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients

A. Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? A. Irreversible B. Progressive C. Precompensatory D. Compensatory

A. Irreversible The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.

The nurse is caring for a client with a dysrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the dysrhythmia to be which of the following? A. Ischemic heart disease B. Aortic stenosis C. Peripheral vascular disease D. Atherosclerotic heart disease

A. Ischemic heart disease The nurse realizes that the most common cause of dysrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque buildup in the vessels may be a component of the disease process but not the best answer.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? A. Left ventricular function B. Right ventricular function C. Right atrial function D. Left atrial function

A. Left ventricular function The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

A nurse is planning a community education program on lifestyle modification to manage hypertension. Which topic should be included in the teaching plan? Select all that apply. A. Limit alcohol consumption. B. Avoid aerobic physical activity. C. Reduce dietary sodium intake. D. Stop smoking. E. Consume a diet rich in fruits, vegetables, and low-fat dairy products.

A. Limit alcohol consumption. C. Reduce dietary sodium intake. D. Stop smoking. E. Consume a diet rich in fruits, vegetables, and low-fat dairy products. Hypertension lifestyle modification includes the maintenance of normal body weight (BMI, 18.5-24.9 kg/m2). Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan includes consuming a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat 8-14 mm Hg. Dietary sodium should be reduced to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride). Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day). Alcohol consumption should be moderate, with consumption of no more than 2 drinks (1 oz [30 mL] ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and 1 drink per day in women and persons of lighter weight.

The nurse is caring for a client newly diagnosed with sepsis. The client has a serum lactate concentration of 6 mmol/L and fluid resuscitation has been initiated. Which value indicates that the client has received adequate fluid resuscitation? A. Mean arterial pressure of 70 mm Hg B. Central venous pressure of 6 mm Hg C. Urine output of 0.2 mL/kg/hr D. ScvO2 of 60%

A. Mean arterial pressure of 70 mm Hg The nurse administers fluids to achieve a target central venous pressure of 8 to 12 mm Hg, mean arterial pressure >65 mm Hg, urine output of 0.5 mL/kg/hr, and an ScvO2 of 70%.

The nurse working in the emergency room triages a client who comes in reporting chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myocardial infarction. The client is given a nitrate, which does nothing for his pain. Which medication should the nurse suspect the doctor will order next for the pain? A. Morphine B. Codeine C. Demerol D. Fentanyl

A. Morphine Although a number of analgesic agents have been used to treat pain of myocardial infarction, morphine is the drug of choice and is usually indicated if chest pain is unrelieved with oxygen and nitrates.

While lecturing on blood pressure, the nurse will emphasize that the body maintains its blood pressure by adjusting the cardiac output to compensate for changes in which physiologic process? A. Peripheral vascular resistance B. Rigidity of the ventricular walls C. Release of stress hormones D. Electrical impulses in the heart

A. Peripheral vascular resistance The systolic and diastolic components of blood pressure are determined by cardiac output and total peripheral vascular resistance and can be expressed as the product of the two (blood pressure = cardiac output × total peripheral resistance). The body maintains its blood pressure by adjusting the cardiac output to compensate for changes in peripheral vascular resistance, and it changes the peripheral vascular resistance to compensate for changes in cardiac output. Electrical impulses from the SA node regulate heart rate. Release of stress hormones and rigidity of the ventricular walls do not primarily influence BP; however, they may impact this secondarily.

A formerly normotensive woman, pregnant for the first time, develops hypertension and headaches at 26 weeks' gestation. Her blood pressure is 154/110 mm Hg and she has proteinuria. What other labs should be ordered for her? A. Platelet count; serum creatinine; liver enzymes B. Urinary catecholamines and metabolites C. Urinary sodium and potassium D. Plasma angiotensin I and II and renin

A. Platelet count; serum creatinine; liver enzymes This woman shows signs and symptoms of preeclampsia. A low platelet count with elevated serum creatinine and liver enzymes would reinforce this diagnosis. The other tests might indicate kidney problems or the presence of a pheochromocytoma, but her symptoms do not indicate a need for these tests.

Which is the most common cause of esophageal varices? A. Portal hypertension B. Asterixis C. Ascites D. Jaundice

A. Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

The nurse is evaluating a client with cardiac problems and notes that the client's peripheral pulse is different than the apical pulse. To which physiologic response would the nurse attribute the difference in rates? A. Premature beats not following normal conduction pathways B. Multiple ectopic respond at various cycles C. An overexcited electrical impulse D. Confusion within the sinus node

A. Premature beats not following normal conduction pathways Premature ventricular contractions (PVCs) do not follow the same conduction pathways as the impulses initiated by the SA node, and due to refractoriness the myocardium cannot respond with a normal mechanical response to the stimulation. This same refractoriness interferes with the ability of the myocardium to respond to impulses arising from the normal conduction pathways also.

