Test Questions Chapter 22, 27, 28 Med Surg
It reduces ventricular ejection volume Reducing ventricular ejection volume because diastole, during which the ventricle fills with blood (preload), is shortened as a result of a tachydysrhythmia. Causing a loss of elasticity in the muscle is a result of cardiomyopathy. Afterload is decreased, not increased.
A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia?
C Feedback: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? A) The client says that he has been urinating less frequently at night. B) The client says he has been hungry in the evening. C) The client says his rings have become tight and are difficult to remove. D) The client says he is short of breath when ambulating.
Experiences exertional dyspnea when walking 3 feet; states, "I cannot catch my breath." Exertional dyspnea is the effort at breathing when active.
The nurse assists the client to the bathroom, which is approximately 10 feet from the bed. The client ambulates 3 feet and states, "I cannot catch my breath." How would the nurse document this finding?
There is excess fluid volume in the interstitial space in areas affected by gravity.
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
heart failure A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
tricuspid valve
The nurse is auscultating a client's heart sounds and notes a murmur at the left fourth intercostal space and lateral to the sternum. At which cardiac valve would the nurse document this murmur?
irregular heart rate The posterior wall of the right atrium is the location of the sinoatrial node (SA node), which is the pacemaker of the heart. Damage to this location may result in an irregular heart rate caused by a disturbance of electrical pulse initiation. Depending on muscle damage, the client may have respiratory compromise, chest pain, and/or cyanosis.
The nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding would the nurse anticipate relating to the infarction location?
chordae tendineae Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Options B, C, and D are distractors.
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?
Multiple Gated Acquisition (MUGA) Sign The MUGA is a test that detects how efficiently or inefficiently the heart pumps blood. Echocardiography and chest radiography are used to reveal an enlarged left ventricle. The computed tomography scan is used to reveal abnormalities in blood pressure.
The nurse is caring for a client with hypertension who is experiencing complications. What diagnostic test evaluates the efficiency or inefficiency of the heart to pump blood?
right ventricle Right and left ventricles are the hearts major pumping chamber. The right ventricle pumps to the lungs to oxygenate the blood. The left ventricle pumps blood to the tissue and cells.
The nurse is caring for a client with nursing diagnosis of ineffective tissue perfusion. Which area of the heart would the nurse anticipate being compromised?
Offer small, frequent feedings Preventing stomach distention increases the space in the thoracic cavity for lung expansion. Medication for appetite stimulation would not be given before trying the small, frequent feedings. The client should not be given foods high in sodium and should not be given any foods he or she desires. Three large meals would distend the abdomen and would not increase intrathoracic pressure.
The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?
Using accessory muscles during respiration The use of accessory muscles such as neck or abdominal muscles during respiration is an indication that the client is having difficulty breathing. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable.
The nurse is caring for a client with right-sided heart failure. When assessing the respiratory rate, what is an indication that the client is having difficulty breathing?
heart and blood vessels
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?
Report any numbness, tingling, or sharp pain in the extremity.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?
Stress reduction to lower prehypertensive state That blood pressure is considered to be in the lower range of prehypertension. Knowledge of stress reduction may be helpful in lowering the blood pressure without medication. You wouldn't need medication for a BP of 124/84. Diagnostic testing for cardiac functioning is not typical for a client with prehypertension.
The nurse is employed in a physician's office and is caring for a client present for an annual exam. A blood pressure of 124/84 mm Hg is documented. Following revised guidelines for identifying hypertension, which educational pamphlet is of help?
Orange, the same color as the endocardium Folds of the endocardium, the innermost layer, form the heart valves. Pericardial tissue is the outer layer. Myocardial tissue is the middle muscle tissue.
The nurse is explaining the three layers of tissue which make up the heart wall. As the nurse draws the layers in different colors to highlight the layers, which color would the nurse use for the heart valves?
Sit on the edge of the chair and rise slowly. By doing so, the client reduces the possibility of falls related to postural hypotension.
The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?
Thiazide diuretic Clients with hypertension, unable to be lowered by lifestyle changes, are usually placed on a thiazide diuretic initially. However, most people with hypertension will need two or more antihypertensive medications to reduce their blood pressure.
The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification does the nurse anticipate first?
Low sodium diet
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
Alveoli Gas exchanges occur in the lung where oxygen is inspired air exchanges for CO2 in the venous blood. The CO2 is then transferred to the alveoli to be exhaled.
The nurse is reviewing lab work for a client whose blood CO2 level is elevated. The nurse is most correct to suspect an impairment of which?
Autonomic Nervous system
The nurse is teaching a health class at the local community center. What body system would the nurse explain regulates arterial blood pressure?
Older adults are at increased risk for toxicity.
The nurse is working in a long-term care facility with a group of older adults with cardiac disorders. Why would it be important for the nurse to closely monitor an older adult receiving digitalis preparations for cardiac disorders?
The difference is due to the location of pressure measurement. Central aortic systolic pressure results, reflecting pressure at the root of the aorta, can be documented as 30 mm Hg lower then when corresponding results obtained at the brachial arm.
The nurse is working on a clinical research study, obtaining data evaluating central aortic systolic pressure and brachial arm systolic pressure. The client notes difference in the readings. Which response by the nurse is most accurate?
It may indicate a problem with oxygenation.
The nurse notes that the client has had a change in mental status. Why would the nurse report extremes in the thought process of a client with cardiovascular disorder to the physician?
C Feedback: Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It depends on the resistance of the arterioles and the diastolic filing times. Central aortic pressure is the blood pressure pumped from the left ventricle and measured at the root of the aorta. Systolic blood pressure is determined by the force and volume of blood that the left ventricle ejects. Central venous pressure reflects the blood pressure returning to the heart.
The nurse obtains a blood pressure of 136/86 mm Hg on morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation? A) Central aortic pressure b)Systolic pressure c) Diastolic pressure D) Central venous pressure
Stroke A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. The other options are not usually consequences of untreated chronic hypertension.
The nursing student is part of a group of nursing students who are making a presentation on chronic hypertension. What is one subject the nursing student would need to include in the presentation as a possible consequence of untreated chronic hypertension?
Using a urinary catheter To evaluate response to diuretics, a urinary catheter is used. Mechanical ventilation helps maintain a normal breathing pattern. A pulmonary artery catheter helps estimate cardiac output. A biventricular pacemaker is used to sustain life.
The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?
During the refractory period The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is waiting for the electrical signal. Depolarization occurs during muscle contraction.
When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells are resistant to stimulation?
A client diagnosed with kidney disease Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atherosclerosis.
Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension?
Renal dysfunction resulting from atherosclerosis
Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?
Increase exercise Sarcopenia refers to changes in composition of muscle tissue that can occur in aging as a result of deconditioning.
Which of the following suggestions can the nurse provide to a client to reduce sarcopenia?
