Prep U Unit 8: Cardiovascular System

A client with hypercholesterolemia is being treated with diet and exercise. Which assessment finding is a positive outcome of this treatment regimen?

increased high-density lipoproteins A goal in prescribing exercise and diet control in clients with hypercholesterolemia is to lower the level of low-density lipoproteins (LDL) and increase the high-density lipoproteins (HDL). Elevated blood glucose is evidence of possible diabetes mellitus.

Knowing the high incidence and prevalence of heart failure among older adults, the manager of a long-term care home has organized a workshop on the identification of early signs and symptoms of heart failure. Which teaching point is most accurate?

"Displays of aggression, confusion, and restlessness when the resident has no history of such behavior can be a sign of heart failure." Cognitive changes can often accompany heart failure in older adults. Pulmonary edema is a later sign and older adults are less likely to display coughing, chest pain, or flushed skin and fever.

ST-elevated myocardial infarction (STEMI) is accompanied by severe, crushing pain. Morphine is the drug of choice used to treat the pain of STEMI when the pain cannot be relieved with oxygen and nitrates. Why is morphine considered the drug of choice in STEMI?

Action decreases metabolic demands of the heart. Although a number of analgesic agents have been used to treat the pain of STEMI, morphine is usually the drug of choice. It usually is indicated if chest pain is unrelieved with oxygen and nitrates. The reduction in anxiety that accompanies the administration of morphine contributes to a decrease in restlessness and autonomic nervous system activity, with a subsequent decrease in the metabolic demands of the heart. Morphine does not cause a feeling of depression to the client.

Anaphylactic shock causes severe hypoxia very quickly because of which reason?

Histamine release causes massive vasodilation. Anaphylactic shock, a severe allergic reaction, rapidly causes severe hypoxia as histamine release results in massive vasodilation. The volume of blood is no longer able to fill the greatly dilated vascular compartment. The other answers are not part of anaphylaxis.

Select the response that best describes the pressure-sensitive receptors that respond to changes in the stretch of the vessel wall.

Baroreceptors Baroreceptors are pressure-sensitive receptors located in the walls of blood vessels and the heart. The arterial chemoreceptors are cells that monitor the oxygen, carbon dioxide, and hydrogen ion content of the blood. The cardiovascular center transmits impulses to the blood vessels. Neural control of the blood pressure is related to the integration and modulation of autonomic nervous system (ANS) response.

The nurse is reviewing a client's medications and lab results. The client has a high LDL level. Which medication can raise this level?

Beta-blockers Medications such as beta-blockers, estrogens and protease inhibitors can increase lipid levels.

The health care provider is discussing major risk factors for coronary artery disease (CAD) with a client. The most important information for the provider to include would be:

History of cigarette smoking and elevated blood pressure The major risk factors for CAD include cigarette smoking, elevated blood pressure, elevated LDL cholesterol, low HDL cholesterol, diabetes, advancing age, abdominal obesity, and physical inactivity.

Which blood vessels function without the benefit of having walls comprised of three muscular layers?

Capillaries The capillaries are small, thin-walled vessels that link the arterial and venous sides of the circulation and allow the exchange of oxygen and metabolites generated by the various tissues. The walls of all blood vessels, except the capillaries, are composed of three layers: tunica externa, tunica media, and tunica intima.

The heart valves control the direction of blood flow. What is the function of the pulmonic valve?

Controls the direction of blood flow from the right side of the heart to the lungs The heart valves control the direction of blood flow from the atria to the ventricles (the AV valves), from the right side of the heart to the lungs (pulmonic valve), and from the left side of the heart to the systemic circulation (aortic valve).

The nurse is reviewing laboratory results for a client who is experiencing angina. Which finding might be expected in a client with dyslipidemia?

Elevated total cholesterol Elevated total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride levels are associated with dyslipidemia. All the other answers are normal findings.

The student attends a health fair and has his serum cholesterol checked. He has a high lipoprotein level (LDL). He understands which of the following about LDL cholesterol?

It is believed to play an active role in the pathogenesis of the atherosclerotic lesion. Hyperlipidemia, particularly LDL, with its high cholesterol content, is also believed to play an active role in the pathogenesis of the atherosclerotic lesion. Dietary cholesterol tends to increase LDL cholesterol. HDL participates in the reverse transport of cholesterol by carrying cholesterol from the peripheral tissues back to the liver.

The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states the blood is shunted to which part of the body?

Left side of the heart to the right side of the heart Defects that result in a left-to-right shunt are categorized as acyanotic disorders since they do not compromise oxygenation of blood in the pulmonary circulation.

A nurse is assessing a female client and notes that her left arm is swollen from the shoulder down to the fingers, with non-pitting edema. The right arm is normal. The client had a left-sided mastectomy 1 year ago. What does the nurse suspect is the problem?

Lymphedema The lymphatic system filters fluid at the lymph nodes and removes foreign particles such as bacteria. When lymph flow is obstructed, a condition called lymphedema occurs. Involvement of lymphatic structures by malignant tumors and removal of lymph nodes at the time of cancer surgery are common causes of lymphedema.

A client presents to the emergency department reporting bilateral cyanosis and pallor of the fingers after being out in the cold weather for 5 minutes. The toes are of normal color. What is a potential diagnosis for this client?

Raynaud disease The symptoms of this client represent Raynaud disease. Frostbite would most likely have affected the feet and the hands. The others apply more to the lower extremities.

The nurse is reviewing the anatomy and physiology of the heart. What is the function of the right atrium?

Receives blood returning to the heart from the systemic circulation The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs. The left ventricle pumps blood into the systemic circulation.

A client has had an acute myocardial infarction (MI). The brother of the client has a history of angina. The client asks how he will know if his brother's pain is angina or if the brother is actually having an MI. Which statement is correct?

Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI. Rest and intake of nitroglycerin relieve chest pain with angina but not with an MI. Pain with angina and MI is a subjective symptom for each client. Pain with angina and MI can occur at a variety of times.

A client has prominent jugular veins. What type of medical problem is associated with prominent jugular veins?

Right-sided heart failure Right-sided heart failure is seen with prominent jugular veins.

A client has a blood pressure of 68/38 mm Hg and fainted after donating a unit of blood. The client is experiencing low preload from loss of blood volume. What is preload?

Venous return to the heart Preload is the amount of venous return to the heart. Afterload is the pressure in which the muscle exerts its contractile force in order to move blood into the aorta. Contractility is the ability of the heart to change its force of contraction without changing its resting length.

The cardiac cycle describes the pumping action of the heart. Which statement is correct about systole?

Ventricles contract and blood is ejected from the heart. Systole occurs when the ventricles contract and blood is ejected from the heart. Diastole occurs when the ventricles are relaxed and blood fills the heart.

The nurse is developing a plan of care for a postsurgical client. A major goal is to prevent the formation of deep vein thrombosis (DVT). Which nursing intervention should the nurse implement?

apply sequential pneumatic compression devices to lower extremities The application of sequential pneumatic compression devices augments blood flow and reduces stasis. Early ambulation is encouraged. Ice applications would not be recommended due to venous constriction.

An older adult client has been diagnosed with chronic heart failure. He is prescribed an ACE inhibitor to treat the symptoms and improve his quality of life. This drug will alleviate the client's symptoms of heart failure by:

blocking the conversion of angiotensin I to angiotensin II. ACE inhibitors block the conversion of angiotensin I to angiotensin II. They do not directly affect renin synthesis, calcium channel function, or afterload.

A client has been diagnosed with chronic obstructive arterial disease. Which client statement indicates she understands how to manage this disease?

"I should have my LDL monitored." Intermittent claudication is the primary symptom of chronic obstructive arterial disease. The two goals of treatment are to decrease the considerable cardiovascular risk and to reduce symptoms. Walking (slowly) to the point of claudication is encouraged because it increases collateral circulation. Addressing blood pressure and high lipid levels are measures to reduce cardiovascular risk. People with diabetes mellitus (DM) develop more extensive and rapidly progressive vascular disease than do people who do not have DM.

An older adult client newly diagnosed with systolic hypertension asks her health care provider why this happens. Which response is most accurate?

"With age, your arteries lose their elasticity and are replaced with collagen, which makes your arteries stiffer." Systolic blood pressure rises almost linearly between 30 and 84 years of age, whereas diastolic pressure rises until 50 years of age and then levels off or decreases. This rise in systolic pressure is thought to be related to increased stiffness of the large arteries. With aging, the elastin fibers in the walls of the arteries are gradually replaced by collagen fibers that render the vessels stiffer and less compliant.

Coronary artery bypass grafting (CABG) is a treatment modality for which disorder of cardiac function?

Atherosclerosis and unstable angina Coronary artery bypass grafting (CABG) may be the treatment of choice for people with significant coronary artery disease (CAD) who do not respond to medical treatment and who are not suitable candidates for percutaneous coronary intervention. CABG does not address valve disorders, pericardial effusion, or cardiomyopathies.

Which one of the following organs are the two primary sites of lipoprotein synthesis?

Small intestine and liver There are two sites of lipoprotein synthesis—the small intestine and the liver.

The nursing instructor is teaching the students about rheumatic fever. She tells the students that it is an important cause of heart disease and is very serious mainly for which reason?

The disabling effects that result from involvement of heart valves Rheumatic fever is a very important cause of heart disease and its most serious and disabling effects result from involvement of the heart valves.

The nurse suspects a client has stage 2 systolic hypertension. What systolic pressure would confirm the nurse's suspicion?

140 mm Hg or higher Classification of blood pressure in adults defines a systolic pressure of 140 mm Hg or higher as stage 2 hypertension. Stage 1 hypertension has a systolic pressure between 130 and 139 mm Hg. Systolic blood pressure between 120 and 129 mm Hg is classified as elevated and 119 mm Hg or lower is classified as normal.

The nurse knows that the main objective of the management of hypertension is to achieve a sustainable level of blood pressure below:

140/90 The main objective of hypertension management is to achieve a pressure of 140/90, although persons with renal disease or diabetes are advised to aim for 130/80 or lower. Persons with blood pressure between 140/90 and 120/80 are considered to be prehypertensive and should be monitored at regular intervals to detect any rise in pressure.

