401 Unit Quiz 2

The nurse is writing a care plan for a client who has been diagnosed with angina pectoris. The client describes herself as being "distressed" and "shocked" by the new diagnosis. What nursing diagnosis is most clearly suggested by the client's statement? A) Anxiety related to cardiac symptoms B) Spiritual distress related to change in health status C) Deficient knowledge related to treatment of angina pectoris D) Acute confusion related to prognosis for recovery

A) Anxiety related to cardiac symptoms Rationale: Although further assessment is warranted, it is not unlikely that the client is experiencing anxiety. In clients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to the client's concerns. Similarly, it is not clear that a lack of knowledge or information is the root of the client's anxiety.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis? A) Distended neck veins B) Pulmonary edema C) Dry cough D) Orthopnea

A) Distended neck veins Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. A) Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines B) Serum lactate greater than 4 mmol/L C) Hypotension that responds to bolus fluid resuscitation D) Mean arterial pressure (MAP) of less than 65 mm Hg E) Exaggerated response to vasoactive medications

A) Drop in systolic blood pressure of greater than or equal to 40 mm Hg from baselines B) Serum lactate greater than 4 mmol/L D) Mean arterial pressure (MAP) of less than 65 mm Hg Rationale: Signs of acute organ dysfunction in the cardiovascular system include systolic blood pressure <90 mm Hg or MAP <65 mm Hg, drop in systolic blood pressure >40 mm Hg from baselines, or serum lactate >4 mmol/L. An exaggerated response to vasoactive medications and an adequate response to fluid resuscitation would not be noted.

A client diagnosed with meningitis says, "I'm just so thirsty. I keep drinking and drinking but I just can't seem to get enough. I've been urinating a lot, too." The nurse checks the client's urine specific gravity and finds it to be very dilute. The nurse suspects that the client may be developing diabetes insipidus. Which assessment finding would support the nurse's suspicion? Select all that apply. A) Dry mucous membranes B) Weight gain C) Decreased heart rate D) Poor skin turgor E) Hypotension

A) Dry mucous membranes D) Poor skin turgor E) Hypotension With diabetes insipidus, daily output of very dilute urine (3 to 20 L) with nocturia, frequency, and a specific gravity of 1.001 to 1.005 occurs. Signs and symptoms of fluid volume deficit that occur as clients are unable to compensate for the massive urinary loss include weight loss, poor skin turgor, dry mucous membranes, increased heart rate, and hypotension.

The nurse is caring for a client with diabetes who developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar level? A) Glucagon B) Estrogen C) Cortisone D) Insulin

A) Glucagon Glucagon, a hormone released by alpha islet cells, raises blood sugar levels by stimulating glycogenolysis, the breakdown of glycogen into glucose, in the liver. Insulin is released to lower the blood sugar levels. Cortisone and estrogen are not released from the pancreas.

A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Highly dilute urine B) Albumin in the urine C) Glucose in the urine D) Leukocytes in the urine

A) Highly dilute urine Clients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but would indicate a urinary tract infection, if present in the urine.

Which of the following clinical signs are associated with diabetes insipidus? A) Hypotension B) Hypertension C) Bradycardia D) Oliguria

A) Hypotension Diabetes insipidus, which causes profound polyuria, may cause clinical signs of volume depletion such as tachycardia and hypotension

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? A) In a high Fowler position B) In a flat, supine position C) In the Trendelenburg position D) On the left side-lying position

A) In a high Fowler position Rationale: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation.

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) B) Ineffective breathing pattern related to decreased cardiac output C) Anxiety related to fear of death D) Impaired skin integrity related to CAD

A) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

An adult client is admitted to the ED with chest pain. The client states that there was unrelieved chest pain for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Morphine sulphate, oxygen, and bed rest B) Bed rest, albuterol nebulizer treatments, and oxygen C) Thrombolytics (fibrinolytics), oxygen administration, and nonsteroidal anti-inflammatories D) Oxygen and beta-adrenergic blockers

A) Morphine sulphate, oxygen, and bed rest Rationale: The client with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A) Relieve client symptoms. B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Improve functional status

A) Relieve client symptoms. C) Extend survival. E) Improve functional status Rationale: The overall goals of management of heart failure are to relieve the client's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care

A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy? A) The client is at an increased risk for developing infection. B) The client may experience short-term changes in cognition. C) The client's diet should be low protein with ample fat. D) The client is at a decreased risk for development of thrombophlebitis and thromboembolism.

A) The client is at an increased risk for developing infection. The client is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? A) The client's symptoms and the activities that precipitate attacks B) The client's coping strategies surrounding the attacks C) The client's activities, limitations, and level of consciousness after the attacks D) The client's understanding of the pathology of angina

A) The client's symptoms and the activities that precipitate attacks Rationale: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? A) Throbbing headache or dizziness B) Drowsiness or blurred vision C) Nervousness or paresthesia D) Tinnitus or diplopia

A) Throbbing headache or dizziness Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

The ICU nurse caring for a client in shock is administering vasoactive medications as per orders. The nurse should administer this medication in what way? A) Through a central venous line B) Mixed with parenteral feedings to balance osmosis C) By IV push for rapid onset of action D) By a gravity infusion IV set

A) Through a central venous line Rationale: Whenever possible, vasoactive medications should be given through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An IV pump or controller must be used to ensure that the medications are delivered safely and accurately. They are never mixed with parenteral nutrition.