The nurse is interpreting an electrocardiogram of a 65-year-old woman. Which should the nurse recognize as representing ventricular depolarization? A. QRS complex B. P wave C. T wave D. ST segment

A. QRS complex The QRS complex--> is representative of ventricular depolarization. The P wave--> is atrial depolarization, the T wave--> is ventricular repolarization, and the ST segment--> is the time to ventricular repolarization.

A male client with chronic obstructive pulmonary disease has a hematocrit of 55%. The practitioner tells the client that he has: A. Secondary polycythemia B. Polycythemia vera C. Relative polycythemia D. Primary polycythemia

A. Secondary polycythemia Secondary polycythemia results from a physiologic increase in the level of erythropoietin, commonly as a compensatory response to hypoxia. Conditions causing hypoxia include chronic heart and lung disease. Polycythemia is an abnormally high total red blood cell mass with a hematocrit greater that 54% in men. Primary polycythemia or polycythemia vera are neoplastic diseases of the pluripotent cells of the bone marrow. In relative polycythemia, the hematocrit rises because of a loss of plasma volume without a corresponding decrease in red cells.

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)? A. Silent unit B. Low ventilation-perfusion ratio C. Dead space D. Normal ratio of perfusion to ventilation

A. Silent unit When ventilation exceeds perfusion a dead space exists. An example of a dead space is a pulmonary emboli. A low ventilation-perfusion ratio exists in pneumonia or with a mucus plug. A silent unit occurs in pneumothorax or ARDS.

A client has been diagnosed with a dissecting aortic aneurysm. It is most important for the nurse to assess the client for: A. Tearing or ripping-type pain in the chest or back B. Chest pain radiating to the right arm C. Tonic-clonic seizures D. Late hypertensive crisis

A. Tearing or ripping-type pain in the chest or back A major symptom of a dissecting aneurysm is the abrupt presence of excruciating pain, described as tearing or ripping. Pain associated with dissection of the ascending aorta frequently is located in the anterior chest, and pain associated with dissection of the descending aorta often is located in the back. In the early stages, blood pressure typically is moderately or markedly elevated.

A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant? A. The patient reports shortness of breath when walking. B. The patient reports chest pain after eating a large meal. C. The patient's has an enlarged liver and edematous abdomen. D. The patient has jugular vein distention and 3+ pedal edema.

A. The patient reports shortness of breath when walking. Dyspnea on exertion is typically the earliest manifestation of mitral valve stenosis. Late signs of right-sided heart failure are jugular vein distention, edema, and enlarged liver. Chest pain rarely occurs with mitral valve stenosis.

A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI? A. Troponin level B. Calcium level C. Complete blood components D. Creatine kinase marker

A. Troponin level The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction (MI). The troponin complex, which is part of the actin filament, consists of three subunits (i.e., TnC, TnT, and TnI) that regulate calcium-mediated actin-myosin contractile process in striated muscle (see Chapter 1, Fig. 1-19). TnI and TnT, which are present in cardiac muscle, begin to rise within 3 hours after the onset of MI and may remain elevated for 7 to 10 days after the event. This is especially adventitious in the late diagnosis of MI. The other blood work may be ordered, but not to confirm the diagnosis of MI.

The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock? A. Weak and rapid pulse rate B. Obstructed airway C. Pooling of secretions in the lungs D. Warm, dry skin

A. Weak and rapid pulse rate Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

The nurse should use the bell of the stethoscope during auscultation of: A. a client's heart murmur. B. a client's apical heart rate. C. a client's breath sounds. D. a client's bowel sounds.

A. a client's heart murmur. The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

The health care provider has determined that a client diagnosed with cardiogenic shock will now require treatment with the intra-aortic balloon pump. The expected effect of the treatment is: A. decreased afterload. B. decreased cardiac output. C. increased preload. D. increased afterload.

A. decreased afterload. The intra-aortic balloon pump, also referred to as counterpulsation, enhances coronary and systemic perfusion, yet decreases afterload and myocardial oxygen demands.

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed? A. heart transplant B. implantable cardiac defibrillator (ICD) C. ventricular access device D. cardiac resynchronization therapy

A. heart transplant Heart transplantation involves replacing a person's diseased heart with a donor heart. This is an option for advanced HF patients when all other therapies have failed. A ventricular access device, ICD, and cardiac resynchronization therapy would be tried prior to a heart transplant.

In the emergency department, a client arrives following a car accident. His pulse is 122; BP 88/60; respiration is 18 bpm. Urine output is 4 mL over the first hour on arrival. When in shock, this lower urine output is primarily due to: A. innervation of the sympathetic nervous system, causing constriction of the afferent arteriole. B. obstruction in the glomerular capillaries due to overabundance of large molecules being released. C. high filtration rates in the glomerulus. D. parasympathetic stimulation, causing the renal arteries to constrict in response to pain.

