Capstone; Module 10 Hemodynamics

When a client has a newly implanted demand pacemaker and the nurse observes spikes on the cardiac monitor at a regular rate but no QRS following the spikes, how will the finding be documented? 1. Failure to sense 2. Failure to capture 3. Loss of battery power 4. Pacer wire displacement

2. Failure to capture Rationale If pacemaker spikes are present, the pacemaker is firing appropriately, but the lack of resulting QRS complexes indicates that it is not stimulating or 'capturing' the heart. Failure to sense would occur if pacemaker spikes continue to be seen even though the client's rate is above the preset pacemaker level. With loss of battery power, the nurse would observe that no spikes occurred even when the client's rate dropped. If pacer wires were displaced, no pacemaker spikes would be observed even if the client rate dropped below the preset pacemaker rate.

Which information would be included in the discharge planning for a client who has had a new permanent pacemaker implanted above the left clavicle? 1. Avoid standing near microwave ovens when they are being used. 2. Take your pulse daily and report changes to the health care provider. 3. Notify the health care provider about swelling or drainage at the incision. 4. Inform airport security about the presence of a pacemaker if you are traveling. 5. Perform full range-of-motion exercises with the left arm to avoid losing function

2. Take your pulse daily and report changes to the health care provider. 3. Notify the health care provider about swelling or drainage at the incision. 4. Inform airport security about the presence of a pacemaker if you are traveling. Rationale After pacemaker implantation, clients are taught to monitor the pulse and notify the health care provider if the rate drops below a preset limit. Swelling or drainage of the incision may indicate infection and should be reported rapidly, because the pacemaker wires go directly into the heart. Because the pacemaker may set off an alarm when the client goes through a metal detector during airport security procedures, security personnel should be informed about the pacemaker. Current microwave ovens do not cause problems with pacemaker function. Take your pulse daily and report changes to the health care provider. Notify the health care provider about swelling or drainage at the incision. Inform airport security about the presence of a pacemaker if you are traveling.

Which activity would the nurse teach clients to avoid after having implantation of a permanent cardiac pacemaker? 1. Having a computed tomography (CT) scan 2. Standing near a microwave 3. Swimming in saltwater 4. Touring a power plant

4. Touring a power plant Rationale Large electrical fields can change pacemaker settings and should be avoided. These clients should avoid magnetic resonance imaging (MRI), not a CT scan. Modern microwaves are shielded and do not cause pacemaker problems. Water, regardless of whether it is fresh or saltwater, will not affect a pacemaker.

Which information would the nurse consider when planning care for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS)? Progressive deterioration until death Deficiencies of essential neurotransmitters Increased risk for respiratory complications Involuntary twitching of small muscle groups

Rationale All three share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome

Which action will the nurse take when measuring a client's pulmonary artery wedge pressure (PAWP)? 1. Deflate the balloon as soon as the PAWP is measured. 2. Have the client bear down when measuring the PAWP. 3. Place the client in a high-Fowler position to measure the PAWP. 4. Advance the catheter if a typical PAWP tracing is not obtained.

Rationale Although the balloon must be inflated to measure the PAWP, it is deflated as soon as the PAWP is obtained to allow blood to continue to flow through the pulmonary artery. Bearing down will increase intrathoracic pressure and lead to an inaccurate PAWP reading. The client would be positions in a supine position at 0 to 45 degrees for PAWP measurement. Repositioning of the catheter may be done by the health care provider, but is not within the scope of nursing practice

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats/minute. Which action is indicated? Administer amiodarone. Administer epinephrine. Assist with insertion of a pacemaker. Administer atropine

Rationale Amiodarone suppresses ventricular activity; therefore it is used for treatment of premature ventricular complexes (PVCs) and ventricular tachycardia. It works directly on the heart tissue and slows the nerve impulses in the heart. Epinephrine hydrochloride is not used for ventricular tachycardia (VT) with a pulse and may even precipitate ventricular fibrillation. A pacemaker is used for symptomatic bradycardia and heart blocks. Atropine is used to treat bradycardia.