In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which level indicates inadequate renal perfusion?

20 mL/hour In hypovolemia, renal vasculature is constricted in a compensatory attempt to circulate blood to more vital organs. Urinary output at 20 mL/hour or below indicates that renal perfusion is too inadequate.

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:

20 mL/hour Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion.

Which hypertensive individual is most likely to have his or her high blood pressure diagnosed as secondary rather than essential?

A 51-year-old male who has been diagnosed with glomerulonephritis Damage to the organs that control and mediate the control of blood pressure, most notably the kidneys, are associated with secondary hypertension. Race, lifestyle, sodium intake, and associated cardiac and metabolic sequelae are associated with essential hypertension.

When trying to educate a client about the release of free radicals and the role they play in formation of atherosclerosis, which statement is most accurate?

Activated cells that release free radicals oxidize LDL, which is harmful to the lining of your blood vessels. Activated macrophages release free radicals that oxidize LDL. Oxidized LDL is toxic to the endothelium, causing endothelial loss and exposure of the subendothelial tissue to the blood components. This leads to platelet adhesion and aggregation and fibrin deposition.

Which client would the nurse recognize as needing to be assessed for orthostatic hypotension?

An 80-year-old client who has experienced two falls while attempting to ambulate to the bathroom Dizziness, blurred vision, palpitations, and syncope (i.e., fainting) are characteristic signs and symptoms of orthostatic hypotension, and both predispose an individual to falls; this is especially the case among older adults. Headaches, edema, diabetes, and vision changes are not associated with orthostatic hypotension.

The nurse knows that which groups of drugs influence the renin-angiotensin-aldosterone system (RAAS) for the treatment of hypertension? Select all that apply.

Angiotensin-receptor blockers ACE inhibitors Beta-adrenergic blockers (beta-blockers) Angiotensin-converting enzyme (ACE) catalyzes the conversion of angiotensin I to angiotensin II, which is a powerful vasoconstrictor and also stimulates the release of aldosterone which enhances sodium and water retention. Both of these physiologic responses cause an increase in blood pressure. ACE inhibitors block the conversion to angiotensin II, thus decreasing vasoconstriction and sodium retention. Angiotensin receptor blockers decrease the actions of angiotensin by decreasing its ability to bind to angiotensin II receptors. Beta-adrenergic blockers inhibit the beta-receptor mediated release of renin. Diuretics and calcium-channel blockers do not interact directly with the RAAS.

The health care provider is reviewing the results of a client's magnetic resonance imaging (MRI). The results indicate a small spherical dilation at the circle of Willis. The provider would interpret this as:

Berry aneurysm The description of the aneurysm describes a berry aneurysm usually found at the circle of Willis. A saccular aneurysm appears sac-like, while the fusiform aneurysm is characterized by a gradual, progressive dilatation of the vessel.

Select the correct sequence of blood return to the heart.

Capillaries, venules, veins, right atrium The correct pathway for blood returning back to the heart is the capillaries, venules, veins, and right atrium. The other options do not support normal blood flow.

A nurse educator explains a type of cardiac condition as "a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually exhibit inappropriate ventricular hypertrophy or dilation and often lead to cardiovascular death or progressive heart failure." Which condition fits this definition?

Cardiomyopathy Cardiomyopathies result from genetic and/or environmental factors and will result in heart failure. MI and rheumatic diseases may lead to heart failure, but the mechanism is different.

Which client with cardiomyopathy does the nurse identify as having the greatest risk for a complication?

Client with an ejection fraction of 25% and atrial fibrillation Although each set of symptoms is characteristic of cardiomyopathy, the nurse determines the greatest risk occurs with the client showing evidence of stasis in the heart that can result from a reduced ejection fraction and atrial fibrillation. This client is most likely to experience an embolus.

What should the nurse teach the pregnant woman about congenital heart defects?

Congenital heart defects occur between the 3rd and 8th weeks of development before you know you are pregnant. Congenital heart defects occur during the 3rd week as the heart is the first functional organ system to develop. This may be before a woman realizes she is pregnant. Congenital heart defects can, to some degree, be prevented. They do not occur prior to conception or during conception, but during the growth of the fetus.

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.

Consume a diet rich in fruits, vegetables, and low-fat dairy products. Reduce dietary sodium intake. Stop smoking. Limit alcohol consumption. 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 heart controls the direction of blood flow. What is the role of the aortic valve?

Controls the direction of blood flow from the left side of the heart to the systemic circulation The heart valves control the direction of blood flow from the atria to the ventricles (the AV valves), from the right side of the heart to the lungs (pulmonic valves) and from the left side of the heart to the systemic circulation (aortic valve).

A client has just experienced stimulation of the vagus nerve. Which sign would the nurse anticipate the client to manifest?

Decreased heart rate The neural control of the circulation occurs primarily through the sympathetic (SNS) and parasympathetic (PNS) divisions of the autonomic nervous system (ANS). The ANS contributes to the control of cardiovascular function through modulation of cardiac function (i.e., heart rate and cardiac contractility) and peripheral vascular resistance. Increased vagal activity (activation of the PNS) produces a slowing of heart rate. Increased cardiac contractility and heart rate refer to SNS stimulation. Blood coagulation is not affected by the autonomic nervous system.

