Ch 17-Cardiac
When using a 0 to 4+ scale to grade pulse quality, how should the nurse record a normal volume pulse? A.) 3+ B.) 4+ C.) 1+ D.) 2+
A Rationale: A 0 to 4+ scale for grading pulse quality is as follows: 0—Absent, +1—Weak, thready, +2—Light volume, +3—Normal volume, and +4—Full, bounding. The nurse should be aware of the type of scale used in different facilities.
The 65-year-old patient complains of leg pain that disappears at rest after having walked a short distance. The nurse recognizes that the patient's symptoms are consistent with which problem? A.) Claudication B.) Deep venous thrombosis C.) Angiospasm D.) Muscle spasm
A Rationale: Intermittent claudication, or cramping pain in the calves, occurs in the presence of arterial insufficiency. This allows the muscles to build up lactic acid and cause pain.
The nurse is caring for an older adult patient. While auscultating the patient's apical pulse, the nurse notices an irregular rhythm. The nurse suspects which causative factor for the patient's dysrhythmia? A.) Loss of cells in the sinoatrial (SA) nodes B.) Atherosclerosis C.) Hypertension D.) Increased peripheral resistance
A Rationale: Loss of cells in the SA nodes via age-related changes is the most common cause of dysrhythmias in the older adult. This nurse should, however, document these findings and report the findings to the primary care provider.
Which statement accurately describes the purpose of a Doppler flow study? A.) To visualize obstructions in leg vessels B.) To assess efficiency of blood flow through heart chambers C.) To detect a defective heart valve D.) To detect a clot in a coronary artery
A Rationale: The Doppler flow study detects obstructions in the vessels of the lower extremities. The Doppler study may also be performed in other areas of the body, such as the carotid arteries.
Which factors may affect the volume of cardiac output? (Select all that apply.) A.) Afterload B.) Contraction strength C.) Peripheral pulses D.) Heart rate E.) Preload
A B D E Rationale: The amount of cardiac output depends on the heart rate, the amount of blood returning to the heart (venous return or preload), the strength of contraction, and the resistance to the ejection of the blood (afterload). Peripheral pulses are dependent on cardiac output.
Which modifiable risk factors increase a patient's risk for heart disease? (Select all that apply.) A.) Obesity B.) Sedentary lifestyle C.) Age D.) Race E.) Smoking
A B E Rationale: Smoking, obesity, and sedentary lifestyle are modifiable risk factors that increase risk of CAD. Race and age are nonmodifiable risk factors for heart disease.
Which disorder(s) is/are examples of congenital heart defects? (Select all that apply.) A.) Valvular defects B.) Arteriosclerosis C.) Coarctation of the aorta D.) Septal defects E.) Atherosclerosis
A C D Rationale: Causes of cardiovascular disorders can be congenital or acquired. Narrowing of the aorta (coarctation), septal defects, or abnormal cardiac valve formation can occur congenitally. Acquired defects include narrowing or hardening of the blood vessels from arteriosclerosis (thickening and loss of elasticity) or atherosclerosis and aneurysms of the large vessels.
Which preventative measure(s) may protect against development of cardiovascular disease? (Select all that apply.) A.) Obtaining and maintaining a healthy weight B.) Maintaining triglycerides above 150 mg/dL C.) Refraining from smoking D.) Maintaining high-density lipoprotein (HDL) greater than 50 mg/dL E.) Exercising regularly for at least 30 minutes a day
A C D E
The nurse is caring for a patient who just returned from a transradial heart catheterization. Which action indicates the priority care for the postprocedure period? A.) The nurse checks the presence and strength of pedal pulses. B.) The nurse places the pulse oximeter on the thumb or first digit of the affected hand. C.) The nurse places the blood pressure cuff on the arm corresponding to the affected hand. D.) The nurse encourages the patient to increase fluid intake.
B Rational: Priority postprocedure care involves carefully monitoring circulation checks to ensure adequate blood flow to the affected hand while maintaining adequate compression on the radial artery to prevent bleeding. The patient will return with a compression band over the radial puncture site. By placing the pulse oximetry probe on the thumb or first digit of the affected hand, the nurse can obtain a pulse oximetry reading that is specific to the radial artery. The nurse can compare this value to the patient's baseline and ensure that the circulation is adequate. Increasing fluid intake helps flush dye out of the patient's system, but it is a lesser priority than adequate perfusion and hemostasis. Presence and strength of pedal pulses are a priority assessment for a transfemoral heart cauterization. The nurse should avoid placing the blood pressure cuff on the same arm as the catheterization site because cuff inflation could induce bleeding or compromise circulation at the site.
The nurse is caring for a patient who is scheduled to undergo a stress echocardiogram. Which statement indicates that the nurse's teaching about preparation for the test has been successful? A.) "I should eat a full meal to give me energy to walk on the treadmill." B.) "I will have to move extremely quickly from the treadmill to the table." C.) "I will avoid smoking for fours before the test." D.) "I should wear comfortable house shoes during the test."
B Rationale: A stress echocardiogram combines exercise on a treadmill with an ultrasound (echocardiogram). Once an optimal heart rate is achieved, the patient must transfer extremely quickly from the treadmill to the table to ensure quality imaging. Patients should avoid eating a heavy meal, avoid smoking for 6 to 8 hours prior to the test, and wear comfortable walking shoes. House shoes are not appropriate footwear for treadmill exercise.
The patient asks if it is harmful for him to drink a glass of wine with dinner on a daily basis. Which is the nurse's best response? A.) "You may want to be careful because drinking wine with dinner may stimulate your appetite significantly." B.) "As long as it is okay with your physician, moderate alcohol intake can be beneficial to your cardiovascular health." C.) "This practice may cause your triglyceride level to rise, so I would discourage it." D.) "Drinking wine on a daily basis may lead to you having issues with increased blood pressure."
B Rationale: Alcohol is a mild vasodilator when consumed in moderate amounts, which can be beneficial to heart health, depending on the patient's condition.
The nurse is assessing a female patient with a family history of coronary artery disease (CAD). Which report is most concerning to the nurse? A.) "I get a little short of breath after climbing the three flights of stairs to my apartment." B.) "I stay tired all of the time, and it feels like my bra is too tight." C.) "I awaken frequently in the night, and my husband says that I snore." D.) "I notice wheezing after I dust or when I exercise."
B Rationale: In addition to displaying a positive family history for CAD, report of fatigue and shoulder and back discomfort are most concerning to the nurse. Chest pain is often atypical in women and may manifest as pain in the shoulders, back, or abdomen. Mild shortness of breath after climbing three flights of stairs is consistent with exertion. Awakening frequently in the night and snoring are suspicious for obstructive sleep apnea. Wheezing in the presence of dust or with exercise are findings consistent with potential asthma.
The nurse is educating a female patient with a family history of coronary artery disease (CAD) about risk factors and prevention of heart disease in women. Which information is most important for the nurse to include? A.) Women should drink one alcoholic beverage daily. B.) Women should incorporate stress-reduction techniques into their daily lifestyle. C.) Women should maintain a body mass index (BMI) of less than 28. D.) Women should utilize estrogen supplementation to decrease risk of heart disease.
B Rationale: Increased stress is a risk factor for cardiovascular disease, especially in women. Women should incorporate stress reduction techniques into their daily lifestyle. Women should maintain a BMI of less than 25. Women should discontinue use of estrogen contraception/supplementation as soon as possible. Women should not consume more than one alcoholic drink per day, and abstaining from alcohol is beneficial.
The 85-year-old patient with a newly diagnosed heart murmur expresses concern that he has never been notified of this finding before. What is the most likely cause of this patient's heart murmur? A.) Hypertension B.) Insufficient valves C.) Atheroslerosis D.) Weakened Pacemaker
B Rationale: Systolic murmurs commonly appear in people over the age of 80. These murmurs are usually related to valvular dysfunction caused by thickening of the valves, especially the mitral and aortic valves.
The nurse is outlining a teaching program for diabetic patients. Which teaching point about heart disease prevention should the nurse emphasize most? A.) Eat meals at regular times. B.) Keep blood sugar below 100 mg/dL. C.) Use sterile technique in insulin injections. D.) Use sterile technique in insulin injections. E.) Prevent infections
B Rationale: The diabetic person who maintains the glucose level below 100 mg/dL will avoid the adverse effects of hyperglycemia on the vessels. Preventing infections, eating at regular times, and using sterile technique are all valid teaching points for the diabetic patient, but they do not specifically address prevention of heart disease.
Which layer of the heart contains muscle fibers that contract to pump blood? A.) Epicardium B.) Myocardium C.) Pericardium D.) Endocardium
B Rationale: The myocardium is the middle layer of muscle fibers of the heart that contract to pump blood. The endocardium is the lining of the inner surface of the heart chambers, the epicardium is the outer layer of the heart muscle, and the pericardium is the membranous sac that surrounds the heart.
The nurse is caring for a patient with a blood pressure of 140/90, an apical pulse of 82, and a radial pulse of 76. Which value indicates that the nurse accurately calculated the patient's pulse pressure? A.) 82 B.) 6 C.) 50 D.) 90
C
The nurse is caring for a patient with a history of hypertension. Which information is most important for the nurse to obtain? A.) "How often do you use antacids?" B.) "How often do you use antacids?" C.) "Do you use over-the-counter decongestants or diet pills?" D.) "How often do you use laxatives?"
C Rationale: Many over-the-counter (OTC) drugs can cause vasoconstriction and elevate blood pressure. Cold remedies, decongestants, and diet pills are particularly noted for having this effect. Patients sometimes do not consider OTC items as medications and do not report their use.
The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates that the nurse's teaching has been successful? A.) "I will need to stay in bed when the monitor is reading my heart waves." B.) "This test will help determine if I have a blockage in my arteries." C.) "The nurses will be able to monitor my heart rate and rhythm." D.) "If there is a problem with my heart valves, it will show up with telemetry."
C D Rationale: Telemetry provides monitoring of the heart's rate and rhythm with the use of electrodes and wire leads from a bedside monitor or battery-operated transmitter unit. Patients may ambulate on the unit and still be monitored. Blockage of arteries is usually diagnosed with an arteriogram, and valvular problems may be diagnosed with echocardiography.
While performing a focused cardiac assessment, the nurse auscultates an abnormal swooshing sound. Which action is most appropriate to clarify the nurse's finding? A.) The nurse asks the patient about a history of heart stents. B.) The nurse uses the diaphragm of the stethoscope while asking the patient to take a deep breath. C.) The nurse asks the patient about a history of cardiac dysrhythmias. D.) The nurse uses the bell of the stethoscope while asking the patient to lean forward.
D Rationale: Heart murmurs usually generate a swooshing sound that results from turbulent blood flow (usually through damaged valves). The nurse should use the bell of the stethoscope and place it lightly on the skin. Leaning the patient forward may amplify or clarify the sound. Asking the patient about heart stents and abnormal heart rhythms does not clarify the presence or history of a heart murmur.
The nurse is caring for a 50-year-old patient who complains of tingling in his toes. Which other assessment finding would cause the nurse to suspect arterial insufficiency? A.) Pedal edema B.) Thin, brittle toenails C.) Equal warmth in bilateral feet D.) Shiny, hairless legs
D Rationale: To distinguish arterial insufficiency, instruct the patient to dangle the feet. In arterial insufficiency, feet display delayed color return, and if severe peripheral arterial disease is present, the dangling feet soon take on a dusky red color (rubor). The skin may be shiny, taunt, and hairless. Equal warmth indicates equal and sufficient blood flow to the extremities. The nails would be thick rather than thin with arterial insufficiency, and pedal edema is an indication of venous insufficiency.
_________ is the acute symptom most experienced by African Americans when having a myocardial infarction (MI).
Dyspnea Rationale: Dyspnea is the most common symptom experienced by African Americans during an acute MI rather than the classic MI symptoms. This often causes the African American patient to delay seeking treatment
The nurse who uses a regular sized adult blood pressure cuff on a large adult will get a blood pressure reading that is falsely __________.
High Rationale: The small cuff compresses the artery in a narrow local area and causes a greater compression than a cuff that is better suited. The result is a falsely high reading.
The nurse assessing the heart places the stethoscope between the fifth and sixth ribs at the mid-clavicular line to hear the point of _________.
Maximal Impulse Rationale: The placement of the stethoscope will allow the loudest beat at the point of maximal impulse (PMI).
When the nurse uses the PQRST tool for pain assessment, the "R" prompts an inquiry about the __________ of the pain.
Radiation Rationale: The tool prompts inquiries about Precipitating events, Quality of pain, Radiation of the pain, Severity of the pain, and Timing of the pain.