CYU #3: CH:16,18,19,20

Hypertension is closely linked to a. obstructive sleep apnea. b. urinary tract infection. c. de Quervain syndrome. d. spinal stenosis.

A. obstructive sleep apnea o Hypertension is present in 45% to 60% of those diagnosed with obstructive sleep apnea.

Patients presenting with symptoms of unstable angina and no ST segment elevation are treated with a. cardiac catheterization. b. antiplatelet drugs. c. acute reperfusion therapy. d. cardiac biomarkers only.

B. antiplatelet drugs o Patients presenting with symptoms of unstable angina and no ST elevation on the ECG would be treated with antiplatelet drugs as a cornerstone of therapy. Coronary angiography may be used as an additional method of diagnosis but would not be the primary option.

An elderly patient's blood pressure is measured at 160/98. How would the patient's left ventricular function be affected by this level of blood pressure? a. This is an expected blood pressure in the elderly and has little effect on left ventricular function. b. Left ventricular workload is increased with high afterload. c. High blood pressure enhances left ventricular perfusion during systole. d. High-pressure workload leads to left ventricular atrophy.

B. Left ventricular workload is increased with high after load. o Activation of the sympathetic nervous system increases the heart rate, contractility, blood pressure, and fluid retention by the kidney. Unfortunately, these compensatory efforts impose a greater workload on the heart. A blood pressure of 160/90 mm Hg is a higher than expected blood pressure in an elderly patient. High blood pressure does not enhance ventricular perfusion. Greater workload on the heart may contribute to further ischemic damage.

Myocarditis should be suspected in a patient who presents with a. chest pain and ST elevation. b. acute onset of left ventricular dysfunction. c. murmur and abnormal valves on echocardiogram. d. family history of cardiomyopathy.

B. acute onset of left ventricular dysfunction o Acute myocarditis is commonly characterized by left ventricular dysfunction or general dilation of all four heart chambers. o Myocarditis is associated with viral infections.

T/F: A patient is diagnosed with cardiogenic shock. The patient is hyperventilating and is therefore at risk for the respiratory complication of respiratory acidosis.

False A patient diagnosed with cardiogenic shock who is hyperventilating is at risk for respiratory alkalosis.

A patient presents to the emergency department with a diastolic blood pressure of 132 mm Hg, retinopathy, and symptoms of an ischemic stroke. This symptomology is likely the result of

Hypertensive crisis - Hypertensive crisis is characterized by a diastolic blood pressure of greater than 120 mm Hg, and symptoms of end-organ damage such as retinopathy and ischemic stroke.

T/F: Lactated Ringer solution and normal saline are commonly used crystalloid solutions that contain electrolytes.

TRUE - Lactated Ringer solution and normal saline are commonly used crystalloid solutions that contain electrolytes.

A patient who reports dizziness and who has absent P waves, wide QRS complexes, and a heart rate of 38 beats/minute on an ECG is most likely in which rhythm?

Ventricular escape rhythm A ventricular escape rhythm originates in the Purkinje fibers, has a rate of 15 to 40 beats/minute, and is characterized by a wide QRS complex. An important clue to identifying escape rhythms is the absence of normal P waves and PR intervals.

Rheumatic heart disease is most often a consequence of

β-hemolytic streptococcal infection. Rheumatic heart disease is an uncommon but serious consequence of rheumatic fever. Rheumatic fever is an acute inflammatory disease that follows infection with group A β-hemolytic streptococci.

A patient with a history of myocardial infarction continues to complain of intermittent chest pain brought on by exertion and relieved by rest. The likely cause of this pain is a. stable angina. b. myocardial infarction. c. coronary vasospasm. d. unstable angina.

A. stable angina o Stable angina is the most common form of chest pain and is characterized by pain that is caused under conditions of increased myocardial workload, such as physical exertion or emotional strain.

A patient with significant aortic stenosis is likely to experience a. syncope. b. hypertension. c. increased pulse pressure. d. peripheral edema.

A. syncope o In the patient with aortic stenosis, syncope and "greying out" episodes may occur when cerebral perfusion is inadequate. Low systolic blood pressure is a common sign of aortic stenosis. Faint pulses are a common sign of aortic stenosis.

The majority of cardiac cells that die after myocardial infarction do so because of

Apoptosis MI results when prolonged or total disruption of blood flow to the myocardium causes cellular death by necrosis or apoptosis.