A. innervation of the sympathetic nervous system, causing constriction of the afferent arteriole. During periods of strong sympathetic stimulation, such as shock, constriction of the afferent arteriole causes a marked decrease in renal blood flow, and thus glomerular filtration pressure. Consequently, urine output can fall almost to zero. The location of the glomerulus between two arterioles allows for maintenance of a high-pressure filtration system. The glomerular filtrate has a chemical composition similar to plasma, but contains almost no proteins because large molecules do not readily pass through the openings in the glomerular capillary wall.

Contraction of the right atrium sends blood through the: A. tricuspid valve. B. aortic valve. C. mitral valve. D. pulmonic valve.

A. tricuspid valve. The tricuspid valve separates the right atrium from the right ventricle; blood flowing from the right atrium into the right ventricle passes through this valve. The mitral valve separates the left atrium and ventricle; blood flowing from the left atrium into the left ventricle passes through this valve. Blood flowing from the right ventricle into the pulmonary artery passes through the pulmonic valve. Blood flowing from the left ventricle into the aorta passes through the aortic valve.

The nurse is revising a care plan for a client with peripheral arterial disease and a risk for impaired skin integrity. Which client outcomes would indicate the client was successful with interventions? Select all that apply. A. Avoids prolonged standing or sitting. B. Avoids trauma and irritation to skin. C. Adheres to meticulous hygiene schedule. D. Wears protective shoes. E. Experiences decreased muscle pain with walking.

B. Avoids trauma and irritation to skin. C. Adheres to meticulous hygiene schedule. D. Wears protective shoes. The client with peripheral arterial disease has a risk for impaired skin integrity due to poor circulation. Adhering to a meticulous hygiene schedule will keep the skin clean and dry; wearing protective shoes can prevent blisters and foot injury. Avoiding trauma and irritation to the skin will help protect the skin from injury. While avoiding prolonged standing or sitting and having decreased muscle pain with walking can help with improved circulation, it does not prevent skin integrity impairment.

Persistent cyanosis has led an infant's care team to suspect a congenital heart defect. Which assessment findings would suggest coarctation of the infant's aorta? A. The child has a split S2 heart sound on auscultation. B. Blood pressure in the child's legs is lower than in the arms. C. ECG reveals atrial fibrillation. D. The child experiences apneic spells after feeding.

B. Blood pressure in the child's legs is lower than in the arms. The classic sign of coarctation of the aorta is a disparity in pulsations and blood pressures in the arms and legs. In coarctation, the pressure in the legs is lower and may be difficult to obtain. A split S2, dysrhythmias, and apneic spells are not characteristics of coarctation of the aorta.

A physician is working with a 30-year-old male client with Down syndrome who has been admitted to hospital with a diagnosis of acute leukemia. Which physical assessment finding would the physician be more likely to find in an examination of this client than other clients without Down syndrome? A. Hepatomegaly B. Congenital heart defects C. Diabetes mellitus D. Decreased visual acuity

B. Congenital heart defects Congenital heart defects are associated with Down syndrome. Hepatomegaly, visual disturbances, and diabetes are not associated.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? A. Expiratory stridor B. Crackles in the lower lobes C. Wheezing in the upper lobes D. Inspiratory stridor

B. Crackles in the lower lobes People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor--> is associated with respiratory infections such as croup. Wheezing---> may be heard in individuals who use tobacco products.

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded? A. Parenteral fluids B. Fruit consumption C. Sips of water D. Frozen fluids

B. Fruit consumption Any water consumption must be recorded in order to closely monitor a client who has congestive heart failure. Many of these clients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following? A. Bradypnea B. Mental confusion C. Hypertension D. Bradycardia

B. Mental confusion Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.

A client has developed cardiogenic shock. The most frequent cause of this type of shock is: A. Hypertension B. Myocardial infarction C. Heart failure D. Allergic reaction

B. Myocardial infarction Cardiogenic shock is a loss of cardiac pumping ability. The most frequent cause of this shock is myocardial infarction, as ischemic damage greatly reduces left ventricular contractility.

When explaining the contraction of the heart muscle, the instructor describes the basic unit as: A. Myosin B. Sarcomere C. Troponin D. Actin

B. Sarcomere The basic structural unit of cardiac muscle is the sarcomere, which contains the proteins actin and myosin. These proteins are kept apart by the protein troponin.