A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing? 1. Septic shock 2. Cardiogenic shock 3. Neurogenic shock 4. Anaphylactic shock

Rationale Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? These seizures increase the risk for injuries from a fall. These seizures are most resistant to medication therapy.

Rationale Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to medication therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

Which assessment finding by the nurse caring for a client with newonset atrial fibrillation would be most important to communicate to the health care provider? Irregular apical pulse Sudden vision change Exertional dyspnea Lower extremity edema

Rationale Atrial fibrillation causes pooling of blood in the atria, leading to atrial clots and risk for stroke if clots are ejected from the left ventricle into the systemic circulation. A sudden onset change in vision may indicate stroke and would be immediately communicated to the health care provider so that actions such as rapid administration of thrombolytic medications can be considered. An irregular apical pulse is characteristic of atrial fibrillation and would not be immediately reported to the health care provider. Although exertional dyspnea would be reported to the health care provider, it is common with atrial fibrillation and does not require any immediate change in treatment. Edema may occur with atrial fibrillation because of decreased cardiac output, but it does not require an immediate change in treatment.

When a client suddenly develops second-degree heart block, type I, with a rate of 48 beats/minute, which action would the nurse take first?

Rationale Because second-degree heart block, type I is usually transient and well tolerated, the nurse's first action would be to assess the client for adequate perfusion by checking parameters such as blood pressure, skin temperature, and alertness. A temporary pacemaker may be needed, but only if the assessment indicates a need to increase heart rate to adequately perfuse the client. Atropine is appropriate if the bradycardia has caused hypotension or decreased alertness, but may not be needed. Notification of the health care provider is appropriate, but the nurse should be able to provide information about blood pressure and other indicators of perfusion to the health care provider

Which finding for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the health care provider?

Rationale Because stagnation of blood in the atria with atrial fibrillation may lead to atrial clot formation and then embolization and stroke, the nurse would immediately notify the health care provider about any stroke symptoms so that thrombolytic medications could be administered as quickly as possible. An irregular heartbeat is expected with atrial fibrillation, which is characterized by an irregularly irregular rhythm. Palpitations can occur with sudden onset of rapid atrial fibrillation and would be expected in a client with this diagnosis. Lightheadedness may occur with rapid atrial rates, but would not require treatment as rapidly as stroke.

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? 1. Bradycardia 2. Hypotension 3. Spastic paralysis 4. Urinary retention 5. Increased pulse pressure

Rationale Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in vasodilation and hypotension. Urinary retention may occur in spinal shock because of autonomic nervous system dysfunction. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume?

Rationale Cardiac output is obtained by multiplying the heart rate and the stroke volume. To obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

Which instruction will the nurse give a client with migraine headaches who is starting triptan medication therapy? Check your pulse before and after administration. Report any chest discomfort to the health care provider. Wait for 1 hour after symptom onset to administer the medication. Stop taking the medication if you experience warm, flushing sensations.

Rationale Clients need to be instructed to report chest discomfort to the health care provider immediately. Clients taking triptan medications who experience chest discomfort must be investigated for myocardial ischemia. Clients on beta-blocker therapy for migraines, not triptan therapy, will be instructed to monitor pulse. Triptan medications are taken as soon as symptoms appear. Warm, flushing sensations are a common experience in clients taking triptan medication; the side effect generally subsides with continued use and does not indicate a need to stop the medication.

Which nursing intervention is anticipated for a client who has Guillain- Barré syndrome?

Rationale Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

When a family member of a client with cardiogenic shock asks the nurse for more information about the condition, how would the nurse describe cardiogenic shock? 1. An irreversible phenomenon 2. A failure of the circulatory pump 3. Usually a fleeting reaction to tissue injury 4. Generally caused by decreased blood volume

Rationale In cardiogenic shock, ineffective cardiac pumping or contraction is the cause of the poor peripheral circulation. In the early stages, cardiogenic shock is reversible. Cardiogenic shock indicates a severe and usually chronic decrease in cardiac function and is not a fleeting reaction to tissue injury (such as might occur with anaphylactic shock). Cardiogenic shock is caused by poor cardiac function and results in hypervolemia. A decrease in blood volume would cause hypovolemic shock.