A client reports extremely frequent urination, sometimes urinating 10 to 12 times each day. What fluid balance disorder would be expected with these symptoms? A) dehydration B) hypokalemia C) hyponatremia D) diluted urine

A) dehydration If the client with diabetes insipidus fails to drink a compensatory volume of fluid, dehydration with concentrated levels of electrolytes occurs.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure? A) A heart murmur B) An S3 heart sound C) Faint breath sounds D) Pleural friction rub

B) An S3 heart sound Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Heart failure does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of heart failure.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? A) Recent surgery B) Atrial fibrillation C) Recurrent pneumonia D) Infective endocarditis

B) Atrial fibrillation Rationale: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment? A) Level of consciousness (LOC) B) Blood pressure C) Oxygen saturation D) Nausea

B) Blood pressure Rationale: Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.

The OR nurse is explaining to a client that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A) Coronary artery bypass graft (CABG) B) Cardiopulmonary bypass C) Percutaneous transluminal coronary angioplasty (PTCA) D) Atherectomy

B) Cardiopulmonary bypass Rationale: Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.

An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock? Initiate total parenteral nutrition (TPN). A) Apply an antibiotic ointment to the client's mucous membranes, as prescribed. B) Remove invasive devices as soon as they are no longer needed. C) Perform passive range-of-motion exercises unless contraindicated.

B) Remove invasive devices as soon as they are no longer needed. Rationale: Early removal of invasive devices can reduce the incidence of infections. Broad application of antibiotic ointments is not performed. TPN may be needed, but this does not directly reduce the risk of further infection. Range-of-motion exercises are not a relevant intervention.

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective? A) "I will have chicken noodle soup with crackers and an apple for lunch." B) "I will have a ham and cheese sandwich for lunch." C) "I will have a baked potato with broiled chicken for dinner." D) "I will have a tossed salad with cheese and croutons for lunch."

C) "I will have a baked potato with broiled chicken for dinner." Rationale: The client's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.

The intensive care nurse caring for a client in shock is planning assessments and interventions related to the client's nutritional needs. Which physiologic process contributes to these increased nutritional needs? A) The increase in gastrointestinal (GI) peristalsis during shock, and the resulting diarrhea B) The use of albumin as an energy source by the body because of the need for increased adenosine triphosphate C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements D) The loss of fluids due to decreased skin integrity and decreased stomach acids due to increased parasympathetic activity

C) The release of catecholamines that creates an increase in metabolic rate and caloric requirements Rationale: Nutritional support is an important aspect of care for clients in shock. Clients in shock may require 3,000 calories daily. This caloric need is directly related to the release of catecholamines and the resulting increase in metabolic rate and caloric requirements. Albumin is not primarily metabolized as an energy source. The special nutritional needs of shock are not related to increased parasympathetic activity, but are instead related to increased sympathetic activity. GI function does not increase during shock.

The nurse is participating in the care conference for a client with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A) Maximizing cardiac output while minimizing heart rate B) Decreasing energy expenditure of the myocardium C) Increasing the size of the myocardial muscle D) Balancing myocardial oxygen supply with demand

D) Balancing myocardial oxygen supply with demand Rationale: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the client with ACS. Treatment is not aimed directly at minimizing heart rate because some clients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium's energy expenditure is often beneficial, but this must be balanced with productivity.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Hyperactive bowel sounds C) Decreased heart rate D) Cool, clammy skin

D) Cool, clammy skin Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

A client presents to the clinic reporting intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? A) Decreased cardiac output B) Decreased cardiac contractility C) Infarction of the myocardium D) Coronary arteriosclerosis

D) Coronary arteriosclerosis Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a client in shock. What goal of this treatment should the nurse identify? A) Absence of pulmonary and peripheral edema B) Reduced stroke volume and cardiac output C) Absence of infarcts or emboli D) Maintenance of adequate mean arterial pressure

D) Maintenance of adequate mean arterial pressure Rationale: Vasoactive medications can be given in all forms of shock to improve the client's hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. They are not specifically used to prevent emboli, edema, or infarcts.

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

D) Neurogenic shock Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics? A) Avoid drinking fluids for 2 hours after taking the diuretic. B) Avoid taking the medication within 2 hours consuming dairy products. C) Take the diuretic only on days when experiencing shortness of breath. D) Take the diuretic in the morning to avoid interfering with sleep.

D) Take the diuretic in the morning to avoid interfering with sleep. Rationale: Oral diuretics should be given early in the morning so that diuresis does not interfere with the client's nighttime rest. Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock? A) The client admitted with malignant hypertension B) The client admitted with acute renal failure C) The client admitted following a stroke D) The client admitted following an MI

D) The client admitted following an MI Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and clients experiencing a stroke are at risk for thrombus formation, the client admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.