Release of which humoral factors will result in vasodilation?

Histamine Histamine has a powerful vasodilator effect on arterioles and has the ability to increase capillary permeability, allowing leakage of both fluid and plasma proteins into the tissues. Norepinephrine, angiotensin II, and serotonin are all potent vasoconstrictors.

A grandmother who works as a cook at a nearby school was recently hospitalized when she lost an extensive amount of blood in a work-related accident. The grandmother tells the nurse that she heard that she would keep feeling faint until the brain made more blood. The nurse knows that when the blood pressure dropped, the pressure in the carotid arteries decreased. This was detected by baroreceptors in the carotid arteries. What did the baroreceptors do?

Increase sympathetic stimulation of the heart and blood vessels The baroreceptors in the carotid arteries increase sympathetic, not parasympathetic, stimulation of the heart and blood vessels. The baroreceptors do not stimulate the brain to form new red blood cells or inhibit renin release from the kidneys to promote fluid retention.

If a client experiences sympathetic nervous stimulation of the heart, the nurse will observe which changes in manifestations?

Increased heart rate and increased contractility The sympathetic nervous system has an excitatory influence on heart rate and contractility, and it serves as the final common pathway for controlling the smooth muscle tone of the blood vessels. With stimulation of sympathetic nervous system, both heart rate and contractility would increase.

Which of the following is true regarding pulmonary circulation?

It is a low-pressure system that allows for improved gas exchange. The pulmonary circulation consists of the right heart and the pulmonary artery, capillaries, and veins. It is the smaller of the systems and functions at a lower pressure to assist with gas exchange.

The nurse is counseling a client regarding a high cholesterol level. The nurse teaches the client that which lipoprotein is the main carrier of cholesterol?

LDL LDL is the main carrier of cholesterol. HDL is 50 percent protein; VLDL carries a large amount of triglycerides. IDLs are fragments of VLDLs after the triglycerides are removed and can be recycled to form VLDLs or converted to LDLs.

When the semilunar valves open it signals the onset of the ejection period. The aortic pressure reflects changes in the ejection of blood from which part of the heart?

Left ventricle The aortic pressure reflects changes in the ejection of blood from the left ventricle, not the right ventricle or atrium.

Which related circulatory complication can result from surgical treatment for metastatic breast cancer?

Lymphedema in the affected arm Involvement of lymphatic structures by malignant tumors and removal of lymph nodes at the time of cancer surgery are common causes of lymphedema. The other options are not related to the surgery that would have removed any affected lymph nodes.

A nurse is caring for a client with right heart failure caused by pulmonary hypertension. Which hemodynamic parameter is most appropriate for the nurse to monitor?

Pulmonary arterial pressure (PAP) The pulmonary arterial pressure is the main source of afterload work on the right heart.

The heart is a four-chambered pump. What is the function of the right ventricle?

Pumps blood to the lungs The right ventricle pumps blood to the lungs. The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The left ventricle pumps blood into the systemic circulation.

The electrical activity of the heart is recorded on the ECG. What does the T wave on the ECG represent?

Repolarization of the ventricles The P wave represents the depolarization of the sinoatrial node. The QRS complex represents the depolarization of the ventricles. The T wave represents repolarization of the ventricles, not the atrium.

The nurse knows that which food is excluded from the Dietary Approaches to Stop Hypertension (DASH) diet?

Steak The DASH diet, emphasizing consumption of whole grains, fruits, and vegetables—and exclusion of red meats and sweets—has been shown in many studies to reduce hypertension.

A client diagnosed with giant cell arteritis will likely experience pain located in which region of the head?

Temporal Giant cell (temporal) arteritis, the most common of the large vessel vasculitides, is an acute and chronic inflammation of large to small arteries. It mainly affects arteries of the head—especially the temporal arteries—but may include the vertebral and ophthalmic arteries. The most common clinical presentations are headache and tenderness over the superficial temporal artery.

The nurse is reviewing the circulatory system. Which statements are correct about the functional organization of the circulatory system? Select all that apply.

The arterial system distributes oxygenated blood to the tissues. The venous system collects deoxygenated blood from the tissues. The circulatory system consists of the heart, which pumps blood; the arterial system, which distributes oxygenated blood to the tissues; the venous system, which collects deoxygenated blood from the tissues and returns it to the heart; and the capillaries, where exchange of gases, nutrients, and waste takes place.

The heart consists of four valves. Which are the heart's atrioventricular valves? Select all that apply.

Tricuspid Mitral The heart's atrioventricular valves are the tricuspid and the mitral. The semilunar valves are the pulmonary and aortic.

Mitral valve prolapse occurs frequently in the population at large. Its treatment is aimed at relieving the symptoms and preventing complications of the disorder. Which drug is used in the treatment of mitral valve prolapse to relieve symptoms and aid in preventing complications?

beta-adrenergic blocking drugs (beta-blockers) Persons with palpitations and mild tachyarrhythmias or increased adrenergic symptoms and those with chest discomfort, anxiety, and fatigue often respond to therapy with the beta-adrenergic blocking drugs. None of the other types of drugs are used in the treatment of mitral valve prolapse to relieve symptoms or prevent complications.

A preventive measure to decrease the risk of developing rheumatic heart disease includes:

prompt diagnosis of streptococcal infections with a throat culture. Rheumatic heart disease is normally caused by streptococcal infections; therefore, early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a client has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the client may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.

Which sequence is the correct pathway for blood flow through the heart?

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.

A nurse working with a client in heart failure is explaining why the symptoms of the heart failure were not evident for a long period of time. When describing the Frank-Starling mechanism, the nurse will explain:

the relationship between venous return and stroke volume. The Frank-Starling principle addresses the relationship between venous return and stroke volume. It does not directly address the characteristics of actin and myosin. The principle is unrelated to coronary circulation, chemoreceptors and baroreceptors.

Anaphylactic shock is directly associated with:

type I hypersensitivity response. Explanation: Anaphylaxis, a type of distributive shock, is a clinical syndrome that represents the most severe systemic allergic reaction. It results from an immunologic-mediated reaction in which vasodilator substances such as histamine are released into the blood. Bacterial blood infection is the cause of sepsis. Circulatory shock may be due to blood volume loss (hypovolemic shock) or myocardial infarction/ heart failure (cardiogenic shock).

A client with a history of heart failure has the following echocardiogram results: heart rate 80 beats/minute; end-diastolic volume 120 mL; and end-systolic volume 60 mL. What is this client's ejection fraction (EF)?

50% Ejection fracture = stroke volume ÷ end-diastolic volume. Stroke volume equals the difference between end-diastolic and end-systolic volume. Therefore, EF = 60 ÷ 120, or 50%.

Four clients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which client most likely experienced myocardial infarction?

80-year-old woman whose pain was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other clients have angina of varying severity.

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 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.

Which intervention would the nurse know is not a primary treatment for the client in hypovolemic shock?

Administration of vasoconstrictive drugs The treatment of hypovolemic shock is directed toward correcting or controlling the underlying cause and improving tissue perfusion. Ongoing loss of blood must be corrected [such as in surgery]. Oxygen is administered to increase oxygen delivery to the tissues. Medications usually are administered intravenously. In hypovolemic shock, the goal of treatment is to restore vascular volume. This can be accomplished through intravenous administration of fluids and blood. The crystalloids (e.g., isotonic saline and Ringer's lactate) are readily available and effective, at least temporarily. Plasma volume expanders (e.g., pentastarch and colloidal albumin) have a high molecular weight, do not necessitate blood typing, and remain in the vascular space for longer periods than do the crystalloids, such as dextrose and saline. Blood or blood products (packed or frozen red cells) are administered based on hematocrit and hemodynamic findings. Fluids and blood are best administered based on volume indicators such as CVP and urine output. Vasoactive medications are agents capable of constricting or dilating blood vessels. Considerable controversy exists about the advantages or disadvantages related to the use of these drugs. As a general rule, vasoconstrictor agents are not used as a primary form of therapy in hypovolemic shock and may be detrimental. These agents are given only when volume deficits have been corrected but hypotension persists.

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?

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.

A client is rushed to the emergency department with assessment findings of urticaria, wheezing, chest tightness, and difficulty breathing. The client is most likely experiencing which type of shock?

Anaphylactic Signs and symptoms associated with impending anaphylactic shock include abdominal cramps; apprehension; warm or burning sensation of the skin; itching; urticaria (i.e., hives); coughing; choking; wheezing; chest tightness; and difficulty in breathing. The other types of shock do not have these clinical manifestations.

A client presents to the emergency department with a sudden onset of acute pain in his left lower leg. The practitioner is unable to palpate pedal pulses and finds the client to be in atrial fibrillation. Which test will the practitioner order to find the source of the emboli?

Echocardiogram Most acute arterial occlusions are the result of an embolus or thrombus. Most emboli arise in the heart and are caused by conditions (such as atrial fibrillation) that cause blood clots to develop on the wall of a heart chamber or valve surface. An echocardiogram looks at the structure of the heart. The other tests do not demonstrate blood clots in the heart.

A client has been diagnosed with diabetes mellitus. Which lab result would the practitioner expect?

Elevation of triglycerides In diabetes mellitus and the metabolic syndrome, typical dyslipidemia is seen with elevation of triglycerides, low HDL, and minimal or modest elevation of LDL. High calorie intake and diabetes mellitus increase the production of VLDL.

The health care provider is teaching a client about modifiable risk factors for atherosclerosis. The most appropriate information to provide would be:

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.

An 86-year-old client is disappointed to learn that he or she has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which age-related change predisposes older adults to the development of heart failure?

Increased vascular stiffness 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.

The heart is a four-chambered pump. Which chamber of the heart pumps blood into the systemic circulation?

Left ventricle The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs. The left ventricle pumps blood into the systemic circulation.