Which imaging technique is specific for Alzheimer disease?

Rationale In diseases such as Alzheimer disease, stroke, and epilepsy, the biochemical process in the brain is altered. Abnormalities in biochemical processes of the brain are diagnosed with MRS. DI is used to evaluate ischemia in the brain to determine the location and severity of a stroke. MRI involves taking multiple sets of images to determine normal and abnormal anatomy. MRA is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations in the brain.

After a client has had a cardiac catheterization, which finding requires the most rapid action by the nurse?

Rationale Increased heart rate is the initial compensatory mechanism for bleeding at the arterial catheter insertion site, which is the most common complication after cardiac catheterization. The nurse would quickly assess for other signs of bleeding, such as decreased blood pressure and blood or swelling at the catheter insertion site. A respiratory rate of 24 breaths/minute is slightly above normal and the nurse will continue to monitor the rate, but no other immediate action is needed. Urine output usually is increased post cardiac catheterization because of the osmotic effect of the contrast dye. Premature atrial contractions are common in clients with coronary artery disease and usually do not require any treatment.

The nurse will anticipate the need to administer which type of medication when a client with cardiogenic shock has an increased pulmonary artery wedge pressure reading of 30 mm Hg?

Rationale Increased pulmonary artery wedge pressure indicates increased left ventricular preload; the nurse will anticipate the need to decrease preload by administration of a loop diuretic. A vasopressor would not decrease ventricular preload and vasopressors are not usually used in cardiogenic shock because they increase cardiac workload and oxygen demand. There is no indication that the client has a dysrhythmia and antidysrhythmic treatment is not indicated. A beta-adrenergic blocker would decrease cardiac output and likely increase left ventricular preload.

Which finding in a client with pulmonary edema requires the most rapid action by the nurse?

Rationale Oxygen saturation less than 90% indicates hypoxemia, which affects functioning of all tissues and organs and needs to be quickly corrected through administration of high oxygen levels, typically via non-rebreather mask. The other findings are also of concern but are not as essential as correcting hypoxemia. A weak, rapid pulse and low blood pressure occur in pulmonary edema because of decreased left ventricular function and poor cardiac output. The blood pressure indicates that cardiac output is currently low but adequate to perfuse tissues. Crackles heard throughout both lungs are consistent with pulmonary edema and need to be rapidly treated with diuresis, after oxygen is started to correct hypoxemia.

After a client has had a ventricular pacemaker inserted, which point on the rhythm strip shows a pacemaker spike?

Rationale Pacemaker impulses are represented by a spike (letter B), which should be followed by a QRS complex. Letters A, C, and D do not indicate the pacemaker spike.

When a critically ill client has a pulmonary artery catheter inserted, which measurement provides the most useful information about the client's left ventricular pressure? Right atrial pressure Central venous pressure Pulmonary artery diastolic pressure Pulmonary artery wedge pressure

Rationale Pulmonary artery wedge pressure (PAWP) is an indirect measure of left ventricular end-diastolic pressure. Right atrial pressure measures only the function of the right side of the heart, which frequently does not reflect left ventricular function. Central venous pressure (CVP) is the same as right atrial pressure, because the large central veins are contiguous with the right atrium. CVP also reflects right-sided cardiac pressures and is not usually a good indicator of left ventricular function. Pulmonary artery diastolic pressure is frequently a good indicator of left ventricular end-diastolic pressure, but may be inaccurate in clients with chronic obstructive pulmonary disease or pulmonary hypertension.

A home care nurse counsels a client with amyotrophic lateral sclerosis (ALS). Which information would the nurse include in their discussion? Space planned activities throughout the day. Engage in social interactions with large groups. Request an opioid if leg pain becomes excessive. Anticipate the use of alternative ways to communicate. Use leg restraints to decrease the risk for physical injury.

Rationale Spacing activities throughout the day is a strategy to help conserve the client's energy. The client will use alternative ways to communicate (e.g., writing, electronic devices) when speech becomes difficult because of muscle weakness. The client should avoid large groups to limit the risk for infection; respiratory complications are the leading cause of death. Clients with ALS do not use opioid medications because they may depress respirations. Lower extremity pain usually is not a problem associated with ALS. Braces and splints, not restraints, may be used.

When a client has supraventricular tachycardia that has persisted despite treatment with vagal maneuvers and medications, which collaborative intervention will the nurse anticipate to treat the dysrhythmia?

Rationale Synchronized cardioversion is application of a shock that is timed to land on the R wave to depolarize the myocardium and allow the normal cardiac pacemaker in the sinoatrial node to take over normal cardiac stimulation. Defibrillation is not synchronized and might cause fatal dysrhythmias such as ventricular fibrillation if used on a client with supraventricular tachycardia. A pacemaker would be used for slow heart rates such as might occur with atrioventricular blocks. Cardiac resynchronization therapy is used for clients with severe left ventricular failure to synchronize the contraction of the right and left ventricles and improve cardiac output.

A client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, and double vision. Which phase of this headache involves double vision? Aura phase Headache phase Prodromal phase Termination phase

Rationale The aura phase involves visual changes, flashing lights, or diplopia (double vision). Throbbing and unilateral headaches that are often associated with nausea or sensitivity to light and sound, flashes of light, and double vision may be migraine headaches. There are three types of migraines: migraine with aura, migraine without aura, and typical migraine. The headache phase involves a severe throbbing head ache. The prodromal phase involves specific symptoms, such as food cravings or mood changes. Intensity of the headache will start to decrease in termination phase.

In what order does normal cardiac conduction occur through the heart?

Rationale The cardiac cycle begins with an impulse generated from a small concentrated area of pacemaker cells high in the right atria called the sinus or sinoatrial node. The impulse quickly reaches the AV node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The electrical impulse then is conducted rapidly through the bundle of His to the ventricles via the left and right bundle

Which information can be obtained from monitoring the pulmonary artery pressure? 1. Stroke volume 2. Lung function 3. Coronary artery patency 4. Left ventricular functioning

Rationale The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Pulmonary artery pressure is not a measure of lung function, which is usually tested through spirometry. The patency of the coronary arteries usually is evaluated by cardiac catheterization.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, in which part of the brain would the nurse suspect the tumor is located? Cerebellum Parietal lobe Basal ganglia Occipital lobe

Rationale The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement. The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss. Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease. The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations

How will the nurse calculate pulse pressure for a hospitalized client?

Rationale The pulse pressure is obtained by subtracting the diastolic blood pressure reading from the systolic blood pressure reading. The difference between the apical and radial pulse rates is a pulse deficit. Mean arterial pressure is calculated by adding 2 times the diastolic pressure to the systolic pressure and dividing that total by 3. The difference between the mean arterial pressure and the central venous pressure represents the pressure gradient for venous return and is used as part of the calculation for systemic vascular resistance.

Which assessment finding indicates that a client has had a stroke? Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago

Rationale The signs of a stroke follow the acronym FAST. The F stands for facial drooping (a lopsided smile); A for arm weakness (inability to raise the right arm); and S for speech difficulties (incoherent speech) The T stands for time, as the signs and symptoms need to be evaluated as soon as possible. Tissue plasminogen activator (TPA) can be administered to reestablish blood flow if treatment is initiated within 4½ hours of stroke onset.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. mL/min

Rationale The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

Which action would the nurse anticipate taking when a client develops third degree atrioventricular block with a heart rate of 30 beats/minute?

Rationale Transcutaneous pacing is used for emergency treatment of bradycardia, because it is noninvasive and can be rapidly initiated. Defibrillation would be used for ventricular fibrillation. Synchronized cardioversion would be used as the treatment for rapid atrial or ventricular rhythms such as atrial fibrillation, atrial flutter, and ventricular tachycardia. Cardiopulmonary resuscitation is used when the client has cardiac or respiratory arrest.

Which type of shock is associated with a ruptured abdominal aneurysm? 1. Vasogenic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Hypovolemic shock

Rationale When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

Which clinical finding is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Rationale With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow (not increased as in tachycardia) because the SA node does not initiate the ventricular rhythm. Hemiparesis is associated with a stroke (cerebrovascular accident).

