Critical Care Ch14
ANS: D An aneurysm smaller than 4 cm in diameter can be managed on an outpatient basis with frequent blood pressure monitoring and ultrasound testing to document any changes in the size of the aneurysm. Management includes weight loss, smoking cessation, and control of hypertension as appropriate. An aortic aneurysm larger than 5 cm in diameter requires evaluation for surgical repair or placement of an aortic stent to eliminate the risk of rupture.
31. At what size is an aortic aneurysm evaluated for surgical repair or stent placement? a. 2 cm b. 4 cm c. 5 cm d. >5 cm
ANS: A, B, C, E Many research trials have demonstrated the positive effects of physical activity on the other major cardiac risk factors. Exercise alters the lipid profile by decreasing low-density lipoprotein (LDL) cholesterol and triglyceride levels and increasing high-density lipoprotein (HDL) cholesterol levels. Exercise reduces insulin resistance at the cellular level, lowering the risk for developing type 2 diabetes, especially if combined with a weight loss program.
1. Which physiologic effects can be associated with physical exercise? (Select all that apply.) a. Decreased LDL cholesterol b. Increased HDL cholesterol c. Decreased triglycerides d. Increased insulin resistance e. Decreased incidence of depression
ANS: C Research and epidemiologic data collected during the past 50 years have demonstrated a strong association between specific risk factors and the development of coronary artery disease (CAD). In general, CAD symptoms are seen in persons age 45 years and older. Primary cardiovascular risk factors are different in men and women, with women having higher rates of diabetes and hypertension compared with men. C-reactive protein (CRP) is associated with an increased risk for development of other cardiovascular risk factors including diabetes, hypertension, and weight gain. The higher the value, the greater the risk of a coronary event, especially if all other potential causes of systemic inflammation such as infection can be ruled out.
1. Which statement about coronary artery disease (CAD) is accurate? a. There is a low correlation between modifiable risk factors and CAD. b. The onset of CAD occurs in middle age women sooner than men of the same age. c. There is an association between development of specific risk factors and CAD. d. The lower the C-reactive protein level the higher the risk for a coronary event.
ANS: B Primary topics of education include (1) the importance of a daily weight, (2) fluid restrictions, and (3) written information about the multiple medications used to control the symptoms of heart failure. Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.
10. Which intervention is an essential aspect of the patient teaching plan for the patient with chronic heart failure? a. Instructing the patient to call the practitioner prior to dental surgery b. Stressing the importance of compliance with diuretic therapy c. Instructing the patient to take nitroglycerin if chest pain occurs d. Teaching the patient how to take an apical pulse
ANS: A In the acute phase after ST segment elevation myocardial infarction, heparin is administered in combination with fibrinolytic therapy to recanalize (open) the coronary artery. For patients who will receive fibrinolytic therapy, an initial heparin bolus of 60 units/kg (maximum, 5000 units) is given intravenously followed by a continuous heparin drip at 12 units/kg/hr (maximum 1000 units/hr) to maintain an activated partial thromboplastin time between 50 and 70 seconds (1.5 to 2.0 times control).
11. In the acute phase after ST segment elevation myocardial infarction (STEMI), fibrinolytic therapy is used in combination with heparin to recanalize the coronary artery. What dosage is the initial heparin bolus? a. 60 units/kg maximum 5000 units b. 30 units/kg maximum 3000 units c. 25 units/kg maximum of 2500 units d. 12 units/kg maximum of 1000 units
ANS: C Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and have a sensation of suffocation. They expectorate pink, frothy sputum and feel as if they are drowning. They may sit bolt upright, gasp for breath, or thrash about. The respiratory rate is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck muscles. Respirations are characterized by loud inspiratory and expiratory gurgling sounds.
12. The nurse is caring for a patient with left-sided heart failure. The nurse suspects the patient is developing pulmonary edema. Which finding would confirm the nurse's suspicions? a. Pulmonary crackles b. Peripheral edema c. Pink, frothy sputum d. Elevated central venous pressure
ANS: A Pharmacologic management includes beta-blockers to decrease left ventricular workload, medications to control and prevent atrial and ventricular dysrhythmias, anticoagulation if atrial fibrillation or left ventricular thrombi are present, and, finally, drugs to manage heart failure.
