Socrative Questions (Quiz 4)
A patient awaiting a heart transplant is experiencing decompensation of her left ventricle that will not respond to medications. The physicians suggest placing the patient on a ventricular assist device (VAD). The patient asks what this equipment will do. The health care providers respond:
"This device will decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure." Rationale: Refractory heart failure reflects deterioration in cardiac function that is unresponsive to medical or surgical interventions. Ventricular assist devices (VADs) are mechanical pumps used to support ventricular function. VADs are used to decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure. This decreases the workload on the ventricle and allows it to rest and recover. The rest of the distractors relate to the monitoring in an ICU of cardiac functioning. Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. With the balloon inflated, the catheter monitors pulmonary capillary pressures (i.e., pulmonary capillary wedge pressure or pulmonary artery occlusion pressure), which reflect pressures from the left ventricle. The pulmonary capillary pressures provide a means of assessing the pumping ability of the left ventricle. One type of pulmonary artery catheter is equipped with a thermistor probe to obtain thermodilution measurements of cardiac output.
A health care provider was asked by a client, "Why do my hands turn blue when I drive my car in the winter without gloves?" Which of the following is the best response?
"Your arteries in your hands/fingers are going into spasm, which decreases blood flow and circulating oxygen." Rationale: Raynaud disease is caused by vasospasms of small distal arteries; thromboangiitis obliterans is caused by an inflammatory process that affects veins and nerves
A 42 y/o patient is extremely anxious after being diagnosed with an abdominal aortic aneurysm and learning that the cardiologist's recommendation is to monitor the aneurysm rather than immediately repairing the aneurysm surgically. The nurse understands which factors were part of the consideration to monitor the aneurysm rather than immediately repair?
- BP 118/76 reduces the risk of rupture - Aneurysm size = 2 cm reduces the risk of rupture Rationale: hypertension and aneurysm > 5cm are both significant factors in increasing risk of rupture; age < 50 reduces incidence but does not impact risk of rupture; any aneurysm can rupture regardless of location, family history does not impact risk of rupture
A patient is admitted with dilated cardiomyopathy with left ventricular dysfunction. The nurse should assess for which of the following clinical manifestations? Select all that apply.
- Dyspnea - Orthopnea - Extreme fatigue with activity Rationale: The most common clinical manifestations of DCM are those related to heart failure, such as dyspnea, orthopnea, and reduced exercise capacity. Hypertrophic cardiomyopathy (HCM) is characterized by myocardial thickening and abnormal diastolic filling. They experience fainting/syncope. Restrictive cardiomyopathy, in which there is excessive rigidity of the ventricular wall, increases the work of ventricular emptying and causes cardiac hypertrophy. These patients experience excess abdominal fluid (ascites).
At the cellular level, cardiac muscle cells respond to an increase in ventricular volume to the point of overload by: Select all that apply - remember this is chamber stretch, not pressure overload.....
- Elongating the cardiac muscle cells - Thinning of the ventricular walls Rationale: At the cellular level, cardiac muscle cells respond to stimuli from stress placed on the ventricular wall by pressure and volume overload by initiating several different processes that lead to hypertrophy. With ventricular volume overload, the increase in wall stress leads to replication of myofibrils in series, elongation of the cardiac muscle cells, and eccentric hypertrophy. Eccentric hypertrophy leads to a decrease in ventricular wall thickness or thinning of the wall with an increase in diastolic volume and wall tension. Production of a symmetric hypertrophy occurs with a proportionate increase in muscle length and width, as occurs in athletes; concentric hypertrophy with an increase in wall thickness, as occurs in hypertension; and eccentric hypertrophy with a disproportionate increase in muscle length, as occurs in dilated cardiomyopathy. When the primary stimulus for hypertrophy is pressure overload, the increase in wall stress leads to parallel replication of myofibrils, thickening of the individual myocytes, and concentric hypertrophy. Concentric hypertrophy may preserve systolic function for a time, but eventually the work performed by the ventricle exceeds the vascular reserve, predisposing to ischemia.