A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively? 1. Decreased anxiety 2. Reduced chest pain 3. Rationale A decreased heart rate is the expected response to a beta blocker. Beta-blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta-blockers reduce blood pressure. 4. Increased blood pressure

Rationale A decreased heart rate is the expected response to a beta blocker. Beta-blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta-blockers reduce blood pressure.Rationale A decreased heart rate is the expected response to a beta blocker. Beta-blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta-blockers reduce blood pressure.

A female client is receiving intravenous antibiotic therapy for toxic shock syndrome. Which statement indicates to the nurse that the client understands the teaching regarding future care? 1. 'I will call the clinic if I get a rash.' 2. 'I will call the clinic if the menstrual cramps return.' 3. 'I now know how to insert my diaphragm correctly.' 4. 'I now know how to perform correct tampon hygiene.'

'I will call the clinic if I get a rash.' Rationale Toxic shock syndrome may recur during the first 3 months after treatment; a sunburn-like rash with peeling skin often occurs in the late stages of the syndrome. There is no need for the client to call the clinic if menstrual cramps return because this is not specifically related to toxic shock syndrome. Whether the diaphragm is inserted properly is not the issue; it is linked to toxic shock syndrome if it is not removed 6 to 8 hours after intercourse. Tampons are linked to the development of toxic shock syndrome and should not be used by this client at this time.

A client's cardiac monitor indicates multiple multifocal premature ventricular complexes (PVCs). Which medication is indicated for the treatment of ventricular dysrhythmias? 1. Amiodarone 2. Epinephrine 3. Methyldopa 4. Hydrochlorothiazide

Amiodarone Rationale Amiodarone has an antiarrhythmic action that stabilizes cell membranes of the heart, reducing cardiac excitability; it is used for acute ventricular dysrhythmias. Methyldopa is used to treat hypertension, not PVCs. Epinephrine increases the contractibility of the heart; the effect is opposite of that which is needed. Hydrochlorothiazide is a diuretic used for hypertension, not for correcting multiple PVCs.

Which action would the nurse perform immediately for a client with dysrhythmias according to priority? 1. Monitor oxygen saturation. 2. Establish intravenous access. 3. Administer oxygen via a nonrebreather mask. 4. Ensure airway-breathing-circulation (ABC).

Ensure airway-breathing-circulation (ABC). Rationale The client with any life-threatening complication such as dysrhythmias should be assessed for ABCs immediately because the client may be experiencing airway obstruction. Oxygen saturation should be monitored during ongoing assessments and after providing the client with initial treatment. Intravenous access should be established after performing initial assessments such as vital signs. After assessing ABCs in a client with dysrhythmias, the client should be provided with oxygen via nasal cannula or nonrebreather mask to maintain oxygen levels.

When explaining to a client with atrial tachycardia how the use of the Valsalva maneuver may decrease the client's heart rate, which information will the nurse include? 1. The vagus nerve is stimulated. 2. The glottis closes momentarily. 3. Thoracic pressure decreases. 4. Respiratory pattern is interrupted.

The vagus nerve is stimulated. Rationale Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart. Although the glottis closes, this does not interrupt the dysrhythmia. Thoracic pressure increases, not decrease, during the Valsalva maneuver. Although the respiratory pattern is interrupted briefly, this does not interrupt the dysrhythmia.

A client who sustained serious burns now has a stress ulcer. If complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? 1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities 5. Flushed skin tone

Weakness Diaphoresis Tachycardia Cold extremities Rationale The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed, because of peripheral vasoconstriction.

When assisting a client with Parkinson's disease to ambulate, which instruction would the nurse provide the client? Avoid leaning forward. Hesitate between steps. Rest when tremors are experienced. Keep arms close to the center of gravity.

Avoid leaning forward. Rationale The client with Parkinson's disease often has a stooped posture because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson's disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

A client on a telemetry unit demonstrates a sinus rhythm with an occasional premature atrial contraction (PAC). Which action would the nurse take? 1. Continue to monitor. 2. Activate the Rapid Response Team. 3. Ensure that a defibrillator is available close by. 4. Give lidocaine intravenously as per protocol.

Continue to monitor Rationale Occasional PACs (premature atrial contractions) are benign and will not affect cardiac output, but the nurse will continue to monitor the client for increased numbers of PACs or other dysrhythmias. Activation of the Rapid Response Team is inappropriate because there is no indication that the client is unstable. No defibrillator is needed for this benign atrial dysrhythmia. Lidocaine is specific for ventricular, not atrial, irritability.

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? 1. Slow heart rate 2. Cool skin temperature 3. Bounding radial pulses 4. Increased urine output

Cool skin temperature Rationale Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion. Tachycardia, not bradycardia (slow heart rate), occurs as a compensatory mechanism in hypovolemic shock. The pulses in hypovolemic shock are weak and thready because of decreased blood pressure. Urine output will decrease because of decreased kidney perfusion in hypovolemic shock.

When caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option? Overdrive pacing Demand pacemakers Cardiac resynchronization therapy Implantable cardioverter-defibrillators

Demand pacemakers Rationale Treatment for symptomatic bradycardia typically includes placement of a temporary or permanent demand pacemaker to prevent heart rate from dropping below a preset rate. Overdrive pacing is used to treat atrial tachycardias such as atrial flutter. Cardiac resynchronization therapy is used to improve ventricular function and cardiac output in clients with severe heart failure. Implantable cardioverter-defibrillators are used for clients at risk for sudden cardiac death caused by ventricular tachycardia or ventricular fibrillation.

The nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary health care provider prescriptions would the nurse do first? Draw peripheral blood cultures from two different sites. Administer levofloxacin 500 mg intravenously over 30 minutes. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. Take the client to x-ray for an abdominal computed tomography (CT) scan.

Draw peripheral blood cultures from two different sites. Rationale This question requires the learner to recall the priority treatments for clients with sepsis. Mortality in septic clients increases by 7.6% for every hour an antibiotic is delayed. Because this client is hemodynamically stable, the priority is to draw the blood cultures so that the antibiotic can be initiated as soon as possible. Administering the antibiotic before obtaining blood cultures could mask the infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures would delay antibiotic initiation.

When a client who is admitted for coronary artery bypass graft (CABG) surgery asks the nurse about the purpose of pacemaker wires inserted during surgery, which explanation will the nurse give? Defibrillation of the heart after surgery Prevention of slow heart rate after surgery Maintenance of rate of at least 100 beats/minute during surgery Inhibition of too-rapid heart rate during the postoperative period

Prevention of slow heart rate after surgery Rationale Pacing wires are sometimes placed during CABG so that pacing is rapidly available in case of bradycardia during the postoperative period. Pacing wires are not used for defibrillation. The heart is usually placed into cardiac arrest during CABG to facilitate the suturing of grafts into place. Medications to slow heart rate would be used rather than overdrive pacing during the postoperative period after CABG.

A client with a supratentorial brain tumor is scheduled for external radiation therapy. Which information would the nurse plan to teach the client? A low-residue diet is recommended during therapy. Expect to feel very tired. All adults receive the same dose of radiation. Memory loss may occur

Expect to feel very tired. Rationale External radiation causes fatigue, regardless of the site; myelosuppression and its resultant anemia occur more frequently when radiation therapy involves the skull, pelvic region, sacrum, ribs, shoulder region, sternum, and thoracic and lumbar vertebrae. A low-residue diet is not necessary because the gastrointestinal tract is not affected. The dose is individualized and depends on safety, malignant cell type, location of malignancy, and cellular sensitivity. Loss of memory does not occur with this treatment.

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? 1. Spasticity 2. Incontinence 3. Flaccid paralysis 4. Respiratory failure 5. Lack of reflexes below the injury

Flaccid paralysis Lack of reflexes below the injury Rationale Spinal shock (spinal shock syndrome) is immediate after the transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of the injury. Spasticity occurs after the spinal shock has subsided. During the acute phase, retention of urine and feces occurs because of the decreased tone of the bladder and bowel; thus incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating the level of injury is below C4, and respirations are not affected.

A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/minute. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective? 1. Increased urine output 2. Blood pressure of 90/60 mm Hg 3. Heart rate of 98 beats/minute 4. No longer complaining of heart palpations

Heart rate of 98 beats/minute Rationale Diltiazem hydrochloride's purpose is to slow down the heart rate. SVT has a heart rate of 150 to 250 beats/minute. A heart rate of 110 beats/minute indicates that the diltiazem hydrochloride is having the desired effect. Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palpations is a positive finding but is not present in all clients. Increased urine output may occur over a period of time because of the increased ventricular filling time but would not occur until after the heart rate had stabilized.

Which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 beats/minute to 121 beats/minute? 1. Septic shock 2. Cardiogenic shock 3. Hemorrhagic shock 4. Neurogenic shock

Hemorrhagic shock Rationale With a history of a traumatic injury and abdominal pain associated with assessment findings of hypotension and tachycardia, the most likely type of shock is hemorrhagic. A client with septic shock would have tachycardia and hypotension, but symptoms would also include fever and warm, flushed skin. Cardiogenic shock might also present with tachycardia and hypotension, but the client would report chest discomfort and dyspnea. Neurogenic shock presents with hypotension and bradycardia.

Which action would the nurse perform when a client is in ventricular fibrillation? 1. Initiating CPR 2. Assessing the EKG 3. Using a defibrillator 4. Obtaining electrolytes 5. Administering epinephrine

Initiating CPR Assessing the EKG Using a defibrillator Obtaining electrolytes Administering epinephrine Rationale Ventricular fibrillation is an abnormal heart rhythm that can be fatal. Key nursing interventions include initiating CPR, continuing to assess the heart rhythm through an EKG while performing interventions, and using a defibrillator to try to convert the client back to a normal sinus rhythm. An electrolyte panel can be used to determine if hyperkalemia led to the dysrhythmia as this imbalance would need to be corrected. Epinephrine and/or amiodarone may be administered when attempting to change the abnormal rhythm.

cardiogenic shock

In cardiogenic shock, ineffective cardiac pumping or contraction is the cause of the poor peripheral circulation.

A client is diagnosed with the neuroleptic malignant syndrome (NMS). The nurse trains the nursing student on providing supportive care. Which actions by the nursing student indicate effective education? 1. Increasing the client's fluid intake 2. Administering lorazepam to the client 3. Providing the client with cooling blankets 4. Withdrawing the neuroleptic medication immediately 5. Switching to another first-generation antipsychotic

Increasing the client's fluid intake Providing the client with cooling blankets Withdrawing the neuroleptic medication immediately Rationale NMS is a rare reaction that carries a 4% risk of death. Symptoms include blood pressure fluctuations, fever, sweating, rigidity, and dysrhythmias. Supportive treatment includes giving the client cooling blankets to reduce high body temperature. Rehydrating the client by increasing the fluid intake also is indicated. The nurse also would administer dantrolene and immediately withdraw the neuroleptic. The nurse would not administer lorazepam. The primary health care provider will switch the client to a second-generation antipsychotic if a second episode occurs.

Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy?

Individuals taking phenytoin must floss their teeth regularly. Rationale Gingival hyperplasia is a common side effect of phenytoin. Clients may decrease or delay development of gingival hyperplasia by regular brushing and flossing of their teeth. Although lifelong treatment with antiseizure medication often is required, some people are able to wean from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal electroencephalogram and neurological examination. Driving laws for people with epilepsy vary from state to state. For example, some states require a seizure-free period of several months and some states require a seizure-free period of up to a year before reinstating or issuing a driver's license. The person who has experienced a single seizure may not need to go to the hospital, unless the event is a first-time seizure, the seizure is prolonged, or the seizure results in bodily harm.