A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing:

Onset of STEMI The onset of STEMI involves abrupt and significant chest pain. The pain typically is severe, often described as being constricting, suffocating, and crushing. Substernal pain that radiates to the left arm, neck, or jaw is common, although it may be experienced in other areas of the chest and back. Unlike that of angina, the pain associated with MI is more prolonged and not relieved by rest or nitroglycerin.

On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right-sided heart failure. Which manifestation exhibited by the father does the nurse know might have preceded this diagnosis?

Peripheral edema, weight gain In right-sided heart failure, blood backs up into the venous side of the circulatory system causing increased hydrostatic pressure in capillaries and leakage of plasma, which forms peripheral edema and becomes apparent as weight gain. The other manifestations listed are not characteristic of right-sided failure.

The nurse identifies the blood vessel layer that constricts to regulate and control diameter as:

Tunica media The tunica media, the middle layer, is largely a smooth muscle layer that constricts to regulate and control the diameter of the vessel. The tunica externa, also known as the tunica adventitia, refers to the outermost layer of a vessel. The tunica intima refers to the innermost layer that prevents platelet adherence and blood clotting.

A client is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as:

Valvular regurgitation When cardiac valves such as the aortic or mitral fail to close properly, blood does not efficiently exit from the left ventricle. This condition is valvular regurgitation. Valvular stenosis is a narrowing of the lumen of the valve. Pericardial effusion, an accumulation of fluid in the pericardial sac, causes obstructive shock, as it impedes ventricular filling. Infective endocarditis could trigger septic shock.

A person with blood pressure of 68/38 fainted after donating a unit of blood. The blood bank technician stated that the person was experiencing low preload from loss of blood volume. The nurse knows that preload refers to which of the following?

Venous return to the heart Preload refers to the volume of blood in the ventricle at the end of diastole. This is directly related to venous return, the amount of blood returning to the heart. Blood ejected with each left ventricular contraction is stroke volume. Blood pumped in 1 minute is cardiac output.

The lymph system correlates with the vascular system without actually being a part of the vascular system. Among other things, the lymph system is the main route for the absorption of fats from the gastrointestinal system. The lymph system empties into the right and left thoracic ducts, which are the points of juncture with the vascular system. What are these points of juncture?

junctions of the subclavian and internal jugular veins The lymph capillaries drain into larger lymph vessels that ultimately empty into the right and left thoracic ducts. The thoracic ducts empty into the circulation at the junctions of the subclavian and internal jugular veins. The lymphatic system only joins the vascular system in one place, so no other answer is accurate.

A client is prescribed an angiotensin-converting enzyme (ACE) inhibitor for hypertension. The nurse questions the prescription of an ACE inhibitor for a client with which condition?

renal artery stenosis ACE inhibitors are contraindicated in renal artery stenosis, because blocking of efferent glomerular capillaries will interfere with normal compensation for the stenosis and cause a further drop in glomerular filtration pressure. The kidney relies on the renin-angiotensin-aldosterone system to maintain adequate renal perfusion. ACE inhibitors are used clinically in the management of heart failure. Coronary artery disease and diabetes do not contraindicate ACE inhibitor use.

What is the most important factor in myocardial oxygen demand?

Heart rate The heart rate is the most important factor in myocardial oxygen demand since, as heart rate increases, myocardial oxygen demands increase. The degree of effect the other options have on myocardial oxygen demand is related to how much effect they have on heart rate.

The nurse must achieve which clinical objectives for a client in cardiogenic shock? Select all that apply.

Improve cardiac output Regulate blood volume Increase coronary perfusion Correct pulmonary edema Objectives in the management of cardiogenic shock include measures to increase cardiac output yet decrease cardiac workload and oxygen demand. Increased oxygen demand would cause further hypoxia and myocardial cell death. Coronary perfusion must be increased to deliver oxygen to the myocardium. Blood volume must be adequate to support cardiac output yet low enough to prevent fluid overload and ameliorate pulmonary edema.

Which factor represents the amount of blood that the heart must pump with each beat and is determined by the stretch of the cardiac muscle fibers and the actions of the heart prior to cardiac contraction?

Preload Preload is the distending force that stretches the heart muscle just prior to the work of the onset of ventricular contraction. It represents the volume of blood stretching the ventricular muscle fibers at the end of diastole (i.e., end-diastolic volume) and is the sum of the blood remaining in the heart at the end of systole (end-systolic volume) and the venous return to the heart.

A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education?

Raising the head of the bed to a high Fowler's position Treatment measures include close monitoring of cardiovascular and respiratory function; maintenance of respiratory gas exchange, cardiac output, and tissue perfusion; and the administration of oxygen, antihistamine drugs, and corticosteroids. The person should be placed in a supine position. This is extremely important because venous return can be severely compromised in the sitting position. This in turn produces a pulseless mechanical contraction of the heart and predisposes to arrhythmias. In several cases, death has occurred immediately after assuming the sitting position.

In infants and children, secondary hypertension is the most common form of hypertension. What is the most common cause of hypertension in an infant?

Renal artery thrombosis Hypertension in infants is associated most commonly with high umbilical catheterization and renal artery obstruction caused by thrombosis. Cerebral vascular bleeds, coarctation of the aorta, and pheochromocytoma all can raise blood pressure; they are not the most common cause of hypertension in an infant.