In contrast to all other types of shock, the hyperdynamic phase of septic shock is associated with a. high afterload. b. low cardiac output. c. high cardiac output. d. reduced contractility.

C. high cardiac output o In the hyperdynamic stage of septic shock, blood pressure falls because of the decreased (SVR) systemic vascular resistance and (DVR) decreased venous return. The heart rate and stroke volume increase and cardiac output are higher than normal. o In the hyperdynamic phase of septic shock, afterload is not high.

High blood pressure increases the workload of the left ventricle, because it increases a. stroke volume. b. blood volume. c. preload. d. afterload.

D. afterload o Hypertension reflects an elevation in SVR; rising afterload increases myocardial oxygen demand and overall cardiac workload. **The workload of the left ventricle does not increase the stroke volume, blood volume, or preload.

Which serum biomarker(s) are indicative of irreversible damage to myocardial cells?

Elevated CK-MB, troponin I, and troponin T Elevated cardiac biomarkers are one indication of myocardial necrosis. Cardiac biomarkers may not be utilized if a patient presents with chest pain and evidence of acute ischemia on the electrocardiogram. Cardiac biomarkers are elevated in the presence of MI.

T/F: A type of shock that includes brain trauma that results in depression of the vasomotor center is cardiogenic.

FALSE - A type of shock that includes brain trauma that results in depression of the vasomotor center is neurogenic shock.

T/F: Chronic elevation of myocardial wall tension results in atrophy.

FALSE - Chronic elevation of myocardial wall tension results in hypertrophy.

Critically ill patients may have parenterally administered vasoactive drugs that are adjusted according to their _____ pressure.

Mean Arterial Pressure (MAP) The mean arterial pressure is used to make incremental adjustments to vasoactive drugs. The MAP is the calculated average pressure within the circulatory system throughout the cardiac cycle.

Beta-blockers are advocated in the management of heart failure because they

Reduce cardiac output Beta-blockers are advocated in the management of heart failure to inhibit the cardiac effects of sympathetic activation. These drugs are negative inotropes and have the potential to reduce cardiac output. The goal with the use of beta-blockers in heart failure is to reduce cardiac output.

Cardiogenic shock is characterized by

Reduced cardiac output Cardiogenic shock occurs primarily as a result of severe dysfunction of the left or right ventricles, or both, that results in inadequate cardiac pumping. The low cardiac output state is associated with a high left ventricular diastolic filling pressure.

Cor pulmonale refers to

Right ventricular hypertrophy secondary to pulmonary hypertension. Pulmonary disorders that result in increased pulmonary vascular resistance impose a high afterload on the right ventricle. The resultant right ventricular hypertrophy known as cor pulmonale may progress to right ventricular failure as the lung disease worsens.

T/F: The ingestion of certain drugs, foods, or chemicals can lead to secondary hypertension.

TRUE - The ingestion of certain drugs, foods, or chemicals can lead to secondary hypertension.

T/F: Disseminated intravascular coagulation is a serious complication of septic shock characterized by abnormal clot formation in the microvasculature throughout the body.

True Disseminated intravascular coagulation is a serious complication of septic shock characterized by abnormal clot formation in the microvasculature throughout the body.

What results when systemic blood pressure is increased?

Vasoconstriction At the smooth muscle of the arterial system, neurotransmitters bind to receptors to initiate vasoconstriction and increase systemic vascular resistance. An increase in vascular resistance causes the heart to work harder and thus increases blood pressure.

Sepsis has been recently redefined as

a systemic inflammatory response to infection. Systemic inflammatory response syndrome is the body's response to infection or other insults, which result in systemic signs and symptoms of widespread inflammation. Sepsis results from the presence of microorganisms in the bloodstream (bacteremia). Sepsis occurs as a result of bacteremia and is defined as a systemic inflammatory response to infection. Severe hypotension may be the result of sepsis, but it is not the definition.

Patients with structural evidence of heart failure who exhibit no signs or symptoms are classified into which New York Heart Association heart failure class? a. Class I b. Class II c. Class III d. Class IV

A. Class I o Patients who have structural heart disease, but no signs or symptoms of heart failure are placed in Class I of the NYHA Classes. § Class II patients have current or previous symptoms of heart failure. § Class III patients have current or previous symptoms of heart failure, such as dyspnea or fatigue. § Class IV patients have advanced structural heart disease and marked symptoms at rest.

After being diagnosed with hypertension, a patient returns to the clinic 6 weeks later. The patient reports "moderate" adherence to the recommended lifestyle changes and has experienced a decreased from 165/96 to 148/90 mm Hg in blood pressure. What is the most appropriate intervention for this patient at this time? a. Continue lifestyle modifications only. b. Continue lifestyle modifications plus diuretic therapy. c. Continue lifestyle modifications plus ACE inhibitor therapy. d. Continue lifestyle modifications plus b-blocker therapy.

A. Continue lifestyle modifications only o The patient should be encouraged to continue compliance with lifestyle changes since the patient has exhibited some positive response to his changes. § Diuretics are not needed at this time. § ACE inhibitors should not be added to the therapy yet. § β-blockers are not required at this time.

Which finding is indicative of orthostatic hypotension in a person with a supine blood pressure (BP) of 110/70 and a heart rate (HR) of 100? a. Sitting BP 88/60, HR 118 b. Sitting BP 108/68, HR 102 c. Sitting BP 110/78, HR 98 d. Sitting BP 120/80, HR 100

A. Sitting BP 88/60, HR 118 o The definition of orthostatic hypotension is a decrease in systolic blood pressure greater than 20 mm Hg or a decrease in systolic pressure that is greater than 10 mm Hg within 3 minutes of moving to an upright position.

Constrictive pericarditis is associated with a. impaired cardiac filling. b. cardiac hypertrophy. c. increased cardiac preload. d. elevated myocardial oxygen consumption.

A. impaired cardiac filling o Constrictive pericarditis results in a fibrous scarred pericardium that restricts cardiac filling.

An erroneously low blood pressure measurement may be caused by a. positioning the arm above the heart level. b. using a cuff that is too small. c. positioning the arm at heart level. d. measuring blood pressure after exercise.

A. positioning the arm above the heart level. o An erroneous blood pressure result could occur with the arm above the level of the heart *It is important to measure blood pressure with the appropriate size cuff. *The arm should be positioned at the level of the heart for a more accurate reading. *Measuring pressure after exercise yields a higher measurement.

In which dysrhythmias should treatment be instituted immediately?

Atrial fibrillation with a ventricular rate of 220 beats/minute Atrial fibrillation is a completely disorganized and irregular atrial rhythm accompanied by an irregular ventricular rhythm of variable rate. Atrial fibrillation causes the atria to quiver rather than to contract forcefully. This allows blood to become stagnant in the atria and may lead to formation of thrombi. This condition requires resuscitation because of the reduction in cardiac output. The cause of the bradycardia should be investigated, but is not treated emergently when an individual is not exhibiting any symptoms. Fever-induced tachycardia will correct itself once the fever is lowered. Dysrhythmias are treated if they produce significant symptoms or are expected to progress to a more serious level.

Angiotensin-converting enzyme (ACE) inhibitors block the a. release of rennin. b. conversion of angiotensin I to angiotensin II. c. conversion of angiotensinogen to angiotensin I. d. effect of aldosterone on the kidney.

B. conversion of angiotensin I to angiotensin II o Angiotensin I is converted into angiotensin II while it is circulating through the pulmonary vessels, by the angiotensin-converting enzyme. ACE inhibitors block the conversion of angiotensin I to angiotensin II.

A patient has a history of falls, syncope, dizziness, and blurred vision. The patient's symptomology is most likely related to a. hypertension. b. hypotension. c. deep vein thrombosis. d. angina.

B. hypotension o Hypotension is low blood pressure characterized by dizziness, blurred vision, syncope, and injury from falls. § Hypertension is high blood pressure characterized by headache, confusion, chest pain, and difficulty breathing. § Deep vein thrombosis is evidenced by calf pain or tenderness. § Angina is characterized by chest, shoulder, or jaw pain.

Lusitropic impairment refers to a. poor contractile force. b. impaired diastolic relaxation. c. altered action potential conduction rate. d. altered automaticity.

B. impaired diastolic relaxation o Lusitropic impairment refers to an energy-requiring process that removes free calcium ions from the cytoplasm by pumping them back into the sarcoplasmic reticulum and across the cell membrane into the extracellular fluid. Ischemia interferes with this process in the active phase of diastolic relaxation.

Second-degree heart block type I (Wenckebach) is characterized by a. absent P waves. b. lengthening PR intervals and dropped P wave. c. constant PR interval and dropped QRS complexes. d. no correlation between P waves and QRS complexes.

B. lengthening PR o Type I second-degree block is associated with progressively lengthening PR intervals until one P wave is not conducted and becomes a dropped beat.

A patient who was involved in a fall from a tree becomes short of breath. The lung sounds are absent on one side. This patient is experiencing ________ shock. a. cardiogenic b. obstructive c. hypovolemic d. distributive

B. obstructive o This type of obstructive shock is the result of a tension pneumothorax and is caused by shifting and compression of mediastinal structures including the heart, which compromise left ventricular filling. Accumulation of air in the pleural space may occur because of trauma. Prompt relief of the obstructive event is necessary to restore cardiac output and prevent cardiovascular collapse.

The common denominator in all forms of heart failure is a. poor diastolic filling. b. reduced cardiac output. c. pulmonary edema. d. tissue ischemia.

B. reduced cardiac output o The common manifestation of all forms of heart failure is the failure of the heart to pump blood adequately. The clinical presentation may differ depending on which ventricle fails (left or right, or both).

A patient presenting with fever, hypotension, and lactic acidosis is most likely to be experiencing what type of shock? a. Cardiogenic b. Septic c. Anaphylactic d. Neurogenic

B. septic o Patients presenting with septic shock may have fever and hypotension. In addition, lactic acidosis may be present because of tissue hypoxemia.

Massive release of histamine with consequent vasodilation and hypotension occurs with what type of shock? a. Cardiogenic b. Hypovolemic c. Anaphylactic d. Neurogenic

C. Anaphylactic o Exposure to a specific antigen causes receptors on mast cells and basophils to cross-link and activate histamine. The release of histamine along with other vasoactive chemicals produces bronchoconstriction.

Improvement in a patient with septic shock is indicated by an increase in a. cardiac output. b. SvO2. c. systemic vascular resistance. d. serum lactate level.

C. SVR- Systemic vascular resistance o Systemic vascular resistance results in intravascular pooling in the venous system. Some portions of tissue are over perfused, and some are under perfused. Improvement in systemic vascular resistance is an indication of improvement in septic shock.

Tachycardia is an early sign of low cardiac output that occurs because of a. tissue hypoxia. b. anxiety. c. baroreceptor activity. d. acidosis.

C. baroreceptor activity o A number of compensatory responses are set in motion to restore tissue perfusion and oxygenation in the early stage of shock. o Baroreceptors located in the aorta and carotid arteries quickly sense the decrease in pressure and transmit signals to the vasomotor center in the brainstem medulla. o The sympathetic nervous system stimulates β1 receptors, which respond by increasing the heart rate in an attempt to increase cardiac output.

Increased preload of the cardiac chambers may lead to which patient symptom? a. Decreased heart rate b. Decreased respiratory rate c. Edema d. Excitability

C. edema o Preload reduces glomerular filtration, resulting in fluid conservation, or edema.

Tumor necrosis factor α and interleukin-1 contribute to shock states because they induce production of a. catecholamines. b. clotting factors. c. nitric oxide. d. vasopressin.

C. nitric oxide o In septic shock, tumor necrosis factor-α, interleukin-1, and other inflammatory mediators induce vascular cells to produce excessive amounts of the vasodilator nitric oxide.

Hypertension with a specific, identifiable cause is known as _____ hypertension. a. primary b. orthostatic c. secondary d. malignant

C. secondary o Secondary hypertension has a specific identifiable cause such as a specific pathology or a condition that results in hypertension.

Restriction of which electrolytes are recommended in the management of high blood pressure? a. Calcium b. Potassium c. Sodium d. Magnesium

C. sodium o The balance of the intake of water and sodium with their excretion by the kidney remains the central feature of long-term blood pressure maintenance. Sodium is not rapidly eliminated by the kidney like water and adds to the body's fluid volume.

Administration of which therapy is most appropriate for hypovolemic shock?

Crystalloids Crystalloids are solutions that contain electrolytes. Isotonic solutions, such as lactated Ringers, are commonly used crystalloid solutions. These solutions are preferred for volume resuscitation, because they remain in the extracellular space and are more effective in increasing blood volume. Isotonic crystalloids are the most appropriate fluid for volume resuscitation. Isotonic fluids are preferred over glucose or hypotonic electrolyte solutions.

A patient is exhibiting severe dyspnea and anxiety. The patient also has bubbly crackles in all lung fields with pink, frothy sputum. This patient is most likely experiencing a. right-sided heart failure. b. cardiomyopathy. c. a medication reaction. d. acute cardiogenic pulmonary edema.