13. A patient is admitted with hypertrophic cardiomyopathy. The nurse would expect the medical management of this patient to include which intervention? a. Administration of beta-blockers b. Administration of positive inotropes c. Plans for intensive exercise regimen d. Plans for an aortic valve replacement
ANS: D Education for the patient with acute or chronic heart failure secondary to valvular dysfunction includes (1) information related to diet, (2) fluid restrictions, (3) the actions and side effects of heart failure medications, (4) the need for prophylactic antibiotics before undergoing any invasive procedures such as dental work, and (5) when to call the health care provider to report a negative change in cardiac symptoms.
14. The nurse is developing a patient education plan for a patient with valvular heart disease. Which instruction would be included as part of that plan? a. Increase fluid intake to increase cardiac output. b. Take sodium replacement tablets to replace sodium lost with diuretics. c. Increase daily activity until shortness of breath occurs. d. Take prophylactic antibiotics before undergoing any invasive procedure.
ANS: D Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.
15. A patient has been admitted in hypertensive crisis. Which medication would the nurse expect the practitioner to order for this patient? a. Digitalis b. Vasopressin c. Verapamil d. Sodium nitroprusside
ANS: B The classic clinical presentation is the sudden onset of intense, severe, tearing pain, which may be localized initially in the chest, abdomen, or back. As the aortic tear (dissection) extends, pain radiates to the back or distally toward the lower extremities. Many patients have hypertension upon initial presentation, and the focus is on control of blood pressure and early operation.
16. Which description best describes the pain associated with aortic dissection? a. Substernal pressure b. Tearing in the chest, abdomen, or back c. Numbness and tingling in the left arm d. Stabbing in the epigastric area
ANS: A Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces ischemic muscle pain known as intermittent claudication. This cramping, aching pain while walking is often the first symptom of peripheral arterial occlusive disease. The pain is relieved by rest and may remain stable in occurrence and intensity for many years.
17. Which clinical manifestation is usually the first symptom of peripheral arterial disease (PAD)? a. Cramping when walking b. Thrombophlebitis c. Pulmonary embolism d. Cordlike veins
ANS: A, B, C The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the myocardium are (1) plaque rupture, (2) new coronary artery thrombosis, and (3) coronary artery spasm close to the ruptured plaque.
3. Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.) a. Coronary artery thrombosis b. Plaque rupture c. Coronary artery spasm near the ruptured plaque d. Preinfarction angina e. Hyperlipidemia
ANS: C Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the specific infective endocarditis microbe and patient circumstances. Antibiotic treatment is prolonged, administered in high doses intravenously, and may involve combination therapy. Best outcomes are achieved if therapy is initiated before hemodynamic compromise.
18. The nurse developing a patient education plan for the patient with endocarditis. What information would be included in the plan? a. Endocarditis is a viral infection that is easily treated with antibiotics. b. The risk of this diagnosis is occlusion of the coronary arteries. c. A long course of antibiotics is needed to treat this disorder. d. Complications are rare after antibiotics have been started.
ANS: D The changes in repolarization are seen by the presence of new Q waves. These new, pathologic Q waves are deeper and wider than tiny Q waves found on the normal 12-lead ECG.
19. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for infarction? a. Inverted T waves b. Tall, peaked T waves c. ST segment depression
ANS: A, D, E Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance, (2) fluid retention, or (3) discovery during examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis.
2. Which clinical manifestations are indicative of left ventricular failure? (Select all that apply.) a. Cool, pale extremities b. Jugular venous distention c. Liver tenderness d. Weak peripheral pulses e. Rales
ANS: D All of the reasons are not completely understood, but one recognized physiologic effect is the ability of high-density lipoprotein (HDL) to promote the efflux of cholesterol from cells. This process may minimize the accumulation of foam cells in the artery wall and thus decrease the risk of developing atherosclerosis. High HDL levels confer both antiinflammatory and antioxidant benefits on the arterial wall. In contrast, a low HDL level is an independent risk factor for the development of CAD and other atherosclerotic conditions.
