Perfusion PrepU

A client is suspected of having anorexia nervosa and meets the diagnostic criteria for the disorder. When conducting the physical examination, which would be a probable finding from the assessment? Bradycardia Heat intolerance Hypertension Complaints of heartburn

Bradycardia Associated physical exam findings include cold intolerance, complaints of constipation and abdominal pain, hypotension, and bradycardia.

A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance? By performing daily weights at the same time each day By measuring and recording the patient's oral fluid intake By assessing the patient's skin turgor at several different sites By monitoring the patient's blood urea nitrogen (BUN) and creatinine levels

By performing daily weights at the same time each day Changes in fluid balance can be identified by monitoring the patient's weight on a daily basis. This assessment is more accurate than assessing skin turgor. Intake must be considered in combination with output. BUN and creatinine levels provide important data, but these do not convey the patient's fluid balance when considered in isolation.

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for? Postural hypertension and resulting injury Rebound hypertension Postural hypotension and resulting injury Sexual dysfunction

Postural hypotension and resulting injury Antihypertensive medication can cause hypotension, especially postural hypotension that may result in injury. Rebound hypertension occurs when antihypertensive medication is stopped abruptly. Sexual dysfunction may occur, especially with beta blockers, but other medications are available should this problem ensue. This is not immediately a priority concern. Antihypertensive medications do not usually cause postural hypertension.

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located? The heart's muscle fibers The exterior layer of the heart The thin fibrous sac encasing the heart The inner lining of the heart and valves

The thin fibrous sac encasing the heart The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis.

A nurse who works in a busy emergency department provides care for numerous patients who present with complaints of chest pain. Which of the following questions is most likely to help the nurse differentiate between chest pain that is attributable to angina and chest pain due to myocardial infarction (MI)? "Have you ever been diagnosed with high blood pressure or diabetes?" "Does your chest pain make it difficult to move around like you normally would?" "When was the first time that you recall having chest pain?" "Does resting and remaining still help your chest pain to decrease?"

"Does resting and remaining still help your chest pain to decrease?" In most cases, chest pain due to MI is not relieved by rest. Chest pain from angina usually abates with rest. Questions about risk factors or the original onset of the patient's pain do not help differentiate the etiology of a patient's chest pain.

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? An increased sense of thirst Cardiac volume intolerance Increase in nephrons in the kidneys Increased renal blood flow

Cardiac volume intolerance The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Blood urea nitrogen (BUN) Echocardiogram Serum electrolytes Electrocardiogram (ECG)

Echocardiogram An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure? Kidneys and autonomic nervous system Heart and blood vessels Lung and arteries Brain and sympathetic nervous system

Heart and blood vessels Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.

The client presents to the emergency room with a red, edematous, tender right calf and is diagnosed with deep vein thrombosis (DVT). Which medication(s) should the nurse anticipate administering for DVT while the client is admitted to the hospital? Select all that apply. pseudoephedrine heparin warfarin ASA clopidogrel

Heparin Warfarin Drug therapy for deep vein thrombosis (DVT) includes anticoagulants heparin and warfarin. The other medication options are not appropriate for DVT. ASA is used for inflammation, pseudoephedrine is used to treat nasal and sinus congestion, and clopidogrel is used to reduce the risk of heart disease and stroke in those at high risk.

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified? Similar causes are present in both conditions. Hypovolemia contains only low blood volume. In dehydration, only extracellular is depleted. Both conditions result in abnormal laboratory studies.

In dehydration, only extracellular is depleted. In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.

The central venous pressure (CVP) reading in hypovolemic shock is typically which of the following? Unable to measure Low Normal High

Low The CVP reading is typically low in hypovolemic shock. It increases with effective treatment and is significantly increased with fluid overload and heart failure.

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to? Dyspnea Bradypnea Tachypnea Orthopnea

Orthopnea Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD). Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness of breath) is a multidimensional symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. Tachypnea is abnormally rapid respirations. Bradypnea is abnormally slow respirations.

The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? S4 ventricular gallop sign decreased O2 saturation levels oliguria pitting edema

Pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.

A client's primary care provider has prescribed a β-adrenergic receptor blocker. Which therapeutic effects do the client and care provider likely seek? Decreased production of gastric acid Reduction in heart rate and blood pressure Slowing of gastrointestinal motility Increase in mental acuity

Reduction in heart rate and blood pressure β1-adrenergic receptors are located primarily in the heart, the blood vessels of skeletal muscle, and the bronchioles. As such, drugs that block these receptors can bring about a reduction in heart rate, stroke volume, and blood pressure.

The electrical activity of the heart is recorded on the ECG. What does the T wave on the ECG represent? Repolarization of the ventricles Repolarization of the atrium Depolarization of the ventricular conduction system Depolarization of the sinoatrial node

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.

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle? friction rub ejection click opening snap murmur

friction rub During pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. A murmur is created by the turbulent flow of blood. A cause of the turbulence may be a critically narrowed valve. An opening snap is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. An ejection click is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve.

The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? hypovolemia digoxin hypothyroidism vagal stimulation

hypovolemia The causes of sinus tachycardia include physiologic or psychological stress (acute blood loss, anemia, shock, hypovolemia, fever, and exercise). Vagal stimulation, hypothyroidism, and digoxin will cause a sinus bradycardia.

Which chemical does blood-brain and CSF-brain barrier control with easy entrance? Protein Potassium Glutamate Oxygen

oxygen Two barriers, the blood-brain barrier and the cerebrospinal fluid (CSF)-brain barrier, provide the means for maintaining the stable chemical environment of the brain. Only water, carbon dioxide, and oxygen enter the brain with relative ease. Large molecules such as proteins are largely excluded from crossing the blood-brain barrier. In the brain, ammonia is converted to glutamine by astrocytes. Potassium has controlled entrance into the brain; the result of slight fluctuations of potassium concentration in the brain would be uncontrolled neural activity because ions such as potassium influence the threshold for neural firing.

Considering the PQRST complex of an electrocardiogram (ECG), which letter designation represents atrial depolarization? ST segment T wave P wave QRS complex

p wave The P wave represents the sinoatrial node and atrial depolarization; the QRS complex depicts ventricular depolarization, and the T wave represents repolarization.

A client has been diagnosed with deep vein thrombosis (DVT). The nurse is planning care and recognizes that the client is most at risk for: Polyarteritis nodosa Arterial insufficiency Vasculitis Pulmonary embolism

pulmonary embolism Deep venous thrombosis (DVT) most commonly occurs in the lower extremities. DVT of the lower extremity is a serious disorder, complicated by pulmonary embolism, recurrent episodes of DVT, and development of chronic venous insufficiency. Isolated calf thrombi often are asymptomatic. If left untreated, they may extend to the larger, more proximal veins, with an increased risk of pulmonary emboli.