MS - Cardiovascular Disorders
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's care plan, which expected outcome should a nurse include? "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours." "Client will verbalize the intention to avoid exercise." "Client will verbalize the intention to stop smoking." "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."
"Client will verbalize the intention to stop smoking." A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate? "I will have the surgeon speak with you." "Contact between the donor and the recipient is prohibited." "The transplant coordinator can give you information about the donor's medical history." "Did you want to send the donor family a thank you card?"
"The transplant coordinator can give you information about the donor's medical history." Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers; however, medical history, such as history or hepatitis or HIV infection, is permitted. The transplant coordinator is the liaison for information regarding the donor.
A client recovering from an acute myocardial infarction makes a joke about the client's sexual function to the nurse during morning care. What action should the nurse take? Ask the client if there are questions related to sexuality the client would like to discuss. Firmly explain to the client that sexual harassment will not be tolerated. Ignore the client's comments to avoid rewarding attention-seeking behavior. Respond in a light-hearted way to reduce the tension between nurse and client.
Ask the client if there are questions related to sexuality the client would like to discuss. Clients are often concerned about resuming sexual activity after an acute myocardial infarction but are embarrassed to ask directly about the topic. The joke about the client's sexual function could be an effort to open a dialogue. The nurse has a responsibility to respond compassionately and professionally, a duty that excludes ignoring the comments or making light of them. Given the context—a single comment (not a pattern of comments) after an acute myocardial infarction—there is not enough information to conclude that the joke constitutes harassment. Opening a dialogue to understand the client's motivation is the priority.
A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? bed rest with the affected extremity in the dependent position bed rest with all normal activities as long as there no increased pain on the affected site bed rest with the affected extremity flat Bed rest with the affected extremity elevated
Bed rest with the affected extremity elevated Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.
The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock? restlessness confusion incoherent speech unconsciousness
Confusion In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage.
A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care? decreased cardiac output risk for deficient fluid volume ineffective peripheral tissue perfusion risk for activity intolerance
Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of risk for deficient fluid volume is not applicable. Ineffective peripheral tissue perfusion would be applicable if the client is experiencing an alteration in peripheral pulses, capillary refill time greater than 3 seconds, or a change in skin characteristics. Although it might seem that the diagnosis of risk for activity intolerance would be applicable because of dyspnea and fatigue, addressing cardiac output will help reduce these symptoms.
The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will: Avoid concentrated urine. Prevent the risk of falling. Limit the excretion of electrolytes. Obtain more sleep.
Obtain more sleep. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client will be able to sleep more. The client may be at risk for falling, and the nurse should instruct all clients to rise from a sitting or lying position slowly, but the primary reason for taking the drug in the morning is to limit the number of times the client would need to void during the night if the drug were taken at bedtime. Taking furosemide in the morning has no effect on concentrating the urine or preventing electrolyte imbalances.
A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client? "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." "PTCA involves cutting away blockages with a special catheter." "PTCA involves passing a catheter through the coronary arteries to find blocked arteries." "PTCA involves inserting grafts to divert blood from blocked coronary arteries."
PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. Cutting away blockages with a special catheter is an atherectomy. Passing a catheter through the coronary arteries to find blocked arteries is a cardiac catheterization. Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.
A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene? Ask the client's family to take turns coming to the house at each administration time to assist the client with their medications. Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications. Ask the physician if the client can take fewer pills each day. Come to the client's house each morning to prepare the daily allotment of medications.
Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications. The nurse should intervene by asking a family member to fill a compliance aid each week with the client's weekly supply of medications in the appropriate time slots. Family members can't be expected to come to the client's house four times each day to administer medications. The physician shouldn't change the dosing regimen just for convenience. The home care nurse can't visit the client each morning to prepare the daily medication regimen.
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? The client demonstrates ability to tolerate more activity without chest pain. The client exhibits a heart rate within normal limits. The client requests information regarding smoking cessation. The client is able to verbalize the action of all prescribed medications.
The ability to tolerate more activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. A heart rate within the normal limits of 60-100 per minute does not necessarily indicate a favorable response to treatment. Smoking is a cardiovascular risk factor that the client would be wise to eliminate, but it does not indicate favorable response to treatment. Knowledge of prescribed meds is a good thing, but again does not impact response to treatment.
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The ventricular rate is increasing. The absent pulse is now palpable. The number of premature ventricular contractions is decreasing. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
The number of premature ventricular contractions is decreasing. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
A nurse is teaching a client about maintaining a healthy heart. The nurse should include which point in teaching? Smoke in moderation. Use alcohol in moderation. Consume a diet high in saturated fats and low in cholesterol. Exercise one or two times per week.
Use alcohol in moderation. The nurse should advise the client that alcohol may be used in moderation as long as there are no other contraindications for its use. Smoking, a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat.
Which assessment finding supports the administration of protamine sulfate? RBCs of 5.4 million/mm3 aPTT 3.5-5 times normal platelets of 152 INR 8
aPTT 3.5-5 times normal Protamine sulfate is the antidote specific to heparin. The RBC, and platelet levels are normal. Normal aPTT in heparinized clients is 2-2.5 times normal. INR measurement relates to therapy with warfarin, not heparin. An INR value of 8 is abnormally high and would likely require administration of vitamin K, the antidote for warfarin.
The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor? atrophy contraction gangrene rubor
gangrene The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.
A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to: keep the extremities elevated slightly. participate in a regular walking program. use a heating pad to promote warmth. massage calf muscles if pain occurs.
participate in a regular walking program. Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides. With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. To avoid burns, heating pads should not be used by anyone with impaired circulation. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should administer oxygen. have the client take deep breaths and cough. place the client in high Fowler's position. perform chest physiotherapy.
place the client in high Fowler's position. The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase oxygen content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye? iris cornea retina sclera
retina The retina is especially susceptible to damage in a client with chronic hypertension. The arterioles supplying the retina are damaged. Such damage can lead to vision loss. The iris, cornea, and sclera are not affected by hypertension.
While transferring a load of firewood from the front driveway to the backyard woodpile at 11 a.m., the client experienced a heaviness in the chest and dyspnea. The client stopped working and rested, and the pain subsided. At noon, the pain returned. At 12:30 p.m., the client's spouse took the client to the emergency department. Around 1:30 p.m., the health care provider diagnosed an anterior myocardial infarction (MI). The nurse should anticipate which orders by the health care provider? streptokinase, aspirin, and morphine administration morphine administration, stress testing, and admission to the cardiac care unit serial liver enzyme testing, telemetry, and a lidocaine infusion sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry
sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry The nurse should anticipate an order for sublingual nitroglycerin, tPA, and telemetry. The tPA is appropriate because the client's chest pain began less than 3 hours before diagnosis. The tPA is more specific for cardiac tissue than streptokinase. Stress testing should not be performed during an MI. The client does not exhibit symptoms that indicate the use of lidocaine. Lidocaine is usually used as an anesthetic and is also used for acute treatment of ventricular arrhythmia, but anterior myocardial infarction results from reduction in blood supply to the anterior wall of the heart due to coronary artery occlusion.
A client is in hypovolemic shock. In which position should the nurse place the client? supine semi-Fowler's supine with the legs elevated 15 degrees Trendelenburg's
supine with the legs elevated 15 degrees A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. Neither semi-Fowler's position nor the supine position by itself promotes venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position inhibits respiratory expansion and possibly causes increased intracranial pressure.