Vsim Health Assessment Case: Jared Griffin

The nurse is gathering subjective data during a cardiovascular assessment from a patient's spouse. Which question is particularly appropriate for a patient who has reported that, "My heart seems to skip beats"?

"Have you seen periods when your spouse seems to experience uncommon fatigue?" Rationale: Episodes of fatigue are a symptom associated with compromised cardiac output. Irregular cardiac rhythm (skipped beats) can be a factor associated with impaired cardiac output. Edema and an urgent need to urinate at night (nocturia) are associated with congested heart failure (CHF). Tobacco use is a risk factor for heart disease.

Which patient is expected to have the lowest resting pulse rate (RPR)?

A non-Hispanic Black male Rationale: Non-Hispanic Black males have a lower mean RPR than those of non-Hispanic White males or Mexican American males, whereas non-Hispanic Black females and Mexican American females have lower mean RPRs than non-Hispanic White females. Adult females generally have RPRs that are a few beats faster than adult males.

When reviewing Mr. Griffin's medical record, the nurse recognizes what information as being a risk factor for atrial fibrillation? (Select all that apply.)

History of hypertension, Male over the age of 60 Rationale: Mr. Griffin's medical record confirms risk factors including a history of hypertension and being a male over the age of 60. Neither being black nor being a methicillin-resistant Staphylococcus aureus (MRSA) carrier is considered a risk factor for atrial fibrillation, nor is taking enoxaparin.

Which point on the heart will the nurse use to auscultate an apical pulse?

Apex Rationale: An apical pulse is best heard at the apex of the heart. The remaining options are locations used to auscultate the sounds related to the heart's valves.

Which example of nursing documentation best indicates that the patient has peripheral perfusion that reflects adequate cardiac output?

Capillary refill noted in less than 2 seconds Rationale: A capillary refill time of 2 seconds or less is indication of cardiac output that supports peripheral perfusion. The remaining options are examples of abnormal findings associated with insufficient peripheral perfusion.

The medical record states that the patient's pulse is "small and weak." Which characteristic will the nurse expect to detect when performing a cardiovascular assessment on this patient? (Select all that apply.)

-Diminished pulse pressure -A prolonged systolic peak -Slow upstroke Rationale:Pulse characteristics of a small, weak pulse would include slow upstroke, diminished pulse pressure, and a prolonged systolic peak. Bounding on palpation and a rapid rise and fall of the systolic peak are associated with large, bounding pulses.

The nurse is preparing a patient for a cardiovascular assessment. When providing the patient with information concerning the examination, which physical positions will the nurse indicate will be used during the examination? (Select all that apply.)

-Sitting upright while leaning forward -------Supine -Left lateral Rationale: The positions commonly used to facilitate this assessment include supine, left lateral, and sitting upright while leaning forward. Neither the right lateral nor prone position is useful.

The nurse is providing care for a patient whose partner says, "We're told that he occasionally has an irregular heartbeat. Is that bad?" Which response should the nurse make to best address the partner's concern?

It's normal to experience occasional premature beats. Rationale: Occasional premature beats are normal. Frequent episodes of irregular cardiac rhythm may be a result of a potassium imbalance or hypoxia or triggered by digoxin toxicity.

The life partner of a patient diagnosed with atrial fibrillation (AF) demonstrates a need for instruction when asking the nurse, "Can you tell me why this is a problem?" What is the nurse's best response?

The abnormal heartbeat results in poor blood flow to the heart. Rationale:The result of the irregular, rapid heartbeats is impaired blood flow that can result in a stroke, thromboembolism, and heart failure. Physical findings include hypotension, and laboratory findings can reveal hyperthyroidism. AF is most common in patients older than 60 but affects only approximately 5% of this age group.

What is the nurse's response when Mr. Griffin asks, "What is the biggest worry about having atrial fibrillation?"

The blood tends to pool in your heart's upper chamber, increasing the risk of developing a clot. Rationale:I n atrial fibrillation, or A-Fib, the signals to the upper part of the heart are very fast and not regular. Instead of beating as usual, the atria just quiver. The blood does not empty fully from the upper chambers. It can just pool in the atria. Clots may form, which puts the patient at risk for a stroke. Atrial fibrillation is not responsible for causing dysfunctional valves, triggering an MI, or weakening the cardiac muscle itself.

A nurse is discussing the evaluation of an electrocardiograph recently performed on a patient with a nursing student. Which data will the nurse identify for the student as being within normal limits? (Select all that apply.)

-Heart rate is between 60 and 100 beats/min (bpm) -The T wave is rounded and smooth -A P wave is visible before each QRS complex Rationale: Normal results for an ECG include a heart rate between 60 and 100 beats/min, normal sinus rhythm, a P wave that precedes each QRS complex, a PR interval that lasts 0.12 to 0.20 seconds, a QRS complex that lasts 0.12 seconds, an ST segment less than or equal to 0.1 mV, a T wave that is rounded, smooth, and is positive in leads I, II, V3, V4, V5, and V6. Finally, the QT interval duration varies but usually lasts 0.36 to 0.44 seconds.