Which type of epithelium is found in the lining of blood vessels, lymph nodes, and alveoli of the lungs? A. Transitional epithelium B. Simple squamous epithelium C. Pseudostratified epithelium D. Stratified epithelium

B. Simple squamous epithelium Simple squamous epithelium is adapted for filtration, which works well on the blood vessels, lymph nodes, and alveoli of the lungs. Stratified squamous keratinized epithelium makes up the epidermis of the skin. A pseudostratified ciliated columnar epithelium with goblet cells forms the lining of most of the upper respiratory tract. Transitional epithelium is well adapted for the lining of organs that are constantly changing their volume, such as the urinary bladder.

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? A. The woman is demonstrating the early signs of cardiogenic shock. B. The woman may be experiencing an exacerbation of right-sided HF. C. The woman is also likely to experience shortness of breath. D. The woman has left-sided heart failure.

B. The woman may be experiencing an exacerbation of right-sided HF. Increased JVP is associated with right-sided HF. Dyspnea may or may not be present, but is more closely associated with left-sided HF. Increased JVP is not necessarily indicative of impending shock.

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant? A. Implanted cardioverter-defibrillator (ICD) B. Ventricular assist device (VAD) C. Pacemaker D. Intra-aortic balloon pump (IABP)

B. Ventricular assist device (VAD) VADs may be used for one of three purposes:(1) a bridge to recovery, (2) a bridge to transport, or (2) destination therapy (mechanical circulatory support when there is no option for a heart transplant). An implanted cardioverter-defibrillator or pacemaker is not a bridge to transplant and will only correct the conduction disturbance and not the pumping efficiency. An IABP is a temporary, secondary mechanical circulatory pump to supplement the ineffectual contraction of the left ventricle. The IABP is intended for only a few days

A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). Which evaluation statement suggests that the client needs more instruction? A. "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." B. "Client verbalizes an understanding of the need to seek emergency help if heart rate increases markedly while at rest." C. "Client walks 4 miles in 1 hour every day." D. "Client performs relaxation exercises three times per day to reduce stress."

C. "Client walks 4 miles in 1 hour every day." Four weeks after an MI, a client's walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. Performing relaxation exercises, following a low-fat, low-cholesterol diet, and seeking emergency help if the heart rate increases markedly at rest indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.

A 12-year-old boy taken to the emergency department after a soccer injury cries out, "Look, my leg is bigger now!" How will the nurse respond to the boy? A. "Yes. it is supposed to. This is a good thing." B. "No need to worry. Soccer is a dangerous sport." C. "Swelling is a normal response from your body to prepare for healing." D. "Let me look at that. We may need to have the doctor examine you."

C. "Swelling is a normal response from your body to prepare for healing." Inflammation is a defensive reaction after injury that helps to prepare the site for repair. At the age of 12 years, children should be given age-appropriate responses for better understanding of what is happening to them. The correct choice is the best therapeutic communication response.

The nurse performs a routine prenatal assessment on a client at 35 weeks' gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3° C). Which statement is most appropriate for the nurse to make at this time? A. "Your vital signs are all normal. I will document them on your chart." B. "You have a slight temperature. Do you feel hot?" C. "Your blood pressure is slightly high. I will check it again before you leave." D. "Your pulse is low. Do you exercise a lot?"

C. "Your blood pressure is slightly high. I will check it again before you leave." A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing "white coat" syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vital signs are within normal range.

A client is admitted to the cardiac unit with a diagnosis of pericarditis. The nurse is teaching the client about the anatomical location of the infection. The nurse evaluates the effectiveness of the teaching when the client correctly identifies which of the following as the location of the pericardium? A. The innermost lining of the heart chambers B. The outer muscular layer of the heart C. A membranous sac that encloses the heart D. The electrical conduction system of the heart

C. A membranous sac that encloses the heart The pericardium forms a fibrous covering around the heart, holding it in a fixed position in the thorax and providing physical protection and a barrier to infection. The pericardium is a tri-layer sac consisting of a tough, outer fibrous layer and a thin, inner serous layer.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? A. Hemoglobin levels B. Hematocrit values C. Arterial blood gas D. Pulmonary function

C. Arterial blood gas Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? A. Venous congestion B. Possible necrosis C. Arterial thrombosis D. Infection

C. Arterial thrombosis A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease? A. Assess blood pressure and administer aspirin B. Assess the client's physical history C. Assess chest pain and administer prescribed drugs and oxygen D. It is not important to assess the client or to notify the physician

C. Assess chest pain and administer prescribed drugs and oxygen The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.

The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? A. Assess for any kind of drug abuse. B. Assess the skin of the client. C. Assess the characteristics of chest pain. D. Assess the client's mental and emotional status.

C. Assess the characteristics of chest pain. The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action? A. Call an emergency code B. Perform a Mini Mental Status Examination (MMSE) C. Assess the client's blood pressure D. Assess the client's jugular venous pressure

C. Assess the client's blood pressure Combining phenelzine with beer can precipitate a hypertensive crisis. There is no immediate indication that an emergency code is needed. The client's jugular venous pressure is less likely to be affected and is not a priority for assessment. Performing the MMSE is not a short-term priority.