While creating a discharge plan for a patient who was admitted with an acute exacerbation of heart failure, the nurse wants to include reinforcement teaching of the factors related exacerbations of heart failure. Which of the following would the nurse want to include in the discharge teaching? Select all that apply.
- Follow prescribed medication regimen - Low-sodium, low-fat, low-cholesterol diet - Maintain a balanced level of activity Rationale: patients with heart failure should follow their prescribed medication regimen, follow a low-sodium, low-fat, low-cholesterol diet and maintain a balanced level of activity; vigorous exercise would never be recommended for a patient with poor heart function and fluids should be decreased with exacerbations of symptoms
Electrical burns over a large surface area of a patient's body have resulted in hypovolemic shock after the loss of large amounts of blood and plasma. Following physical assessment, which findings lead the nurse to believe the patient's body is compensating for this fluid loss? Select all that apply.
- Increased heart rate - Complaints of thirst - Deep, rapid respirations Rationale: Compensatory mechanisms in hypovolemic shock include increased heart rate, peripheral vasoconstriction, and fluid and sodium retention in order to preserve vascular volume. Urine output decreases very quickly in hypovolemic shock. Thirst is an early symptom in hypovolemic shock. As shock progresses, the respirations become rapid and deep to compensate for the increased production of acid and decreased availability of oxygen.
When considering the differences between peripheral arterial disease and peripheral venous disease, the nurse recognizes the following to be characteristics of peripheral arterial disease:
- Intermittent claudication - Diminished pulse - Pale Rationale: intermittent claudication, diminished pulse and pale tissue color are all associated with peripheral arterial disease; cramping, brawny skin, red tissue color and warmth are associated with peripheral venous disease
A patient has arrived in the emergency department in cardiogenic shock. Which of the following assessment findings confirm this diagnosis? Select all that apply.
- Less than 5 mL dark concentrated urine in the past hour - Blood pressure reading of 80/65 down from 92/68 15 minutes ago - Difficult to arouse with changes in level of consciousness Rationale: The signs and symptoms of cardiogenic shock are consistent with those of end-stage heart failure. The lips, nail beds, and skin may become cyanotic because of stagnation of blood flow. Mean arterial and systolic blood pressures decrease due to poor stroke volume, and there is a narrow pulse pressure because of arterial vasoconstriction. Urine output decreases because of lower renal perfusion pressures and the increased release of aldosterone. Neurologic changes, such as alterations in cognition or consciousness, may occur because of low cardiac output and poor cerebral perfusion.
Which of the following diagnostic/assessment findings would been seen in a patient with worsening mitral valve stenosis? Select all that apply.
- Low-pitched diastolic murmur that is increasing in duration - Sharp elevation in left atrial pressure - Decreased cardiac output Rationale: The increased left atrial pressure eventually is transmitted to the pulmonary venous system, causing pulmonary congestion. A characteristic auscultatory finding in mitral stenosis is an opening snap following the second heart sound, which is caused by the stiff mitral valve. As the stenosis worsens, there is a localized low-pitched diastolic murmur that increases in duration with the severity of the stenosis. Manifestations are related to the elevation in left atrial pressure and pulmonary congestion such as dyspnea with exertion, decreased cardiac output owing to impaired left ventricular filling, and left atrial enlargement with the development of atrial arrhythmias and mural thrombi. Severe elevation in left ventricular end-diastolic pressure and left ventricle increases its stroke volume occur with aortic regurgitation.
During the discharge teaching of a 44 year old male patient newly diagnosed with primary hypertension, the nurse includes which of the following as possible complications of hypertension? Select all that apply.
- Myocardial infarction - Cerebral vascular accident (stroke) - Renal disease Rationale: MI, CVA, renal disease are all possible complications of HTN; diabetes has associated risk factors but is not a complication of HTN
Modifiable risk factors for hypertension include: (select all that apply)
- Obesity (BMI > 30) - Smoking - High salt diet
A client with a history of heart failure has been referred for an echocardiogram. Results of this diagnostic test reveal the following findings: heart rate 80 beats/minute; end-diastolic volume 120 mL; and end-systolic volume 60 mL. What is this client's ejection fraction?
50% Rationale: Ejection fraction = stroke volume ÷ end-diastolic volume, whereas stroke volume equals the difference between end-diastolic and end-systolic volume. Therefore, EF = 60 ÷ 120, or 50%.
When considering risk factors for atherosclerosis and coronary artery disease (CAD), the nurse recognizes which of the following patients has the greatest risk of having undiagnosed coronary artery disease?
65 y/o female with diabetes mellitus, HDL 41 mg/dL, LDL 118 mg/dL, total cholesterol 253 mg/dL Rationale: patient with DM has multiple risk factors for atherosclerosis and coronary artery disease (CAD) - age, DM, elevated LDL (>100), elevated total cholesterol (>200)
Heart muscle differs from skeletal muscle tissue by being able to generate:
Action potentials Rationale: Heart muscle, or the myocardium, is unique among other muscles in that it is capable of generating and rapidly conducting its own electrical impulses or action potentials. These action potentials result in excitation of muscle fibers throughout the myocardium. Similarities to skeletal muscle include contractility, calcium influx, and actin-myosin (sarcomeres) binding.
The nurse understands the distinction between stable angina and myocardial infarction is best characterized by which of the following statements?
Angina is consistent with myocardial ischemia and ST depression on ECG. Rationale: angina is consistent with intermittent myocardial ischemia d/t reduced blood flow to the coronary arteries, myocardial ischemia produces ST segment depression on ECG; myocardial infarction is consistent with myocardial death, ST elevation, and pathologic Q wave changes on ECG
A child's history of a recurrent sore throat followed by severe knee and ankle pain has resulted in a diagnostic workup and a diagnosis of rheumatic fever. What are the treatment priorities for this child?
Antibiotics and anti-inflammatory drugs Rationale: A diagnosis of rheumatic fever (RF) necessitates the use of antibiotics (usually penicillin) and anti-inflammatory drugs. These measures supersede the importance of pain control and oxygen therapy. Cardiac catheterization, corticosteroid therapy, pacemakers, and b-adrenergic blockers are not common treatment modalities for RF.
A patient diagnosed with left sided heart failure is confused as to why his heart is causing him to be short of breath. How would the nurse best explain the pumping of blood through the left side of the heart?
Blood is pumped from the lungs through the pulmonary vein into the left atrium Rationale: blood flows through the right side of the heart, into the lungs via pulmonary artery, out of the lungs through the pulmonary vein and into the left atrium through mitral valve into the left ventricle and out to the body through the aorta
When evaluating an infant with coarctation of the aorta, which assessment finding beyond cyanosis would the nurse anticipate?
Blood pressure in the child's legs is lower than in the arms Rationale: 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.
When caring for a patient with chronic fluid volume excess, what would the nurse expect to find during the assessment of the patient's vital signs?
BP 142/88, HR 60 Rationale: fluid volume excess contributes to a rise in BP due to an overall increase in body fluid levels; in response to the elevated BP, neural regulation is going to stimulate the PNS in the cardiovascular center in the brain to slow HR, prompt vasodilation; SNS would increase HR & vasoconstriction in response to low BP
A large increase in heart rate can cause:
Decreased stroke volume Rationale: The time spent in diastole and filling of the ventricles becomes shorter as the heart rate increases. This leads to a decrease in stroke volume and, at high heart rates, may produce a decrease in cardiac output. Increased heart rate does not typically cause increased blood viscosity, a loss of action potential, or reduced cardiac contractility.
For which of the following types of shock might intravenous antibiotics be indicated?
Distributive shock Rationale: Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.