D. acute cardiogenic pulmonary edema o Acute cardiogenic pulmonary edema is a life-threatening condition requiring immediate treatment. It is associated with left ventricular failure that severely impairs gas exchange, and produces dramatic signs and symptoms including anxiety, severe dyspnea, an upright posture to breathe effectively, and pink frothy sputum.

The majority of cases of anaphylactic shock occur when a sensitized individual comes in contact with a. perfumes. b. incompatible blood products. c. animal proteins or dander. d. antibiotics.

D. antibiotics o Anaphylactic shock is most frequently associated with antibiotic therapy.

The therapy that most directly improves cardiac contractility in a patient with systolic heart failure is a. afterload reduction. b. β-antagonist agents. c. preload reduction. d. digitalis.

D. digitalis o Digitalis may be used for symptom management of heart failure. Cardiac glycosides directly inhibit the sodium-potassium pump present in the cell membrane of all cells. The intracellular changes allow more calcium to remain in the cell, thus strengthening myocardial contraction.

Angina caused by coronary artery spasm is called _____ angina. a. stable b. classic c. unstable d. Prinzmetal variant

D. prinzmetal variant o Variant, or Prinzmetal, angina is the term applied to vasospasm-initiated anginal symptoms caused by significant atherosclerotic plaques. These spasms usually respond promptly to vasodilating agents.

Hypertrophy of the right ventricle is a compensatory response to a. aortic stenosis. b. aortic regurgitation. c. tricuspid stenosis. d. pulmonary stenosis.

D. pulmonary stenosis o Right ventricular hypertrophy is the direct result of pulmonary disorders that increase pulmonary vascular resistance and impose a high afterload on the right ventricle.

The majority of tachydysrhythmias are believed to occur because of a. triggered activity. b. enhanced automaticity. c. defective gap junctions. d. reentry mechanisms.

D. reentry mechanisms o Reentry is thought to be the culprit in most tachydysrhythmias. Reentry is a complex process in which a cardiac impulse continues to depolarize in a part of the heart after the main impulse has finished its path.

Overproduction of nitric oxide is an important aspect of the pathophysiologic process of what type of shock? a. Cardiogenic b. Hypovolemic c. Anaphylactic d. Septic

D. septic o The overproduction of nitric oxide is seen in septic shock as a result of the release of immune cytokines. **Nitric oxide is not seen in cardiogenic shock. **Hypovolemic shock is not associated with the overproduction of nitric acid. **The pathophysiologic process of anaphylactic shock is not associated with the overproduction of nitric oxide.

What compensatory sign would be expected during periods of physical exertion in a patient with limited ventricular stroke volume? a. Hypotension b. Bradycardia c. Aortic regurgitation d. Tachycardia

D. tachycardia o An individual with reduced stroke volume would exhibit compensatory increases in heart rate. Hypertension is associated with decreased ventricular stroke volume. o An individual with reduced stroke volume would exhibit compensatory increases in heart rate; therefore, bradycardia would not be expected.

Primary treatment for myocardial infarction (MI) is directed at

Decreasing myocardial oxygen demands Reducing oxygen demand may be effective in preserving myocardial muscle. Decreasing demand increases myocardial oxygen supply. Once the cardiac muscle has been damaged, it is more important to preserve remaining muscle and prevent further loss of the myocardium.

Aortic regurgitation is associated with

Diastolic murmur - Aortic regurgitation results from an incompetent aortic valve that allows blood to leak back from the aorta into the left ventricle during diastole. In aortic regurgitation, there is not an elevated left ventricular/aortic pressure gradient. Diastolic blood pressure is generally lower because of rapid runoff of blood into the ventricle. Aortic regurgitation is associated with a longer ventricular ejection phase.

T/F: New-organ damage is a function of both the stage of hypertension and its duration.

FALSE - End-organ damage is a function of both the stage of hypertension and its duration.

A patient with cold and edematous extremities, low cardiac output, and profound hypotension is likely to be experiencing a progressive stage of ________ shock.

Septic - In the progressive stage of septic shock, some patients deteriorate to a hypodynamic state. This is characterized by decreased cardiac output and cold, clammy skin as a result of narrowed pulse pressure.

Which blood pressure reading is considered to be indicative of prehypertension according to the JNC-7 criteria?

a. 128/82 In adults, a normal blood pressure is 120 mm Hg systolic and 80 mm Hg diastolic pressure. Stage 1 hypertension begins with a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg. Between these values, the individual is said to have prehypertension, and interventions related to lifestyle changes should be initiated for primary hypertension.