2. Which value, when elevated, places the patient at lowest risk for coronary artery disease (CAD)? a. Very-low-density lipoproteins (VLDLs) b. Triglycerides c. Low-density lipoproteins (LDLs) d. High-density lipoproteins (HDLs)
ANS: A Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Anterior wall infarctions are manifested by ECG changes in leads V2 to V4. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.
20. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which leads on the ECG would correlate with an inferior wall MI? a. II, III, aVF b. V5 to V6, I, aVL c. V2 to V4 d. V1 to V2
ANS: C Many patients experience complications occurring either early or late in the postinfarction course. These complications may result from electrical dysfunction or from a cardiac contractility problem. Cardiac monitoring for early detection of ventricular dysrhythmias is ongoing. Pumping complications can cause heart failure, pulmonary edema, and cardiogenic shock. The presence of a new murmur in a patient with an acute myocardial infarction warrants special attention because it may indicate rupture of the papillary muscle. The murmur can be indicative of severe damage and impending complications such as heart failure and pulmonary edema.
21. A patient is admitted with an acute myocardial infarction (MI). What common complication should the nurse anticipate in this patient? a. Pulmonary edema b. Cardiogenic shock c. Dysrhythmias d. Deep vein thrombosis
ANS: D Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain an acute myocardial infarction (MI). It is more prevalent with an inferior wall infarction in the first hour after ST segment elevation MI. Sinus tachycardia (heart rate more than 100 beats/min) most often occurs with an anterior wall MI. Premature atrial contractions (PACs) occur frequently in patients who sustain an acute MI. Atrial fibrillation is also common and may occur spontaneously or may be preceded by PACs. Premature ventricular contractions (PVCs) are seen in almost all patients within the first few hours after an MI.
22. Which classification of dysrhythmia is most common with an inferior wall infarction in the first hour after ST segment elevation myocardial infarction (STEMI)? a. Sinus tachycardia b. Multifocal PVCs c. Atrial fibrillation d. Sinus bradycardia
ANS: D Low-density lipoprotein (LDL) cholesterol is usually described as the "bad cholesterol" because high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at low risk of coronary artery disease. Triglyceride levels below 150 are considered normal.
23. Which laboratory value indicates a heightened risk for the development of coronary artery disease (CAD)? a. Total cholesterol level of 170 mg/dL b. HDL cholesterol level of 30 mg/dL c. Triglyceride level of 120 mg/dL d. LDL cholesterol level >190 mg/dL
ANS: C Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise, with up to 50% of patients complaining of myalgias and joint pain. Blood cultures are drawn during periods of elevated temperature
30. A patient is admitted with a fever of unknown origin. The patient is complaining of fatigue, malaise, joint pain, and shivering. The patient's vital signs include temperature, 103° F; heart rate, 90 beats/min; respiratory rate, 22 breaths/min; blood pressure, 132/78; and oxygen saturation, 94% on 2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient has developed which problem? a. Coronary artery disease b. Heart failure c. Endocarditis d. Pulmonary embolus
ANS: C Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Patients become used to the pattern of this type of angina and may describe it as "my usual chest pain." Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic, occurring at the same time every day.
24. A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation. The nurse suspects the patient may have which disorder? a. Silent ischemia b. Stable angina c. Unstable angina d. Prinzmetal angina
ANS: C Longer term education of the patient and the family can begin. Points to cover include (1) risk factor modification, (2) signs and symptoms of angina, (3) when to call the physician, (4) medications, and (5) dealing with emotions and stress. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to the patient as "bearing down" during defecation or breath holding when repositioning in bed. Relaxation therapy and techniques including back rubs are encouraged when appropriate.
25. A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? a. He should stop smoking. b. He can no longer drink colas or coffee. c. He can no longer get a strong back massage. d. He should take stool softeners to prevent straining.
ANS: C Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to V4. Inferior infarctions are manifested by ECG changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.
26. A patient presents with severe substernal chest pain. The patient exclaims, "This is the most severe pain I have ever felt!" The patient reports that the pain came on suddenly about 2 hours ago and that three sublingual nitroglycerin tablets have not relieved the pain. The 12-lead electrocardiogram (ECG) reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and V5; pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4. Which statement is accurate about this patient? a. This patient has an old lateral wall infarction. b. This patient is having an inferior wall infarction. c. This patient is having an acute anterior wall infarction. d. This patient is having a posterior wall infarction.
ANS: C Depression is a phenomenon that occurs across a wide spectrum of human experience. Key symptoms of depression mentioned frequently by cardiac patients are fatigue, change in appetite, and sleep disturbance.
27. A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings the nurse suspects the patient may be experiencing which problem? a. Angina b. Anxiety c. Depression d. Endocarditis
ANS: D Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema are symptoms of cardiac asthma. With dyspnea, the patient feels shortness of breath from pulmonary vascular congestion and decreased lung compliance. In orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of orthopnea in which the patient awakens from sleep gasping for air.
28. Patient is admitted with heart failure. The patient has developed dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema. The nurse suspects the patient may be developing with problem? a. Dyspnea b. Orthopnea c. Paroxysmal nocturnal dyspnea d. Cardiac asthma
ANS: C The primary aim of palliative care is symptom management and the relief of suffering. Fundamental to all symptom management strategies for heart failure is the optimization of medications, according to current guidelines.
29. A patient is admitted for palliative care for end-stage heart failure. What is the nurse's primary goal when caring for this patient? a. To reverse heart failure with the use of diuretics b. To increase activity tolerance c. To manage symptoms and relieve pain d. To increase cardiac output related to alteration of contractility
ANS: D Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and a diastolic blood pressure of 100 mm Hg or above.
3. The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108, respiratory rate 24, temperature 103° F, and oxygen saturation of 94% on oxygen 2L nasal cannula. The patient is responsive and denies chest pain. The physician has ordered a work-up for coronary artery disease (CAD). These findings are suggestive of which diagnosis? a. Silent ischemia b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension
ANS: A Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control is usually achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary artery lumen and thus has a high correlation to coronary artery disease (CAD), not coronary spasm.
4. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina has a low correlation to coronary artery disease (CAD). d. Stable angina is a result of coronary artery spasm.
ANS: C Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, maintenance of a calm environment, and patient and family education. It is important to document the characteristics of the pain and the patient's heart rate and rhythm, blood pressure, respirations, temperature, skin color, peripheral pulses, urine output, mentation, and overall tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis.
5. The nursing management plan for a patient with angina would include which intervention? a. Immediate administration of antiplatelet therapy b. Teaching the patient how to perform the Valsalva maneuver c. Assessment and documentation of chest pain episodes d. Administration of prophylactic lidocaine for ventricular ectopy
ANS: A Many reasons contribute to higher mortality rates from acute myocardial infarction (MI) in women, and these include waiting longer to seek medical care, having smaller coronary arteries, being older when symptoms occur, and experiencing very different symptoms from those of men of the same age. Women do not have a higher risk of coronary spasm than men.
6. Why do women have higher mortality rates from acute myocardial infarction (MI) than men? a. Women wait longer to seek medical care. b. Women have more risk factors for coronary artery disease than men. c. Women have a higher risk of coronary spasm than men. d. Women have smaller hearts than men.
ANS: B When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into ventricular fibrillation.
7. What dysrhythmia is most frequently associated with sudden cardiac death? a. Premature ventricular contractions b. Ventricular tachycardia c. Third degree heart block d. Asystole
ANS: C Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common initial sign. A friction rub is best auscultated with a stethoscope at the sternal border and is described as a grating, scraping, or leathery scratching. Pericarditis frequently produces a pericardial effusion.
8. Assessment of a patient with pericarditis may reveal which signs and symptoms? a. Ventricular gallop and substernal chest pain b. Narrowed pulse pressure and shortness of breath c. Pericardial friction rub and pain d. Pericardial tamponade and widened pulse pressure
ANS: A The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.
9. What are the clinical manifestations of right-sided heart failure? a. Elevated central venous pressure and sacral edema b. Pulmonary congestion and jugular venous distention c. Hypertension and chest pain d. Liver tenderness and pulmonary edema