In caring for an 86 y/o female patient diagnosed with atherosclerosis and hypercholesteremia, the nurse teaches the patient to self-monitor for what early sign of worsening coronary artery disease?
Fatigue Rationale - fatigue is an early sign of CAD due to decreased myocardial blood flow and oxygenation; chest pain is a late sign of the disease indicating angina or MI; anorexia and headache are not associated with CAD
An 86-year-old male patient is disappointed to learn that he has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which of the following age-related changes predisposes older adults to developing heart failure?
Increased vascular stiffness Rationale: Increased vascular stiffness in older adults causes a progressive increase in systolic blood pressure with advancing age, which in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. A loss of action potential does not typically accompany aging, and contractility tends to decrease as a result of cardiac stiffness. Orthostatic hypotension is neither a normal age-related change nor a cause of heart failure.
An elderly female patient who reports increasing fatigue has been diagnosed with aortic stenosis, a disease that her primary care provider believes may have been long-standing. Which of the following compensatory mechanisms has most likely maintained the woman's ejection fraction until recently?
Left ventricular hypertrophy Rationale: Because aortic stenosis develops gradually, the left ventricle has time to adapt by increasing in wall thickness to maintain a normal ejection fraction. Increased blood pressure and heart rate and dilation of the aorta are not responses that mitigate the effects or aortic stenosis.
Unstable, vulnerable plaque and the risk of plaque rupture and thrombus formation is most commonly associated with what acute coronary syndrome?
Myocardial infarction Rationale: rupture of unstable plaque and the formation of a thrombus is most commonly associated with myocardial infarction; the clot obstructs the blood flow of the coronary artery causing blood flow distal to the clot to be blocked and tissue ischemia/infarction to occur resulting in myocardial tissue death; chronic ischemic heart disease is precipitated by narrowing of the coronary vessels, typically r/t atherosclerosis
A patient has been experiencing increasing fatigue in recent months, a trend that has prompted an echocardiogram. Results of this diagnostic test suggest that the patient's end-diastolic volume is insufficient. Which of the following parameters of cardiac performance will directly decrease as a result of this?
Preload Rationale: Preload is the volume of blood stretching the heart muscle at the end of diastole and is normally determined mainly by the venous return to the heart. Afterload represents the force that the contracting heart muscle must generate to eject blood from the filled heart. Cardiac contractility, or inotropy, is the contractile performance of the heart.
The most significant potential complication of a lower extremity DVT is:
Risk of thrombosis to lung Rationale: the greatest potential risk complication is DVT releasing a portion of the thrombus into circulation and becoming lodged in pulmonary circulation to create a PE; venous ulcers are a potential complication due to chronic venous insufficiency, but not directly related to DVT; necrotic infection is typically associated with arterial disease
Persistent cyanosis has led an infant's healthcare team to suspect a congenital heart defect. Which of the following diagnoses would the nurse anticipate based on the infant's cyanosis?
Tetralogy of Fallot Rationale: Tetratlogy of Fallot is the only cyanotic heart defect in the optiona; Cyanotic heart defects shunt blood right to left increasing the amount of unoxygenated blood in circulation to the body; patent ductus arteriosus, ASD, and VSD are all acyanotic defects - acyanotic defects shunt blood left to right and increase heart/lung volumes and result in heart failure symptoms
The most important complication of atherosclerosis that may cause occlusion of small heart vessels is:
Thrombosis Rationale: Thrombus formations on complicated atherosclerotic lesions are the result of sluggish blood flow and turbulence in the ulcerated plaque region. Fatty streaks are preatherosclerotic plaque changes in vessels. Fibrous plaque is part of the atherosclerosis formation, not a complication of it.
Preload represents the volume work of the heart and is largely determined by:
Venous blood return Rationale: Preload represents the amount of blood the heart must pump with each beat and represents the volume of blood stretching the ventricular muscle fibers at the end of diastole. Pressure (resistance), contraction, and ventricular emptying relate to afterload.