A nurse is reviewing an echocardiogram for a client with a congenital defect in the papillary muscles of the heart. Based on this result, which assessment should the nurse complete? A. Auscultate for an extra heart sound due to incomplete semilunar valve closure. B. Palpate the pericardium for a heave or thrill. C. Auscultate for a murmur caused by the backward expulsion of blood through the atrioventricular valves. D. Monitor the blood pressure.

C. Auscultate for a murmur caused by the backward expulsion of blood through the atrioventricular valves. When closed, the AV valves prevent backflow of blood from the ventricles to the atria during systole. The AV valves are supported by the papillary muscles, which project from the wall of the ventricles. Contraction of the papillary muscles at the onset of systole ensures closure by producing tension on the leaflets of the AV valves before the full force of ventricular contraction pushes against them.

A patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder? A. Heart rate of 56-64 bpm B. Shivering C. Blood pressure varying between 120/86 and . 240/130 mm Hg D. Complaints of nausea

C. Blood pressure varying between 120/86 and . 240/130 mm Hg Hypertension associated with pheochromocytoma may be intermittent or persistent. Blood pressures exceeding 250/150 mm Hg have been recorded. Such blood pressure elevations are life threatening and can cause severe complications, such as cardiac dysrhythmias, dissecting aneurysm, stroke, and acute kidney failure.

A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to? A. Aplastic anemia B. Sickle cell disease C. Coagulopathy D. Pancytopenia

C. Coagulopathy The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate.

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved? A. Absence of cough B. Decrease in blood pressure C. Decrease in central venous pressure (CVP) D. Increase in CVP

C. Decrease in central venous pressure (CVP) A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication? A. Obstruction of urine flow from the kidneys B. Structural damage occurred in the nephrons of the kidneys C. Decrease in the blood flow through the kidneys D. Blood clot formed in the kidneys interfered with the flow

C. Decrease in the blood flow through the kidneys Acute renal failure can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.

Brugada syndrome, an autosomal dominant disorder, manifests in adulthood as ST-segment elevation, right bundle branch block, and susceptibility to ventricular tachycardia. In Brugada syndrome, the timing of cardiac events is significant. When do these cardiac events typically occur? A. When first arising in the morning B. Just before bedtime at night C. During sleep or rest D. During exercise

C. During sleep or rest The disorder typically manifests in adulthood with very incomplete penetrance, and a high percentage of mutation carriers are asymptomatic. Cardiac events typically occur during sleep or rest. Cardiac events during exercise, on arising in the morning, and just before bedtime at night are not indicative of Brugada syndrome.

The nurse is teaching a class on reduction of cardiovascular disease. Which action/activity demonstrates an intervention that is cognizant of the modifiable risk factors for hyperlipidemia? A. Encouraging a friend to cook with trans fats, as they extend the shelf life of foods B. Encouraging a friend to be tested for familial hypercholesterolemia C. Going for a brisk walk with a friend and talking to him about continuing to exercise regularly D. Talking to a friend about using more saturated and less unsaturated fats when cooking

C. Going for a brisk walk with a friend and talking to him about continuing to exercise regularly The management of hypercholesterolemia focuses on dietary and therapeutic lifestyle changes. Therapeutic lifestyle changes include an increased emphasis on physical activities such as walking and exercise. Dietary measures to reduce LDL levels include decreasing the use of saturated fats and trans fats. Testing for familial hypercholesterolemia is not a modifiable risk factor

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? A. Supine with arms elevated on pillows above the level of the heart B. Head of the bed elevated 30 degrees and legs elevated on pillows C. Head of the bed elevated 45 degrees and lower arms supported by pillows D. Prone with legs elevated on pillows

C. Head of the bed elevated 45 degrees and lower arms supported by pillows Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.

The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.) A. Respiratory rate B. Lung sounds C. Heart rate D. Character of apical and peripheral pulses E. Heart rhythm

C. Heart rate D. Character of apical and peripheral pulses E. Heart rhythm During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the apical and peripheral pulses to detect the effects of hypertension on the heart and blood vessels.

A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect? A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hyponatremia

C. Hyperkalemia Potassium-sparing diuretics, such as spironolactone, can cause hyperkalemia, especially if given with an ACE inhibitor. Signs of hyperkalemia are nausea, diarrhea, abdominal cramps, and peaked narrow T-waves.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? A. Hypovolemia contains only low blood volume. B. Similar causes are present in both conditions. C. In dehydration, only extracellular is depleted. D. Both conditions result in abnormal laboratory studies.

C. In dehydration, only extracellular is depleted. In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? A. Anaphylactic shock B. Hypovolemic shock C. Neurogenic shock D. Septic shock

C. Neurogenic shock Neurogenic shock can be caused by spinal cord injury. In this case, it resulted by diving into waters of unknown depth. The patient will present with a low blood pressure, bradycardia, and warm dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client? A. Lidocaine B. Insulin C. Nitroprusside D. Dopamine (Inotropin)

C. Nitroprusside Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor. Dopamine is used to treat hypotension, which isn't associated with pheochromocytoma. Pheochromocytoma doesn't affect blood glucose levels, so insulin isn't indicated in this client unless there is an underlying diagnosis of diabetes mellitus. Lidocaine is sometimes used to treat ventricular arrhythmias, which aren't associated with pheochromocytoma.

Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? A. Compensatory B. Refractory C. Progressive D. Irreversible

C. Progressive In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply. A. Tension pneumothorax B. Pancreatitis C. Stroke D. Coronary artery disease E. Myocardial infarction

C. Stroke D. Coronary artery disease E. Myocardial infarction People with hypertension may remain asymptomatic for many years. When specific signs and symptoms appear, however, they usually indicate vascular damage. Coronary artery disease with angina and myocardial infarction are common consequences of hypertension. Cerebrovascular involvement may lead to a stroke. Tension pneumothorax and pancreatitis are not directly related to hypertension.

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from? A. The ventricles B. The AV node C. The sinoatrial node D. The Purkinje fibers

C. The sinoatrial node The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body (Weber & Kelley, 2010).

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD? A. exercise electrocardiography B. electron beam computed tomography C. ankle-brachial index D. photoplethysmography

C. ankle-brachial index The client's symptoms indicate possible peripheral artery disease (PAD). The ankle-brachial index is a simple, noninvasive test used for this diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD. An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures light that is not absorbed by hemoglobin and consequently is reflected back to the machine.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote A. increased glucose demands. B. increased metabolic rate. C. decreased catabolism. D. increased skeletal muscle breakdown.

C. decreased catabolism. Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Which symptom is an early warning sign of acute coronary syndrome (ACS) and heart failure (HF)? A. hypotension B. weight gain C. fatigue D. change in level of consciousness

C. fatigue Fatigue is an early warning symptom of ACS, heart failure, and valvular disease. Other signs and symptoms of cardiovascular disease are hypotension, change in level of consciousness, and weight gain.

A client has received a diagnosis of portal hypertension. What does portal hypertension treatment aim to reduce? Select all that apply. A. blood coagulation B. fluid output C. fluid accumulation D. venous pressure

C. fluid accumulation D. venous pressure Methods of treating portal hypertension aim to reduce venous pressure and fluid accumulation.

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? A. atrial fibrillation rhythm B. urine output of 300 mL in eight hours C. heart rate of 55 beats per minute D. blood pressure of 125/80

C. heart rate of 55 beats per minute Digoxin therapy slows conduction through the AV node. A heart rate of 55 is slow and the digoxin therapy may slow the heart rate further. Blood pressure of 125/80 is normal. Urine output of 300 mL is adequate, so the kidneys are functioning. Atrial fibrillation is not a parameter to hold medication.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival? A. diltiazem B. bumetanide C. lisinopril D. cholestyramine

C. lisinopril Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

The nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate? A. no arterial insufficiency B. moderate insufficiency with ischemic rest pain C. mild to moderate insufficiency D. severe ischemia or tissue loss

C. mild to moderate insufficiency ABI is calculated by dividing the highest systolic pressure for each ankle by the highest brachial pressure. For this client it would be 80/160 mm Hg = 0.50 ABI. This indicates that the client has mild to moderate insufficiency. Clients with ABI of about 1.0 have no arterial insufficiency; clients with ABI of less than 0.50 have ischemic rest pain; and clients with an ABI of 0.40 or less indicates severe ischemia or tissue loss.

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading? A. the ear tip of the stethoscope pointing backwards while taking blood pressure B. the client reporting moderate pain for the past 4 hours C. placing the client's arm at heart level D. using a medium size cuff for a 10-year-old, average weight client

C. placing the client's arm at heart level The nurse should measure blood pressure with the arm at heart level. Elevating the arm above heart level results in a falsely low measurement; positioning the arm below heart level results in a falsely high reading. The ear tip or bell can be pointed in any direction when taking a blood pressure. Using a small cuff is recommended for a 10-year-old normal-sized child. Pain can increase the blood pressure causing a false elevated reporting.