A client reports severe right-sided headache with runny nose, droopy eyelids, tearing of the eye on the right side, and facial sweating. Which medications are specific to treat this headache? Lithium Acetaminophen Naproxen Ibuprofen Oral glucosamine Acetaminophen Naproxen Ibuprofen Oral glucosamine

Lithium Oral glucosamine Rationale Severe unilateral headache with runny nose, drooping eyelids, ipsilateral tearing of the eye, and facial sweating is indicative of cluster headache. Oral glucosamine and lithium are specifically prescribed to treat cluster headache. Naproxen, ibuprofen, and acetaminophen are indicated for relieving mild migraines

When caring for a client in late hypovolemic shock, which complication will the nurse anticipate? 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased Pco 2 levels

Metabolic acidosis Rationale Decreased cellular oxygen caused by poor perfusion increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock, metabolic or respiratory acidosis occurs. The Pco level will increase in profound shock

The nurse assesses a client who is experiencing a profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect? 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased carbon dioxide level

Metabolic acidosis Rationale Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

Which acid-base imbalance would the nurse anticipate in a client in the progressive stage of shock? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic acidosis Rationale Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock.

Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4.Respiratory alkalosis

Metabolic acidosis Rationale Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

Which procedure would the nurse expect as a treatment option for a client newly diagnosed with Guillain-Barré syndrome? Hemodialysis Plasmapheresis Thrombolytic therapy Immunosuppression therapy

Plasmapheresis Rationale A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.

Which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? Place objects within the visual field. Teach passive range-of-motion exercises. Instill artificial teardrops into the affected eye. Reduce time client is positioned on the left side.

Rationale A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

Which finding in a client who has just been admitted indicates that the nurse will anticipate assisting with insertion of a temporary pacemaker?

Rationale The client in third-degree heart block will need a pacemaker to help support heart rate and cardiac output. Shortness of breath is not an indicator for pacemaker insertion. Substernal discomfort is not treated with pacing. Premature ventricular contractions are treated with medications, and a pacemaker is not indicated.

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously that lasted for 10 weeks. Which other symptoms may be manifested by the client? Vertigo Rhinorrhea Lacrimation Phonophobia Pupillary constriction

Rhinorrhea Lacrimation Pupillary constriction Rationale Cluster headaches are short headaches occurring in episodes, with characteristic sharp, stabbing pain. Pain occurs in the oculotemporal or oculofrontal regions or deep around the eye. The headaches may be persistent for about 4 to 12 weeks followed by a period of remission of 9 to 12 months. Cluster headaches are associated with other symptoms, including rhinorrhea (a runny nose), tearing of eyes (lacrimation), myosis (pupillary constriction), and ptosis (drooping eyelids). Vertigo is a neurological change

Which diagnostic test result will the nurse review after noticing large U waves on the electrocardiogram (ECG) for a client who was just admitted to the cardiac unit? 1. Troponin T 2. Serum potassium 3. Oxygen saturation 4. C-reactive protein

Serum potassium Rationale Large U waves suggest possible hypokalemia, which should be corrected to decrease dysrhythmia risk. The nurse may also review the other values, but these are unrelated to the presence of U waves. Troponin T levels increase with myocardial infarction. Oxygen saturation changes do not cause U waves. C-reactive protein elevations indicate inflammation but will not cause changes in the ECG.

Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? Impaired judgment Spatial-perceptual deficits Slow performance and caution Impaired speech/language aphasias Tendency to deny or minimize problems Awareness of deficits with depression and anxiety

Slow performance and caution Impaired speech/language aphasias Awareness of deficits with depression and anxiety Rationale Left-side strokes result in slow performance and cautious behaviors, impaired speech and language aphasias, and awareness of deficits with resultant depression and anxiety. Right-sided strokes cause impaired judgment, spatial-perceptual deficits, and a tendency to deny or minimize problems

Which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? 1. Unchanged by rest 2. Precipitated by light activity 3. Described as a knifelike sharpness 4. Relieved by sublingual nitroglycerin

That' s right! Rationale Relief by sublingual nitroglycerin is a classic reaction because it causes vasodilation of peripheral veins and arteries, thereby decreasing oxygen demand by decreasing preload. To a lesser extent, sublingual nitroglycerin dilates coronary arteries, which increases oxygen to the myocardium, thereby decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness. Unchanged by rest Precipitated by light activity Described as a knifelike sharpness Relieved by sublingual nitroglycerin