Mastery quiz Ch. 19

The nursing student correctly identifies which of the following as major risk factors for coronary artery disease? Select all that apply.

• Cigarette smoking • Elevated LDL • Diabetes • Abdominal obesity

A client who has just been diagnosed with atrial stenosis asks his nurse what can cause a problem with heart valves. Which of the following does the nurse tell this patient can cause a dysfunction of the heart valves? Select all that apply.

• Congenital defects • Rheumatic heart disease • Trauma • Ischemic heart disease • Inflammation • Degenerative changes

When a physician suspects a patient has suffered an acute myocardial infarction, which serum biomarkers should he order? Select all that apply.

• Creatine kinase • Troponin 1 • Troponin T

A client is admitted with dilated cardiomyopathy with left ventricular dysfunction. The nurse should assess for which of the following clinical manifestations? Select all that apply.

• Dyspnea • Orthopnea • Extreme fatigue with activity

A client with a history of acute coronary syndrome asks why she needs to take aspirin 81 mg every day. The most appropriate response by the nurse would be:

"Aspirin will help prevent blood clotting." -Aspirin (i.e., acetylsalicylic acid) is the preferred antiplatelet agent for preventing platelet aggregation in persons with ACS. Aspirin, which acts by inhibiting synthesis of the prostaglandin thromboxane A2, is thought to promote reperfusion and reduce the likelihood of rethrombosis. This dose of aspirin is not appropriate for pain relief, and the final option does not demonstrate therapeutic communication.

The nurse is teaching a patient with a diagnosis of hypertrophic cardiomyopathy and aortic valve stenosis. Which of the following statements by the patient shows that the patient understands this condition?

"I should report episodes of dizziness or fainting." -Hypertrophic cardiomyopathy is defined as unexplained thickening of the left ventricle leading to reduced cardiac output and obstructive outflow. It can cause sudden cardiac death in athletes after exertion. Treatment includes beta blockers to reduce outflow obstruction. The calcium channel blocker verapamil may be used but is avoided in patients with severe outflow obstruction. Patients should pace activity and avoid alcohol. Episodes of dizziness or fainting could indicate reduced cardiac output and should be evaluated.

A 78-year-old man has been experiencing nocturnal chest pain over the last several months, and his family physician has diagnosed him with variant angina. Which of the following teaching points should the physician include in his explanation of the man's new diagnosis?

"I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising." -Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does not normally necessitate blood work, heparin administration, or avoidance of activity.

On a routine physical exam visit, the physician mentions that they hear a new murmur. The patient gets worried and asks, "What does this mean?" The physician responds:

"One of your heart valves is not opening properly. We need to do an echocardiogram to see which valve is having problems." -Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. Blood flow through a normal valve can increase by 5-7 times the resting volume. Valvular disease is not caused by stress. The murmur can be caused by infection but also stenosis or regurgitation of a valve leaflet. The valve problem is very severe if it is causing signs of decrease cardiac output.

Which of the following teaching points would be most appropriate for a group of older adults who are concerned about their cardiac health?

"The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel." -Stable plaque is associated with obstruction of blood flow, while unstable plaque may dislodge and result in thrombus formation. Plaque disruption is noted to correlate with sympathetic events and is not seemingly random; infections and respiratory problems are not noted to be associated, however.

ST-elevated myocardial infarction 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

What is the most common identifiable cause of secondary cardiomyopathy?

Alcohol abuse

Four patients 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 patient most likely experienced myocardial infarction?

An 80-year-old woman whose pain started at 6 a.m. shortly after awakening and 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 patients have angina of varying severity.

The nurse is preparing to auscultate for a mitral valve stenosis murmur Where is the best location to place the stethoscope?

At the apex of the heart

A patient who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which of the following manifestations alerts the nurse to a developing complication?

Decreased level of consciousness -Fibrinolytic therapy is most effective in treating STEMI when administered within 30 minutes after the onset of symptoms. It can still be beneficial up to 12 hours after the onset of ischemic pain. Patients who should not receive fibrinolytic therapy are those with a history of intracranial hemorrhage or significant trauma within the preceding 3 months. The primary complication of fibrinolytic treatment is intracranial bleeding that usually occurs within the first 24 hours following treatment. This would be evident with a change in mental status.

Angina pectoris is a chronic ischemic CAD that is characterized by a symptomatic paroxysmal chest pain or pressure sensation associated with transient myocardial ischemia. What precipitates an attack of angina pectoris?

Emotional stress -Angina pectoris usually is precipitated by situations that increase the work demands of the heart, such as physical exertion, exposure to cold, and emotional stress. The pain typically is described as a constricting, squeezing, or suffocating sensation. It usually is steady, increasing in intensity only at the onset and end of the attack. Changing positions abruptly does not cause an attack of angina pectoris.

Which of the following lab results strongly suggest an immunologic response in the client with possible rheumatic heart disease?

Group A (β-hemolytic) streptococcal antibodies -The pathology of RF does not involve direct bacterial infection of the heart. Rather, the time frame for development of symptoms relative to the onset of pharyngitis and the presence of antibodies to the GAS organism strongly suggests an immunologic response. It is thought that antibodies directed against the M-protein of certain strains of streptococci cross-react with glycoprotein antigens in the heart, joints, and other tissues to produce an autoimmune response through a phenomenon called molecular mimicry. Elevated erythrocyte sedimentation rate (ESR) is a blood test that can reveal inflammatory activity in your body. The level of CRP rises when there is inflammation throughout the body. Elevated WBC indicates an infection

Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?

Have the client sit up and lean forward -With acute periocarditis, the pain typically is pleuritic (aggravated by inspiration and swallowing) and positional (decreases with sitting and leaning forward; increases with moving to the side) because of changes in venous return and cardiac filling.

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.

A young college football player was bought to the emergency room after collapsing on the football field during practice. When arriving he was unconscious and his ECG was abnormal. Subsequently he died after arresting in the emergency room. What does the physician suspect is the likely cause of this?

Hypertrophic cardiomyopathy -Hypertrophic cardiomyopathy is characterized by unexplained left ventricular hypertrophy with disproportionate thickening of the interventricular septum, abnormal diastolic filling, cardiac arrhythmias. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac deat in young athletes.

A client has just been told that he has an infection of the inner surface of the heart. He is also told that the bacteria has invaded his heart valves. What term is used for this disease process?

Infective endocarditis -Infective endocarditis is a serious and potentially life-threatening infection of the inner surface of the heart. Pericarditis involves an inflammatory response of the pericardium. Myocardial infarction is a heart attack while cardiomyopathy is a heart disorder that is confined to the myocardium and can sometimes represent myocardial changes that occur with a variety of systemic disorders.

A client who has suffered a myocardial infarction is being treated in the emergency room. His pain remains severe even though he was given nitrates and oxygen. The physician now orders morphine for the pain. What method should the nurse to administer the morphine?

Intravenous -Morphine is given intravenously when a patient is in the emergency room suffering a myocardial infarction. It is given intravenously because of the rapid onset of action, and it does not elevate enzyme levels. (

While studying the heart the nursing instructor teaches about pericarditis. Which of the following does she tell the student best defines this disease?

It's an inflammatory response

The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states that blood is shunted from the:

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.

Antibodies directed against the M protein of certain strains of streptococcal bacteria seem to cross-react with glycoprotein antigens in the heart, joint, and other tissues to produce an autoimmune response resulting in rheumatic fever and rheumatic heart disease. This occurs through what phenomenon?

Molecular mimicry -It is thought that antibodies directed against the M protein of certain strains of streptococci cross-react with glycoprotein antigens in the heart, joint, and other tissues to produce an autoimmune response through a phenomenon called molecular mimicry. None of the other answers are correct.

Which of the following patients with cardiomyopathy does the nurse identify as having the greatest risk for a complication?

One 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 patient showing evidence of stasis in the heart that can result from a reduced ejection fraction and atrial fibrillation. This patient is most likely to experience an embolus.

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

A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250ML of fluid in the pericardial cavity. Which disease should the nurse suspect this client to be suffering?

Pericardial effusion

Which of the following patients is at the greatest risk of developing rheumatic heart disease?

Teenager with untreated strep throat -Rheumatic fever is caused by group A (beta-hemolytic) streptococcal throat infection. Although the same bacteria cause the skin infection called impetigo, it is not known to cause rheumatic heart disease. Viral infections such as meningitis and shingles (herpes zoster) do not cause rheumatic heart disease.

A client is at high risk for the development of rheumatic heart disease. The most important information for the nurse to provide would be:

Prompt diagnosis and treatment of streptococcal infections -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 the client should have regular dental examinations.

A preventative measure to decrease the risk of developing rheumatic heart disease includes which of the following?

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 patient has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the patient may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.

The health care provider is preparing to assess a client who has been diagnosed with hypertrophic cardiomyopathy. The provider anticipates the assessment data will include:

Reduced chamber size

A client who is experiencing angina at rest that has been increasing in intensity should be instructed to do which of the following?

See the doctor for evaluation immediately.

The diagnosis of chronic stable angina is based on a detailed pain history, the presence of risk factors, invasive and noninvasive studies, and laboratory studies. What test is not used in the diagnosis of angina?

Serum biochemical markers -Serum biochemical markers for MI are normal in clients with chronic stable angina. All other answers are tests used in the diagnosis of angina.

An IV drug abuser walks into the ED telling the nurse that, "they are sick." They look feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and, fatigued. The assessment reveals a loud murmur. An echocardiogram was order that shows a large vegetation growing on their mitral valve. The patient is admitted to ICU. The nurse will be assessing this patient for which possible life-threatening complication?

Systemic emboli, especially to brain.

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.

A client has just been admitted to the cardiac intensive care unit with a diagnosis of infective endocarditis. His wife appears distraught and asks the nurse what caused this to happen to her husband. What would be the nurse's best response?

The most common cause is a staph infection -Staphylococcal infections have now emerged as the leading cause of infective endocarditis, with streptococci and enterococci as the other two most common causes. Informing the client's wife about the drug abuse connection infers that you think he is a drug addict and is not therapeutic. Parasites are never the cause and telling the patient to focus on her husband also is not appropriate as this is a genuine concern for her

A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be:

The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta -Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. This increases the work and volume of the chamber emptying through the narrowed valve—the left atrium in the case of mitral stenosis and the left ventricle in aortic stenosis. An incompetent or regurgitant valve permits backward flow to occur when the valve should be closed—flowing back into the left ventricle during diastole when the aortic valve is affected and back into the left atrium during systole when the mitral valve is diseased.

A teenager comes to the emergency room with a history of strep throat and symptoms that lead the staff to suspect rheumatic fever. Which of the following tests can best establish a diagnosis of rheumatic fever?

There is no definitive test for diagnosing RF.

Which serum biomarker is highly specific for myocardial tissue?

Troponin -The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.

A client comes to the emergency room with all the symptoms of a myodardial infarction. Which lab value does the nurse suspect the physician will order which is known to have a high specificity for myocardial tissue and has become the primary biomarker test for diagnosing an MI?

Troponin assays

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.

The nurse working in the emergency room triages a client who comes in with complaints of chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myodardial infarction. The client is given a nitrate, which does nothing for his pain. Which of the following medications should the nurse suspect the doctor will order next for the pain?

morphine

What can trigger myocardial ischemia even when there is adequate coronary blood flow? Select all that apply.

• Anemia • Carbon monoxide poisoning • Hypoxia -Myocardial oxygen supply is determined by the coronary arteries and capillary inflow, and the ability of hemoglobin to transport and deliver oxygen to the heart muscle. Even with adequate coronary blood flow, myocardial ischemia can occur in situations of hypoxia, anemia, or carbon monoxide poisoning. The other options are not relevant to myocardial ischemia

Two weeks after receiving a prosthetic mitral valve, a patient presents to the emergency department with fever, anorexia, and splinter hemorrhages of the nails. Which of the following interventions will the nurse implement? Select all that apply.

• Blood cultures • Antibiotics • Monitoring for emboli

A nurse assesses a patient with normal biomarkers who reports angina. Which of the following additional manifestations are late signs of aortic stenosis? Select all that apply.

• Dyspnea • Peripheral cyanosis • Syncope -The earliest signs of aortic stenosis are a loud systolic ejection murmur or a single or paradoxically split second heart sound. Angina, syncope, and heart failure are later signs of the disorder.

A nurse is assessing a client who has just been admitted to the unit with a diagnosis of acute pericarditis. The client would most likely manifest: Select all that apply.

• Fever • Chest pain • Pericardial friction rub • Pleuritic pain

Following a ST-segment myocardial infarction (STEMI), the nurse should be assessing the patient for which of the following complications? Select all that apply.

• Large amount of pink, frothy sputum and new onset of murmur. • Tachypnea with respiratory distress. • Frequent ventricular arrhythmia unrelieved with Amiodarone drip. • Complaints of facial numbness and tingling.

Which of the following diagnostic/assessment findings would been seen in a client with worsening mitral valve stenosis? Select all that apply.

• Low-pitched diastolic murmur that is increasing in duration • Sharp elevation in left atrial pressure • Decreased cardiac output

Following cardiac surgery, the nurse suspects the patient may be developing a cardiac tamponade. Which of the following clinical manifestations would support this diagnosis? Select all that apply.

• Muffled heart tones. • Narrowed pulse pressure. • Low BP—84/60.

A pediatric nurse is assessing a newborn diagnosed with persistent patency of the ductus arteriosus. Which of the following findings is associated with this heart defect? Select all that apply.

• Murmur heard at the 2nd intercostals space, during both systole and diastole. • BP 84/30 classified as a wide pulse pressure. -Persistent patency of the ductus arteriosus is defines as remaining open >3 months. A murmur is detected within days of birth. It is loudest at the 2nd Left intercostals space, continuous through systole and diastole. A wide pulse pressure is common (BP 84/30). Most newborns have an elevated respiratory rate with Exertional activity. Stridor is usually associated with bronchial infections or narrowing of the airways. Bulging jugular neck veins is associated with right-sided heart failure

Unstable plaque, a condition of atherosclerotic heart disease, occurs in unstable angina and myocardial infarction. Unstable plaque can rupture, causing platelet aggregation and thrombus formation. What are the major determinants of the vulnerability of plaque to rupture? (Select all that apply.

• Presence of inflammation • Size of lipid-rich core • Thickness of fibrous cap

Unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI) is a clinical syndrome that ranges in severity between stable angina and MI. It is classified according to its risk of causing an acute MI and is diagnosed based on what? (Select all that apply.)

• Serum biomarkers • ECG pattern -UA/NSTEMI is classified as either low or intermediate risk of acute MI, the diagnosis of which is based on the clinical history, ECG pattern, and serum biomarkers. The other answers are not diagnostic of UA/NSTEMI

The nurse is evaluating a client who is in her last month of pregnancy and at risk for peripartum cardiomyopathy. Select the most appropriate information for the nurse to consider. Select all that apply.

• The incidence is greater in women with twin fetuses. • It is a dilated cardiomyopathy. • It is a disorder that can occur in the last month of pregnancy.