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?

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.

Which blood vessel layer is composed primarily of smooth muscle cells?

Tunica media The tunica media consists primarily of circumferentially arranged layers of smooth muscle cells. The tunica externa is composed of loose connective tissue and the tunica intima of endothelial cells. The endothelium is the lining of the vascular system and is composed of endothelial cells.

A client who lives with angina pectoris has taken a sublingual dose of nitroglycerin to treat the chest pain he experiences while mowing his lawn. This drug facilitates release of nitric oxide, which will have what physiologic effect?

Vasodilating effects reducing preload and afterload Nitroglycerin produces its effects by releasing nitric oxide in vascular smooth muscle of the target tissues, resulting in relaxation of this muscle and increased blood flow. Nitroglycerin's effect on the vessels decreases venous return (reduce preload) and arterial blood pressure (reduce afterload). This drug does not decrease heart rate. Because it vasodilates, it decreases preload. Nitroglycerine does not affect cardiac refractory periods.

A client is diagnosed with an abdominal aortic aneurysm that the physician just wants to "watch" for now. When teaching the client about signs/symptoms to watch for, the nurse will base the teaching on which physiologic principle?

As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture. Because the pressure is equal throughout, the tension in the part of the balloon with the smaller radius is less than the tension in the section with the larger radius. The same holds true for an arterial aneurysm in which the tension and risk of rupture increase as the aneurysm grows in size. Wall tension is inversely related to wall thickness, such that the thicker the vessel wall, the lower the tension, and vice versa. Although arteries have a thicker muscular wall than veins, their distensibility allows them to store some of the blood that is ejected from the heart during systole, providing for continuous flow through the capillaries as the heart relaxes during diastole.

The school nurse is doing a health class on the functional organization of the circulatory system. What is the function of the capillaries in the circulatory system?

Exchange gases, nutrients, and wastes The circulatory system consists of the heart, which pumps blood; the arterial system, which distributes oxygenated blood to the tissues; the venous system, which collects deoxygenated blood from the tissues and returns it to the heart; and the capillaries, where exchange of gases, nutrients, and waste takes place.

What should the nurse teach the client with peripheral vascular disease and intermittent claudication about exercise?

Exercise can increase blood vessel growth and help to decrease symptoms. Adaptation to exercise induces angiogenesis with an increased growth of vessels to support blood flow to the exercising muscle. Exercise may help to decrease pain in clients with peripheral vascular disease.

Football fans at a college have been shocked to learn of the sudden death of a star player, an event that was attributed in the media to "an enlarged heart." Which disorder was the player's most likely cause of death?

Hypertrophic cardiomyopathy (HCM) The most frequent symptoms of HCM are dyspnea and chest pain in the absence of coronary artery disease. Syncope (fainting) is also common and is typically postexertional, when diastolic filling diminishes and outflow obstruction increases. Ventricular dysrhythmias are also common, and sudden death may occur, often in athletes after extensive exertion. Risk factors for sudden cardiac death among clients with HCM include a family history of syncope or sudden cardiac death, certain mutations, and extreme hypertrophy of the left ventricle. HCM is characterized by a massively hypertrophied left ventricle with a reduced chamber size.

The nurse should anticipate administering intravenous antibiotic therapy as a priority to a client experiencing which type of shock?

Septic shock 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.

A client has just been diagnosed with hypercholesterolemia and is asking what treatment will be needed. About which topics should the nurse educate the client? Select all that apply.

Smoking cessation Dietary measures to reduce LDL levels Weight reduction if overweight The management of hypercholesterolemia focuses on dietary and therapeutic lifestyle changes; when these are unsuccessful, pharmacologic treatment may be necessary. Therapeutic lifestyle changes include an increased emphasis on physical activity, dietary measures to reduce LDL levels, smoking cessation, and weight reduction for people who are overweight. Increased intake of fats and sodium would cause weight gain and hypertension and result in a negative consequence.

During an assessment of a client with ankle swelling, the nurse observes jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What is the correct interpretation of this finding?

The client has increased pressure related to right-sided heart failure. The jugular veins are normally flat or collapsed. Since there are no valves at the atrial sites (i.e., venae cavae and pulmonary veins) where blood enters the heart, they can become prominent in severe right-sided heart failure. This means that excess blood is pushed back into the veins when the atria become distended.

Downstream peripheral pulses have a higher pulse pressure because the pressure wave travels faster than the blood itself. What occurs in peripheral arterial disease?

The pulse decreases, rather than increases, in amplitude. With peripheral arterial disease, there is a delay in the transmission of the reflected wave so that the pulse decreases, rather than increases, in amplitude.

A cardiac nurse is describing to a colleague the relationship between the law of Laplace and a client's peripheral vascular disease. To express the law of Laplace in an equation, the nurses need to know which values? Select all that apply.

The tension that exists in the walls of a blood vessel The radius of a particular blood vessel The pressure that exists in the lumen of a vessel The law of Laplace is determined by the equation, P = T/r, in which T is wall tension, P is the intraluminal pressure, and r is vessel radius. The client's stroke volume is not directly relevant to the equation. The thickness of a vessel will affect wall tension, but this is not an explicit component of the equation.

The troponin complex is one of a number of important proteins that regulate actin-myosin binding. Troponin works in striated muscle to help regulate calcium-mediated contraction of the muscle. Which of the troponin complexes is diagnostic of a myocardial infarction?

Troponin T and troponin I In clinical practice, the measurement of the cardiac forms of troponin T and troponin I is used in the diagnosis of myocardial infarction. Troponin C is not diagnostic of a myocardial infarction. Troponin A is not one of the troponin complexes.

A 45-year-old client is undergoing exercise stress testing. At which point will the test be halted and not allowed to continue?

When the client experiences chest pain The test of aerobic fitness that is performed on a bicycle or treadmill ergometer starts at a slower pace and builds toward the maximum. It will be stopped when the client experiences abnormal ECG or vital signs, chest pain, severe shortness of breath or a decrease in blood pressure. Maximal heart rate is generally predicted by subtracting age from 220. For the 45-year-old client, a maximal heart rate is 175 beats/min. The test is not stopped unless the client reaches at least 85% of the maximum calculated rate. Because the heart rate of 135 beats/min is only 77% of the maximum, the client would be allowed to continue the test.

The pathophysiology of heart failure involves an interaction between decreased pumping ability and the ________ to maintain cardiac output.

compensatory mechanisms The pathophysiology of heart failure involves an interaction between two factors: a decrease in pumping ability of the heart with a consequent decrease in the cardiac reserve and the compensatory mechanisms that serve to maintain the cardiac output while also contributing to the progression of heart failure. Myocardial muscle hypertrophy has an important role in long-term adaptation to hemodynamic overload. Stimulation of the sympathetic nervous system plays an important role in the compensatory response to decreased cardiac output and to the pathogenesis of heart failure. Heart failure is a muscle contractility problem, unrelated to the electrical conduction that stimulates it.

The client undergoes a cardiac catheterization to evaluate symptoms of chest pain and shortness of breath. The test shows lesions in the coronary arteries that have begun to reduce the size of the vessel lumen. This type of lesion is known as:

Fibrous atheromatous plaque The lesions associated with atherosclerosis are of three types — the fatty streak, the fibrous atheromatous plaque, and the complicated lesion. Fatty streaks are thin, flat, yellow intimal discolorations. The fibrous atheromatous plaque grows larger and proliferates into the smooth muscle. As they increase in size, they encroach on the lumen of the artery. More advanced complicated lesions contain hemorrhage, ulceration, and scar deposits and can cause thrombus formation that may occlude the vessel.

In the ICU setting, clients who develop shock need thorough head-to-toe assessments. Which clinical manifestation would alert the health care provider that the client may be developing ischemia associated with gastrointestinal redistribution of blood flow?

Gastric bleeding In shock, there is widespread constriction of blood vessels that supply the gastrointestinal tract, causing a redistribution of blood flow that severely diminishes mucosal perfusion. Bleeding is a common symptom of gastrointestinal ulceration caused by shock, with onset usually within 2 to 10 days after the original insult. Nausea is unrelated to ischemic damage; irritable bowel syndrome is stress related. With ischemia, the bowel ceases to function, causing a lack of peristalsis and no fecal output.

A client with malignant hypertension is at risk for a hypertensive crisis, including the cerebral vascular system often causing cerebral edema. The nurse would assess this client for which signs and symptoms?

Headache and confusion Cerebral vasoconstriction probably is an exaggerated homeostatic response designed to protect the brain from excesses of blood pressure and flow. The regulatory mechanisms often are insufficient to protect the capillaries, and cerebral edema frequently develops. As it advances, papilledema (i.e., swelling of the optic nerve at its point of entrance into the eye) ensues, giving evidence of the effects of pressure on the optic nerve and retinal vessels. The client may have headache, restlessness, confusion, stupor, motor and sensory deficits, and visual disturbances. In severe cases, convulsions and coma follow. Lethargy, nervousness, and hyperreflexia are not signs or symptoms of cerebral edema in malignant hypertension.

A client has systolic hypertension. The nurse knows that systolic pressure is influenced by which factors? Select all that apply.

Heart rate Compliance of arteries Stroke volume Contractile force Systolic pressure is influenced by the volume of blood forced into the systemic circulation with each heart beat (stroke volume). Faster heart rate and greater contractile force will increase systolic pressure. Good arterial compliance or flexibility will result in lower systolic pressure. Venous resistance does not influence systolic pressure.

The client has been diagnosed with Raynaud disease. Which treatment measure will the nurse teach the client?

The client must protect the entire body from cold, not just the extremities. Treatment measures are directed toward eliminating factors that cause vasospasm. Abstinence from smoking and protection from cold are priorities. The entire body must be protected from cold, not just the extremities. Avoidance of stress and anxiety is another important factor, as they may precipitate vascular spasm in predisposed people. Vasoconstrictor medications, such as decongestants, should be avoided. Treatment with vasodilator drugs may be indicated.