Which sequence is the correct pathway for blood flow through the heart? A. left atrium - bicuspid valve - left ventricle - pulmonary artery - lungs - pulmonary vein - right atrium - tricuspid valve - right ventricle - aorta B. left atrium - tricuspid valve - left ventricle - pulmonary artery - lungs - pulmonary vein - right atrium - mitral valve - right ventricle - aorta C. right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta D. right atrium - bicuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - tricuspid valve - left ventricle - aorta

C. right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta The correct pathway for blood flow through the heart is the right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta.

The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension? A. Bronchial thickening causes increased resistance and pressure in the pulmonary vascular bed. B. Chronic lung disease causes scaring in the bronchioles raising pressure in the pulmonary vascular bed. C. Left-sided heart failure causes increased resistance and pressure in the pulmonary vascular bed. D. Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.

D. Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed. Therefore options A, B, and C are incorrect.

The older adult client with a history of congestive heart failure is upset following the death of her husband yesterday. The practitioner observes the client for which of the following? A. Cerebrovascular accident B. Anemia C. Renal failure D. Dysrhythmias

D. Dysrhythmias For people with limited coping abilities, either because of physical or mental health, the acute stress response may be detrimental. For people with preexisting heart disease, the overwhelming sympathetic behaviors associated with stress can lead to dysrhythmias. The other options are not stimulated by the sympathetic response.

The nurse is caring for a client with heart failure. What procedure should the nurse prepare the client for in order to determine the ejection fraction to measure the efficiency of the heart as a pump? A. Electrocardiogram B. A chest radiograph C. A pulmonary arteriography D. Echocardiogram

D. Echocardiogram The heart's ejection fraction is measured using an echocardiogram or multiple gated acquisition scan. A pulmonary arteriography--> is used to confirm cor pulmonale. A chest radiograph--> can reveal the enlargement of the heart. An electrocardiogram--> is used to determine the activity of the heart's conduction system.

A patient's gradual decline in activity tolerance and increased shortness of breath have prompted her health care provider to assess the structure and size of her heart. Which of the following diagnostic tests is most likely to yield these assessment data? A. Cardiac catheterization B. Electrocardiography (ECG) C. Angiography D. Echocardiography

D. Echocardiography An echocardiogram yields a two-dimensional rendering of the heart's structure and mechanical function. An ECG indicates the heart's electrical activity, and angiography and cardiac catheterization are used to assess the patency of the coronary arteries.

A nurse examines the laboratory values of a client in heart failure. Which value indicates a compensatory hormone mechanism? A. Decreased red blood cell count B. Decreased hematocrit C. Elevated serum pH D. Elevated atrial natriuretic hormone

D. Elevated atrial natriuretic hormone In heart failure, the client experiences fluid backlog in the heart as venous blood continues to return, but cardiac output is reduced. This stretches the atria, which secrete atrial natriuretic hormone (or peptide) to stimulate vasodilation and increased renal excretion of sodium and water. This reduces the volume and the strain in the heart.

A nurse examines the laboratory values of a client in heart failure. Which value indicates a compensatory hormone mechanism? A. Decreased red blood cell count B. Elevated serum pH C. Decreased hematocrit D. Elevated atrial natriuretic hormone

D. Elevated atrial natriuretic hormone In heart failure, the client experiences fluid backlog in the heart as venous blood continues to return, but cardiac output is reduced. This stretches the atria, which secrete atrial natriuretic hormone (or peptide) to stimulate vasodilation and increased renal excretion of sodium and water. This reduces the volume and the strain in the heart.

Infectious mononucleosis is a lymphoproliferative disorder caused by the Epstein-Barr virus (EBV) that is usually self-limiting and nonlethal. Which complication can arise during this mostly benign disease? A. Rupture of the lymph nodes B. Peripheral nerve palsies C. Severe bacterial infections D. Enlarged spleen

D. Enlarged spleen Hepatitis and splenomegaly are common manifestations of infectious mononucleosis and are thought to be immune mediated. Hepatitis is characterized by hepatomegaly, nausea, anorexia, and jaundice. Although discomforting, it usually is a benign condition that resolves without causing permanent liver damage. The spleen may be enlarged two to three times its normal size, but rupture of the spleen is an infrequent complication. Cranial nerve palsies, not peripheral nerve palsies, can occur. Lymph nodes do not rupture. Severe bacterial infections are complications of Kostmann syndrome.

A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition? A. Stomatitis B. Periodontitis C. Gingivitis D. Glossitis

D. Glossitis Glossitis is an inflammation of the tongue. Gingivitis--> is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis--> is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis--> is an inflammation of the oral mucosa.

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? A. Supine with arms elevated on pillows above the level of the heart B. Head of the bed elevated 30 degrees and legs elevated on pillows C. Prone with legs elevated on pillows D. Head of the bed elevated 45 degrees and lower arms supported by pillows

D. Head of the bed elevated 45 degrees and lower arms supported by pillows Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.

Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color? A. Milia B. Nevi C. Xanthelasma D. Hemangioma

D. Hemangioma Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia--> are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma--> are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of the aging of the skin or a lipid disorder. Nevi--> are freckles.

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? A. Bleeding B. Dysrhythmias C. Inflammation D. Iodine allergy

D. Iodine allergy During lung scans, a radioactive contrast medium is administered intravenously for the perfusion scan. Before the perfusion scan, nurses must assess the client to check for allergies to iodine. Laryngoscopy--> determines inflammation. Dysrhythmias and bleeding are possible complications of mediastinoscopy.

The nurse is caring for a client with a dysrhythmia. While assessing the data in the history of the chart, the nurse anticipates the cause of the dysrhythmia to be which of the following? A. Peripheral vascular disease B. Aortic stenosis C. Atherosclerotic heart disease D. Ischemic heart disease

D. Ischemic heart disease The nurse realizes that the most common cause of dysrhythmias is ischemic heart disease. When the heart does not obtain sufficient blood to meet demands, the heart works harder to circulate body fluids and becomes inefficient in the process. Problems with the peripheral vessels, narrowing of the aorta and plaque buildup in the vessels may be a component of the disease process but not the best answer.

Which chemical does blood-brain and CSF-brain barrier control with easy entrance? A. Glutamate B. Potassium C. Protein D. Oxygen

D. Oxygen Two barriers, the blood-brain barrier and the cerebrospinal fluid (CSF)-brain barrier, provide the means for maintaining the stable chemical environment of the brain. Only water, carbon dioxide, and oxygen enter the brain with relative ease. Large molecules such as proteins are largely excluded from crossing the blood-brain barrier. In the brain, ammonia is converted to glutamine by astrocytes. Potassium has controlled entrance into the brain; the result of slight fluctuations of potassium concentration in the brain would be uncontrolled neural activity because ions such as potassium influence the threshold for neural firing.

Heparin is an anticoagulant given by injection to prevent the formation of blood clots. How does heparin work? A. Binds to factor Xa B. Binds to factor X C. Promotes the inactivation of factor VIII D. Promotes the inactivation of clotting factors

D. Promotes the inactivation of clotting factors Heparin binds to antithrombin III, causing a conformational change that increases the ability of antithrombin III to inactivate thrombin, factor Xa, and other clotting factors. By promoting the inactivation of clotting factors, heparin ultimately suppresses the formation of fibrin. Heparin does not bind to factors X and Xa. Heparin does not inactivate factor VIII.

A client has severe aortic valve disease. When educating the client about anatomy, what would the nurse include? A. The aortic valve separates the right atrium and right ventricle. B. The aortic valve separates the left atrium and left ventricle. C. The aortic valve separates the right ventricle and pulmonary artery. D. The aortic valve separates the left ventricle and aorta.

D. The aortic valve separates the left ventricle and aorta. Heart valves function to maintain the one-way flow of blood and prevent backflow. The mitral valve separates the left atrium and left ventricle. The tricuspid valve separates the right atrium and right ventricle. The pulmonic valve separates the right ventricle and pulmonary artery. The aortic valve separates the left ventricle and aorta.

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which phenomenon is most likely taking place? A. Bronchoconstriction and hyperventilation are initiated as a compensatory mechanism. B. Intracellular potassium and extracellular sodium levels are rising as a result of sodium-potassium pump failure. C. Hemolysis and blood pooling are taking place in the man's peripheral circulation. D. The man's alpha- and beta-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate.

D. The man's alpha- and beta-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate Alpha- and beta-adrenergic receptor activation is a central response to all types of shock. Hemolysis is not a noted accompaniment to shock. Bronchodilation, not bronchoconstriction, often results from adrenergic stimulation. Sodium-potassium pump failure results in increased extracellular potassium and intracellular sodium.

A client comes to the emergency room with all the symptoms of a myocardial infarction. Which lab value, known to have a high specificity for myocardial tissue considered the primary biomarker test for diagnosing an MI, does the nurse suspect the physician will order? A. Potassium B. Phosphorous C. Creatine kinase D. Troponin assays

D. Troponin assays The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction. Creatine kinase is an intracellular enzyme found in muscle cells. The troponin level identifies necrosis in cardiac muscles earlier than creatine kinase. The others are not necessarily used when suspecting a myocardial infarction.

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms? A. liver dysfunction B. unsteady gait C. weight loss D. organ damage

D. organ damage When the body is unable to counteract the effects of shock, further system failure occurs, leading to organ damage and ultimately death. Liver dysfunction may occur as one of the organs that fail. Weight fluctuations may occur if the client retains fluid or is administered a diuretic. Large fluctuations are not noted between shifts. The client's unsteady gait is not a result of an inadequate compensatory mechanism with shock but a result of immobility.