The nurse and a nursing student are reviewing the electrocardiograph (ECG) of a patient diagnosed with atrial fibrillation (AF). Which characteristics noted will the nurse identify as being associated with this cardiac condition? (Select all that apply.)

-Irregular QRS complexes -Absent P waves -Low-amplitude fibrillation waves Rationale: The ECG associated with atrial fibrillation is characterized by irregular QRS complexes with low-amplitude fibrillation waves without a P wave. Neither of the other options is associated with AF.

A patient has been recently diagnosed with atrial fibrillation. Which expected outcome will the nurse include in the care plan to address the resulting anxiety?

Patient will learn and demonstrate effective coping behaviors Rationale:Effective coping will assist the patient in effectively managing the resulting anxiety. Increased energy is associated with the presence of activity intolerance. Mental status is associated with cardiac output, whereas an understanding of treatment regimen is directed toward correcting a knowledge deficiency.

A patient is diagnosed with atrial fibrillation (AF) based on an electrocardiogram (ECG). Which of the following nursing assessment findings could also be demonstrated by a patient experiencing AF? (Select all that apply.)

-History of chest pain -Jugular vein distension -Tachycardia -An irregular pulse Rationale: Irregular pulse, tachycardia, elevated jugular venous pressure (leading to jugular vein distension), and a history of chest pain are assessment findings that support a diagnosis of AF. An audible carotid bruit is not associated with AF.

When preparing a patient for an electrocardiograph (ECG) the nurse will include which instructional information? (Select all that apply.)

-It is important that the patient remain as still and relaxed as possible during the test -The test is painless -The patient will be asked to lie on his or her back for the length of the test, which is 5-10 minutes, -Sticky-backed electrodes will be attached directly to the skin on the patient's arms, legs, and chest Rationale: Instructional information regarding an ECG should include the use of sticky electrodes being attached to the skin on the arms, legs, and chest. The importance of remaining physically still and relaxed while lying on the back for approximately 5-10 minutes should also be discussed. It is important that the patient be reassured that the test is painless. The patient is not required to answer questions during the test, and talking is discouraged.

Preparing for an electrocardiogram (ECG) is a priority nursing intervention for which patient? (Select all that apply.)

A patient newly diagnosed with mild hypokalemia, A patient who just had a pacemaker placed, A patient reporting, "I feel like my heart is skipping beats", A patient experiencing diaphoresis and arm pain Rationale: The ECG is used to identify conduction abnormalities, cardiac arrhythmias (associated with hypokalemia), and myocardial infarctions. It is also used to document pacemaker performance. It is reasonable to expect that the patient recovering from the MI will be prescribed an ECG to monitor ongoing status of heart conduction, but this does not take priority over identifying the acute presence of cardiac dysfunction presented by the correct options.

To assess a patient's heart during a physical assessment, which actions will the nurse perform? (Select all that apply.)

Assess heart rate and rhythm using the diaphragm of the stethoscope, Ask the patient to lie on the left side to assess sounds from the apex of the heart, Assess the apex, left sternal border, and base of the heart for abnormal pulsations, Auscultate over the aortic, pulmonic, tricuspid, and mitral areas, as well as Erb's point Rationale: Effective technique for the assessment of the heart would include assessing the apex, left sternal border, and base of the heart for abnormal pulsations; auscultating over the aortic, pulmonic, tricuspid, and mitral areas, as well Erb's point; assessing sounds from the apex of the heart while the patient is positioned on the left side; and using the diaphragm of the stethoscope to assess the heart's rate and rhythm. Assessing S1 and S2 heart sounds is done using the diaphragm of the stethoscope, not the bell.

Which action taken during a cardiovascular assessment will best assist the nurse in determining the hemodynamics of the right side of a patient's heart?

Inspection of the jugular venous pulse level Rationale: The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic ï¬lling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure. Auscultation of the carotid artery is associated with the detection of a bruit, indicative of some degree of occlusion. Palpation of the carotid artery is done to detect a loss of elasticity that is associated with arteriosclerosis. Inspection for apical impulse is done to determine the presence of an enlarged ventricle.

Of the medications Mr. Griffin has been prescribed, which one will the nurse discuss with the surgeon regarding its possible association with the patient's irregular heartbeat?

Oxycodone/acetaminophen Rationale: A cardiovascular adverse reaction associated with oxycodone/acetaminophen is arrhythmia. None of the remaining options has this known risk

Which assessment findings suggest an arterial vascular system abnormality? (Select all that apply.)

Thin, shiny skin over calves, Absence of hair over the lower legs Rationale: Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles are associated with venous insufficiency. Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks—but rarely in the feet with activity. These symptoms are quickly relieved by rest. Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle.