Wagner, Ch. 12 Determinants & Assessment of Cardiac Function

A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education? 1. The patients functional status prior to illness 2. Family history of disease, diet history, and prior medical history 3. Demographic data including age, sex, race, and weight of patient 4. Cardiovascular risk factors, such as history of smoking and stress level

Correct Answer: 1 Rationale 1: Knowledge of the patients functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patients pre-illness capabilities. Rationale 2: Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patients capabilities. Rationale 3: Demographic data is not as important as other assessment components for use in determining realistic goals. Rationale 4: Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but does not specifically address goals of therapy. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5

A patient admitted with a cardiac arrhythmia is scheduled to have an electrophysiology study (EPS). The nurse would reinforce which teaching about this test? 1. This test will be helpful in determining if you need a pacemaker. 2. This test will help us determine how your heart responds to stress. 3. We can learn about the strength of your heart valves with this test. 4. This test will reveal the health of your hearts blood supply system.

Correct Answer: 1 Rationale 1: The electrophysiology study is an invasive procedure that evaluates the cardiac conduction system and helps classify cardiac arrhythmias. The findings from this study help to determine if the patient would benefit from further interventions such as a pacemaker, implantable cardiodefibrillator, and radiofrequency ablation or medication therapy. Rationale 2: Exercise electrocardiograms evaluate heart muscle and its blood supply during physical stress. Rationale 3: Echocardiograms are used to visualize blood, cardiac valves, the myocardium, and the pericardium. Rationale 4: Cardiac catheterization is performed to determine the presence and extent of coronary artery disease, evaluate left ventricular function, and to evaluate valvular or myocardial disorders. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart? 1. Right ventricle 2. Anterior aspect of the left ventricle 3. The septum 4. The lateral wall of the left ventricle

Correct Answer: 1 Rationale 1: The right coronary artery supplies the right ventricle. Rationale 2: The left anterior descending artery supplies the anterior aspect of the left ventricle. Rationale 3: The left anterior descending artery supplies the septum. Rationale 4: The left circumflex artery supplies the lateral wall of the left ventricle. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning

Which assessment techniques will the nurse use to evaluate the patients cardiac output? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Inspection of color changes in the periphery 2. Strength of pulses 3. Percussion of heart borders 4. Auscultation of heart sounds 5. Pulse pressure determination

Correct Answer: 1,2,4,5 Rationale 1: Color changes in the periphery can indicate decreased cardiac output. Rationale 2: Strength of pulse is an indirect measure of cardiac output and contractility. Rationale 3: Percussion is incorrect because it measures heart size very crudely but not output. Rationale 4: Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output. Rationale 5: Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5

It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Cardiac glycosides 2. Loop diuretics 3. Sympathomimetic agents 4. Phosphodiesterase inhibitors 5. Ace-inhibitors

Correct Answer: 1,3,4 Rationale 1: Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility. Rationale 2: Diuretics are given to decrease the work load on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility. Rationale 3: Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility. Rationale 4: Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility. Rationale 5: ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-4

A patients cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Assure that there is an accurate current weight on the medical record. 2. Compare fluid input and output for the last 12 hours. 3. Measure the patients height. 4. Figure the patients age in years and months. 5. Obtain the patients current heart rate.

Correct Answer: 1,3,5 Rationale 1: Weight is a component of cardiac index. Rationale 2: There is no need to compare fluid intake and output in order to calculate cardiac index. Rationale 3: Height is used to calculate cardiac index. Rationale 4: Age is not a consideration when calculating cardiac index. Rationale 5: Heart rate is a component of cardiac index. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3

A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patients cardiac status? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Increase in cardiac output 2. Increase in blood pressure 3. Decrease in cardiac output 4. Decrease in blood pressure 5. No change in blood pressure or cardiac output

Correct Answer: 1,4 Rationale 1: Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues. Rationale 2: Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure. Rationale 3: Initially the decrease in afterload will increase cardiac output. Rationale 4: Decrease in afterload results in decrease in blood pressure. Rationale 5: Changes in afterload will change both blood pressure and cardiac output. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-4

A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition? 1. Increased output of very clear urine 2. Changes in skin color 3. Localized edema in the calf 4. Skin that is warm and damp

Correct Answer: 2 Rationale 1: A decrease in cardiac output generally results in a decrease in urine output. Rationale 2: Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output. Rationale 3: Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein. Rationale 4: Cool skin is a finding associated with decreased cardiac output. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Testing reveals that a patients myocardial infarction damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication? 1. Extension of the myocardial damage 2. Catastrophic left heart failure 3. Pulmonary edema from right heart failure 4. Pulmonary embolism from clots in the left atrium

Correct Answer: 2 Rationale 1: All patients who have MI are at risk for extension of the damage. It is not specific to this patient. Rationale 2: The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur. Rationale 3: The mitral valve is on the left side of the heart. Rationale 4: The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning

A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin? 1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours 2. What precipitated the pain, what it feels like, and where it is located 3. Changes in dietary habits, smoking history, and presence of cough 4. What home remedies were tried, activity level, and fluid intake changes

Correct Answer: 2 Rationale 1: Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain. Rationale 2: Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin. Rationale 3: This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin. Rationale 4: This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5

The nurse is instructing a patient who is scheduled for a cardiac catheterization. Which comment made by the patient would indicate the need for additional education? 1. The nurse will check my feet very often after the procedure. 2. I will place a warm pack at the puncture site for pain relief. 3. I should let the nurse know if I need to cough after the procedure is done. 4. I will have someone available to drive me home following the procedure.

Correct Answer: 2 Rationale 1: Pedal pulses are checked bilaterally after the procedure. Rationale 2: The vasodilatory effect of a warm pack would cause vessel rupture and, therefore, is the choice that indicates a need for further education. Rationale 3: In order to minimize stress on the insertion site, it should be manually compressed when the patient coughs. Rationale 4: Many of these procedures are done as outpatient procedures, which would require someone to drive the patient home. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12-6

A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic? 1. The amount of blood the heart pumps every minute 2. The strength of the heartbeat 3. The amount of resistance the heart beats against 4. The amount of blood in the heart before it beats

Correct Answer: 2 Rationale 1: The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction. Rationale 2: Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function. Rationale 3: Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output. Rationale 4: Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12-3

A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patients care would consider which physiology when explaining this disorder to the patients family? 1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema. 2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema. 3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema. 4. The arteries of the pulmonary circuit are single layer.

Correct Answer: 2 Rationale 1: The pulmonary circuit is normally a low-pressure system. Rationale 2: There are no valves in the pulmonary veins so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema. Rationale 3: The blood that enters the pulmonary circuit oxygen-poor. Rationale 4: The capillaries in the lungs are single layer, but the arteries have three layers. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test? 1. Oral fluids 2. A defibrillator 3. External pacemaker 4. Portable chest x-ray machine

Correct Answer: 2 Rationale 1: There is no reason that oral fluids are required for this test. Rationale 2: Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment. Rationale 3: There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place. Rationale 4: There is no reason for a portable x-ray machine to be present in the room during this test. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Planning

The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient? 1. Dim the lights in the room. 2. Monitor for bradycardia and hypotension. 3. Assess pedal pulses bilaterally. 4. Apply pressure to the puncture site.

Correct Answer: 2 Rationale 1: There is no specific reason to dim the room lights. Rationale 2: The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patients vagus nerve. Rationale 3: There is no specific indication that assessing pedal pulses is necessary during this procedure. Rationale 4: There is no puncture site in a TEE. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation

The nurse has auscultated the patients heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment? 1. Pulse pressure of 38 mm Hg 2. Bounding, vigorous pulse 3. Split of S2 4. Apical pulse of 66

Correct Answer: 3 Rationale 1: The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range. Rationale 2: A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment. Rationale 3: The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment. Rationale 4: The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-5

A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence? 1. This fluctuation will occur until maximum preload has been reached. 2. The patients heart rate is increasing, which causes a drop in stroke volume. 3. The patients preload has reached a critical point and now stroke volume will decrease. 4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.

Correct Answer: 3 Rationale 1: There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached. Rationale 2: The information in this question does not support increase in the heart rate. Rationale 3: Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract. Rationale 4: There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3

Testing indicates that a patient has a high preload. What changes would the nurse expect in this patients cardiac function? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Heart rate will decrease. 2. Afterload will increase. 3. Stroke volume will decrease. 4. Stoke volume will increase. 5. Blood pressure will decrease.

Correct Answer: 3,4 Rationale 1: It is not possible to predict what change in heart rate will occur in the face of increased preload. Depending upon the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same. Rationale 2: Afterload represents the force the heart must overcome to pump blood. It is not affected by preload. Rationale 3: If the increase in preload is high enough that a critical point is reached stroke volume will decrease. Rationale 4: The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume. Rationale 5: It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume which will result in increased blood pressure. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12-3

It is suspected that a patient who was severely injured in an automobile accident may have had a myocardial infarction prior to the crash. Which laboratory test result drawn while the patient was in the emergency department would the nurse evaluate as supporting that theory? 1. Increased serum potassium 2. Increased creatine kinase level 3. Increased BNP level 4. Increased troponin level

Correct Answer: 4 Rationale 1: Potassium level changes may indicate damage to muscle tissue, but is not specific to heart muscle. Rationale 2: Creatine kinase levels do not rise until 4 to 12 hours after onset of myocardial necrosis. Unless a CK-MB level was drawn, the CK level is not specific to cardiac muscle. Rationale 3: BNP level is assessed for the presence of heart failure. Rationale 4: Troponin is a protein found in cardiac muscle and can appear in the blood as early as 1 to 3 hours after symptoms of MI. Troponin has a higher sensitivity and specificity of identifying myocardial damage than does creatine kinase. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment

Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect? 1. S1 followed closely by S2 2. S1 followed closely by S2 followed closely by S3 3. S1 followed closely by a split S2 4. S4 followed by S1 followed by S2 followed by S3 followed by S4

Correct Answer: 4 Rationale 1: S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop. Rationale 2: Presence of a third heart sound is documented as a ventricular gallop. Rationale 3: Splitting of S2 does occur, but this is not documented as a summation gallop. Rationale 4: The S4 heart sound is heart during atrial contraction, so it sounds as if it occurs before S1. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment