Ch 27 cardiac function

The nurse working in the ICU knows that chronic elevation of left ventricular end-diastolic pressure will result in the patient displaying which of the following clinical manifestations? A) Chest pain and intermittent ventricular tachycardia B) Dyspnea and crackles in bilateral lung bases C) Petechia and spontaneous bleeding D) Muscle cramping and cyanosis in the feet

Ans: B Feedback: Although it may preserve the resting cardiac output, the resulting chronic elevation of left ventricular end-diastolic pressure is transmitted to the atria and the pulmonary circulation, causing pulmonary congestion.

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which of the following phenomena is most likely taking place? A) The man's - and -adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate. B) Hemolysis and blood pooling are taking place in the man's peripheral circulation. C) Bronchoconstriction and hyperventilation are initiated as a compensatory mechanism. D) Intracellular potassium and extracellular sodium levels are rising as a result of sodium-potassium pump failure.

Ans: A Feedback: - and -adrenergic receptor activation is a central response to all types of shock. Hemolysis is not a noted accompaniment to shock. Bronchodilation, not bronchoconstriction, often results from adrenergic stimulation, and sodium-potassium pump failure results in increased extracellular potassium and intracellular sodium.

As part of the diagnostic workup for a male client with a complex history of cardiovascular disease, the care team has identified the need for a record of the electrical activity of his heart, insight into the metabolism of his myocardium, and physical measurements and imaging of his heart. Which of the following series of tests is most likely to provide the needed data for his diagnosis and care? A) Echocardiogram, PET scan, ECG B) Ambulatory ECG, cardiac MRI, echocardiogram C) Serum creatinine levels, chest auscultation, myocardial perfusion scintigraphy D) Cardiac catheterization, cardiac CT, exercise stress testing

Ans: A Feedback: An echocardiogram would provide an image of the client's heart, while a PET scan reveals metabolic activity and an ECG the electrical activity. Answer B would lack data on the client's myocardial metabolism; answer C would lack electrical and physical measurement information; answer D would lack electrical measurement of his heart.

A female older adult client has presented with a new onset of shortness of breath, and her physician has ordered measurement of her brain natriuretic peptide (BNP) levels along with other diagnostic tests. What is the most accurate rationale for the physician's choice of blood work? A) BNP is released as a compensatory mechanism during heart failure, and measuring it can help differentiate the client's dyspnea from a respiratory pathology. B) BNP is an indirect indicator of the effectiveness of the renin-angiotensin-aldosterone (RAA) system in compensating for heart failure. C) BNP levels correlate with the client's risk of developing cognitive deficits secondary to heart failure and consequent brain hypoxia. D) BNP becomes elevated in cases of cardiac asthma, Cheyne-Stokes respirations, and acute pulmonary edema, and measurement can gauge the severity of pulmonary effects.

Ans: A Feedback: BNP is released to compensate for heart failure, and elevated levels help confirm the diagnosis of heart failure as opposed to respiratory etiologies. It does not measure the effectiveness of the RAA system, the risk of cognitive deficits, or the specific severity of pulmonary symptoms of heart failure.

A nurse educator in a geriatric medicine unit of a hospital is teaching a group of new graduates specific assessment criteria related to heart failure. Which of the following assessment criteria should the nurses prioritize in their practice? A) Measurement of urine output and mental status assessment B) Pupil response and counting the patient's apical heart rate C) Palpation of pedal (foot) pulses and pain assessment D) Activity tolerance and integumentary inspection

Ans: A Feedback: Both increased and decreased urine output can be markers of heart failure, as can changes in mental status not attributable to other factors. While heart auscultation, pedal pulses, and activity tolerance are relevant parameters, integumentary inspection, pupil response, and pain assessment are less likely to be relevant assessment components.

Knowing the high incidence and prevalence of heart failure among the elderly, the manager of a long-term care home has organized a workshop on the identification of early signs and symptoms of heart failure. Which of the following teaching points is most accurate? A) "Displays of aggression, confusion, and restlessness when the resident has no history of such behavior can be a sign of heart failure." B) "Heart failure will often first show up with persistent coughing and lung crackles." C) "Residents in early heart failure will often be flushed and have warm skin and a fever." D) "Complaints of chest pain are actually more often related to heart failure than to myocardial infarction."

Ans: A Feedback: Cognitive changes can often accompany heart failure in the elderly. Pulmonary edema is a later sign, and they are less likely to display coughing, chest pain of flushed skin, and fever.

A 31-year-old African American female who is in her 30th week of pregnancy has been diagnosed with peripartum cardiomyopathy. Which of the following statements best captures an aspect of peripartum cardiomyopathy? A) Her diagnosis might be attributable to a disordered immune response, nutritional factors, or infectious processes. B) Treatment is possible in postpartum women, but antepartum women are dependent on spontaneous resolution of the problem. C) Mortality exceeds 50%, and very few surviving women regain normal heart function. D) Symptomatology mimics that of stable angina and is diagnosed and treated similarly.

Ans: A Feedback: Immune responses, diet, and infections are all potential etiologies of peripartum cardiomyopathy. Treatment is complicated, but not impossible, in antepartum women due to possible teratogenic drug effects. About half of women suffer long-term effects on cardiac function, while signs and symptoms are similar to those of early heart failure.

An IV drug abuser walks into the ED telling the nurse that, "he is sick." He looks feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and fatigued. The assessment reveals a loud murmur. An echocardiogram was ordered that shows a large vegetation growing on his mitral valve. The patient is admitted to the ICU. The nurse will be assessing this patient for which possible life-threatening complications? A) Systemic emboli, especially to the brain B) Petechial hemorrhages under the skin and nail beds C) GI upset from the massive amount of antibiotics required to kill the bacteria D) Pancreas enlargement due to increased need for insulin secretion

Ans: A Feedback: Systemic emboli develop and break off the mitral valve and travel into the vascular system. There is a high probability that the emboli could lodge in the brain, kidneys, lower extremities, etc. Answer choice B refers that petechial hemorrhages are signs and symptoms of IE. GI upset is common following antibiotic therapy but is not usually life threatening. Stress can increase insulin needs but not associated with pancreas enlargement.

A pediatrician is teaching a group of medical students about some of the particularities of heart failure in children as compared with older adults. Which of the physician's following statements best captures an aspect of these differences? A) "You'll find that in pediatric patients, pulmonary edema is more often interstitial rather than alveolar, so you often won't hear crackles." B) "Because of their higher relative blood volume, jugular venous distention is a better assessment technique for suspected heart failure in young patients." C) "Signs and symptoms in children may sometimes mimic those of shock, with a low blood pressure and high heart rate." D) "Fever is a sign of heart failure in children that you are unlikely to see in older adults."

Ans: A Feedback: The pulmonary edema that accompanies heart failure is more often interstitial rather than alveolar in children. Jugular venous distention is difficult to gauge in children, and low blood pressure and fever are not noted signs of heart failure in children.

All of the following interventions are ordered stat. for a patient stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first? A) Epinephrine (Adrenalin) B) Normal saline infusion C) Dexamethasone (Decadron) D) Diphenhydramine (Benadryl)

Ans: A Feedback: Treatment includes immediate discontinuation of the inciting agent; close monitoring of CV and respiratory function; and maintenance of respiratory gas exchange, cardiac output, and tissue perfusion. Epinephrine is given in an anaphylactic reaction because it constricts blood vessels and relaxes the smooth muscle in the bronchioles.

A pediatric nurse is assessing a newborn diagnosed with persistent patency of the ductus arteriosus. Which of the following findings are associated with this heart defect? Select all that apply. A) Murmur heard at the second intercostal space, during both systole and diastole B) BP 84/30 classified as a wide pulse pressure C) Shortness of breath with activity such as kicking D) Stridor with inspiratory wheezes E) Bulging jugular neck veins

Ans: A, B Feedback: Persistent patency of the ductus arteriosus is defined as a duct that remains open for greater than 3 months. A murmur is detected within days of birth. It is loudest at the second left intercostal space and is continuous through systole and diastole. A wide pulse pressure is common (BP 84/30). Most newborns have an elevated respiratory rate with exertional activity. Stridor is usually associated with bronchial infections or narrowing of the airways. Bulging jugular neck veins are associated with right-sided heart failure.

Following cardiac surgery, the nurse suspects the patient may be developing a cardiac tamponade. Which of the following clinical manifestations would support this diagnosis? Select all that apply. A) Muffled heart tones B) Narrowed pulse pressure C) Low BP—84/60 D) Heart rate 78 E) Bounding femoral pulse

Ans: A, B, C Feedback: Cardiac tamponade results in increased intracardiac pressure, progressive limitation of ventricular diastolic filling, and decreased stroke volume and cardiac output. This accumulation of fluid results in tachycardia, elevated CVP, jugular vein distention, fall in systolic BP, narrowed pulse pressure, and signs of shock. Heart sounds may be muffled. A pulse rate of 78 is normal (not tachycardic). With pulsus paradoxus, the arterial pulse as palpated at the carotid or femoral artery becomes weakened (not bulging) or absent with inspiration.

Following a ST-segment myocardial infarction (STEMI), the nurse should be assessing the patient for which of the following complications? Select all that apply. A) Large amount of pink, frothy sputum and new onset of murmur B) Tachypnea with respiratory distress C) Frequent ventricular arrhythmia unrelieved with amiodarone drip D) Complaints of facial numbness and tingling E) Enhanced renal perfusion as seen as an increase in urine output

Ans: A, B, C, D Feedback: Following MI, many complications can occur: Answer choice A relates to pulmonary edema or papillary muscle rupture; answer choice B refers that acute respiratory distress could result from heart failure; answer choice C relates to life-threatening arrhythmias; answer choice D relates to acute stroke.

Following coronary bypass graft (CABG) surgery for a massive myocardial infarction (MI) located on his left ventricle, the ICU nurses are assessing for clinical manifestations of cardiogenic shock. Which of the following assessment findings would confirm that the client may be in the early stages of cardiogenic shock? Select all that apply. A) Decreasing mean arterial pressure (MAP) B) Low BP reading of 86/60 C) Urine output of 15 mL last hour D) Low pulmonary capillary wedge pressure (PCWP) E) Periods of confusion

Ans: A, B, C, E Feedback: Signs and symptoms of cardiogenic shock include indications of hypoperfusion with hypotension (BP 96/60), decrease in mean arterial pressure (MAP) due to poor stroke volume, and a narrow pulse pressure. Urine output decreases because of lower renal perfusion pressures. PCWP is usually elevated due to increased preload. Periods of confusion or altered cognition/consciousness may occur because of low cardiac output.

A client has many residual health problems related to compromised circulation following recovery from septic shock. The nurse knows that which of the following complications listed below are a result of being diagnosed with septic shock and therefore should be assessed frequently? Select all that apply. A) Profound dyspnea due to acute respiratory distress syndrome B) Atelectasis resulting in injury to endothelial lining of pulmonary vessels, which allows fluid/plasma to build up in alveolar spaces C) Formation of plaque within vessels supplying blood to the heart causing muscle damage and chest pain D) Acute renal failure due to decreased/impaired renal perfusion as a result of low BP E) Flushed skin and pounding headache that coincides with each heart beat

Ans: A, B, D Feedback: ARDS, atelectasis, and acute renal failure are all noted consequences of shock that might be, respectively, treated by dialysis, an ostomy, or platelet transfusion. Plaque formation to heart vessels is not directly related to any of the identified consequences of shock. Pounding headache that coincides with each heart beat may occur with migraine headaches.

A 66-year-old client's echocardiogram report reveals a hypertrophied left ventricle. The health care provider suspects the client has aortic stenosis. Which of the following clinical manifestations would be observed if this client has aortic stenosis? Select all that apply. A) Decrease in exercise tolerance B) Exertional dyspnea C) Palpitations D) Syncope E) Heartburn

Ans: A, B, D Feedback: Because of the slow onset of aortic valve stenosis, the heart is able to compensate by hypertrophying and may still maintain a normal chamber volume and ejection fraction. As the stenosis progresses, the patient will experience classic symptoms of angina, syncope, heart failure, and decrease in exercise tolerance or exertional dyspnea. Palpitations and heartburn are not usually noted with aortic stenosis.

A 34-year-old man who is an intravenous drug user has presented to the emergency department with malaise, abdominal pain, and lethargy. The health care team wants to rule out endocarditis as a diagnosis. Staff of the department would most realistically anticipate which of the following sets of diagnostics? A) CT of the heart, chest x-ray, and ECG B) Echocardiogram, blood cultures, and temperature C) ECG, blood pressure, and stress test D) Cardiac catheterization, chest x-ray, electrolyte measurement, and white cell count

Ans: B Feedback: An echocardiogram would help visualize the heart, while blood cultures would confirm the presence or absence of microorganisms in circulation, and temperature would gauge the presence of infection. A chest x-ray, blood pressure measurement, and cardiac catheterization would be less likely to indicate infective endocarditis.

A 77-year-old patient with a history of coronary artery disease and heart failure has arrived in the emergency room with a rapid heart rate and feeling of "impending doom." Based on pathophysiologic principles, the nurse knows the rapid heart rate could A) decrease renal perfusion and result in the development of ascites. B) be a result of catecholamines released from SNS that could increase the myocardial oxygen demand. C) desensitize the -adrenergic receptors leading to increase in norepinephrine levels. D) prolong the electrical firing from the SA node resulting in the development of a heart block.

Ans: B Feedback: An increase in sympathetic activity by stimulation of the -adrenergic receptors of the heart leads to tachycardia, vasoconstriction, and arrhythmias. Acutely, tachycardia significantly increases the workload of the heart, thus increasing myocardial O2 demand and leading to cardiac ischemia, myocyte damage, and decreased contractility. Decreased renal perfusion would activate the RAA system, increasing heart rate and BP further. Ventricular arrhythmias are primarily seen at this stage of HF.

A nurse is administering morning medications to a number of patients on a medical unit. Which of the following medication regimens is most suggestive that the patient has a diagnosis of heart failure? A) Antihypertensive, diuretic, antiplatelet aggregator B) Diuretic, ACE inhibitor, beta-blocker C) Anticoagulant, antihypertensive, calcium supplement D) Beta-blocker, potassium supplement, anticoagulant

Ans: B Feedback: Diuretics, ACE inhibitors, and beta-blockers are all commonly used in the treatment of heart failure. Antiplatelet aggregators, calcium and potassium supplements, and anticoagulants are less likely to relate directly to a diagnosis of heart failure.

A 13-year-old boy has had a sore throat for at least a week and has been vomiting for 2 days. His glands are swollen, and he moves stiffly because his joints hurt. His parents, who believe in "natural remedies," have been treating him with various herbal preparations without success and are now seeking antibiotic treatment. Throat cultures show infection with group A streptococci. This child is at high risk for A) myocarditis. B) mitral valve stenosis. C) infective endocarditis. D) vasculitis.

Ans: B Feedback: Group A streptococcal infection can be adequately treated with antibiotics, but this infection may have been present long enough to trigger an immune response—rheumatic fever—that will damage his heart valves, ultimately causing mitral valve stenosis. Group A streptococcal infection is not known to predispose to myocarditis, endocarditis, or vasculitis and aneurysm of coronary arteries.

A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushed skin accompanying his sudden decline in level of consciousness. The patient also has arterial and venous dilatation and a decrease in systemic vascular resistance. What is this client's most likely diagnosis? A) Hypovolemic shock B) Septic shock C) Neurogenic shock D) Obstructive shock

Ans: B Feedback: Low blood pressure accompanied by warm, flushed skin and cognitive changes is indicative of septic shock, as is vessel dilatation and decreased vascular resistance.

A client has been diagnosed with mitral valve stenosis following his recovery from rheumatic fever. Which of the following teaching points would be most accurate to convey to the client? A) "The normal tissue that makes up the valve between the right sides of your heart has stiffened." B) "Your mitral valve isn't opening up enough for blood to flow into the part of your heart that sends blood into circulation." C) "Your heart's mitral valve isn't closing properly so blood is flowing backward in your heart and eventually into your lungs." D) "The valve between your left ventricle and left atria is infected and isn't allowing enough blood through."

Ans: B Feedback: Mitral valve stenosis represents the incomplete opening of the mitral valve during diastole with left atrial distention and impaired filling of the left ventricle. It does not exist in the right side of the heart, and the problem is associated primarily with improper ventricular filling and with pulmonary backflow only secondarily. Although it is often caused by infection, it is not an infectious process of the valve per se.

In which of the following patient situations would a physician be most justified in preliminarily ruling out pericarditis as a contributing pathology to the patient's health problems? A) A 61-year-old man whose ECG was characterized by widespread T-wave inversions on admission but whose T waves have recently normalized B) A 77-year-old with diminished S3 and S4 heart tones, irregular heart rate, and a history of atrial fibrillation C) A 56-year-old obese man who is complaining of chest pain that is exacerbated by deep inspiration and is radiating to his neck and scapular ridge D) A 60-year-old woman whose admission blood work indicates elevated white cells, erythrocyte sedimentation rate, and C-reactive protein levels

Ans: B Feedback: S3 and S4 irregularities and irregular heart rate are not noted symptoms of pericarditis. Widespread T-wave inversions that later normalize; chest pain radiating to the neck and scapula that is worse on inspiration; and high white cells, erythrocyte sedimentation rate, and C-reactive protein levels are all indicators of pericarditis.

Which of the following teaching points would be most appropriate for a group of older adults who are concerned about their cardiac health? A) "People with plaque in their arteries experience attacks of blood flow disruption at seemingly random times." B) "The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel." C) "Infections of any sort are often a signal that plaque disruption is in danger of occurring." D) "The impaired function of the lungs that accompanies pneumonia or chronic obstructive pulmonary disease is a precursor to plaque disruption."

Ans: B Feedback: Stable plaque is associated with obstruction of blood flow, while unstable plaque may dislodge and result in thrombus formation. Plaque disruption is noted to correlate with sympathetic events and is not seemingly random; infections and respiratory problems are not noted to be associated with obstruction of blood flow, however.

Which of the following ECG patterns would the nurse observe in a patient admitted for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)? Select all that apply. A) Atrial flutter B) Ventricular tachycardia with left bundle branch block pattern C) T-wave inversion in the right precordial leads D) Sinus arrhythmia with a first-degree AV block E) Development of a "U" wave following a normal T wave

Ans: B, C Feedback: The electrical (ECG) changes associated with ARVC/D include ventricular tachycardia with LBBB, T-wave inversion in the right precordial leads, and epsilon waves. Right ventricular BBB may also be present. Atrial flutter and sinus arrhythmia with a first-degree AV block are not characteristic of this form of cardiomyopathy.

Which of the following phenomena would be most likely to accompany increased myocardial oxygen demand (MVO2)? A) Inadequate ventricular end-diastolic pressure B) Use of calcium channel blocker medications C) Increased aortic pressure D) Ventricular atrophy

Ans: C Feedback: An increase in aortic pressure results in a rise in afterload, wall tension, and, ultimately, MVO2. Increased, not inadequate, ventricular end-diastolic pressure would cause an increase in MVO2, and medications such as calcium channel blockers would decrease MVO2. Hypertrophy of ventricles would occur in response to prolonged wall stress and consequent oxygen demand.

A 78-year-old man has been experiencing nocturnal chest pain over the last several months, and his family physician has diagnosed him with variant angina. Which of the following teaching points should the physician include in his explanation of the man's new diagnosis? A) "I'll be able to help track the course of your angina through regular blood work that we will schedule at a lab in the community." B) "With some simple lifestyle modifications and taking your heparin regularly, we can realistically cure you of this." C) "I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising." D) "There are things you can do to reduce the chance that you will need a heart bypass, including limiting physical activity as much as possible."

Ans: C Feedback: Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does not normally necessitate blood work, heparin administration, or avoidance of activity.

A 30-year-old woman presents at a hospital after fainting at a memorial service, and she is diagnosed as being in neurogenic shock. Which of the following signs and symptoms is she most likely to display? A) Faster than normal heart rate B) Pain C) Dry and warm skin D) Increased thirst

Ans: C Feedback: In contrast to hypovolemic shock, in which the heart rate is faster than normal and the skin is cold and clammy, a person in neurogenic shock is likely to have a slower than normal heart rate and dry, warm skin. Fainting due to emotional causes is a transient form of neurogenic shock, while increased thirst is an early sign of hypovolemic shock.

A 22-year-old male is experiencing hypovolemic shock following a fight in which his carotid artery was cut with a broken bottle. What immediate treatments are likely to most benefit the man? A) Resolution of compensatory pulmonary edema and heart arrhythmias B) Infusion of vasodilators to foster perfusion and inotropes to improve heart contractility C) Infusion of normal saline or Ringer lactate to maintain the vascular space D) Administration of oxygen and epinephrine to promote perfusion

Ans: C Feedback: Maintenance of vascular volume is the primary goal in the treatment of hypovolemic shock and can be achieved in the short term through intravenous administration of saline or Ringer lactate. Resolution of pulmonary edema and heart arrhythmias and infusion of vasodilators are associated with treatment of cardiogenic shock, while oxygen and epinephrine would address anaphylactic shock.

Which of the following statements provides blood work results and rationale that would be most closely associated with acute coronary syndrome? A) Increased serum creatinine and troponin I as a result of enzyme release from damaged cells B) Increased serum potassium and decreased sodium as a result of myocardial cell lysis, release of normally intracellular potassium, and disruption of the sodium-potassium pump C) Elevated creatine kinase and troponin, both of which normally exist intracellularly rather than in circulation D) Low circulatory levels of myoglobin and creatine kinase as a result of the inflammatory response

Ans: C Feedback: Myocardial necrosis releases creatine kinase and troponins that normally exist intracellularly. Serum creatinine and potassium are not core markers of heart damage, and myoglobin and creatine kinase levels rise, not fall, with cardiac events.

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client A) has a distended bladder, facial edema, and nighttime difficulty breathing. B) complains of dyspnea and has adventitious breath sounds on auscultation (listening). C) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. D) has cyanotic lips and extremities, low urine output, and low blood pressure.

Ans: C Feedback: Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-sided failure when the liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine output, and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs and symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.

On a routine physical exam visit, the physician mentions that he hears a new murmur. The patient gets worried and asks, "What does this mean?" The physician responds, A) "It would be caused by stress. Let's keep our eye on it and see if it goes away with your next visit." B) "This could be caused by an infection. Have you been feeling well the past few weeks?" C) "One of your heart valves is not opening properly. We need to do an echocardiogram to see which valve is having problem." D) "This may make you a little more fatigued than usual. Let me know if you start getting dizzy or light-headed."

Ans: C Feedback: Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. Blood flow through a normal valve can increase by five to seven times the resting volume. Valvular disease is not caused by stress. The murmur can be caused not only by infection but also by stenosis or regurgitation of a valve leaflet. The valve problem is very severe if it is causing signs of decreased cardiac output.

A nurse who works on a pediatric cardiology unit of a hospital is providing care for an infant with a diagnosis of tetralogy of Fallot. Which of the following pathophysiologic results should the nurse anticipate? A) There is a break in the normal wall between the right and left atria that results in compromised oxygenation. B) The aortic valve is stenotic, resulting in increased afterload. C) Blood outflow into the pulmonary circulation is restricted by pulmonic valve stenosis. D) The right ventricle is atrophic as a consequence of impaired myocardial blood supply.

Ans: C Feedback: Tetralogy of Fallot is marked by obstruction or narrowing of the pulmonary outflow channel, including pulmonic valve stenosis, a decrease in the size of the pulmonary trunk, or both. The characteristic septal defect is ventricular, not atrial. Aortic valve stenosis and right ventricular atrophy are not associated with the diagnosis.

Four patients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which patient most likely experienced myocardial infarction? A) A 33-year-old male whose pain started at 7 AM during moderate exercise and was relieved by nitrates; ECG was normal; cardiac markers remained stable. B) A 67-year-old female whose pain started at 2 AM while she was asleep and responded to nitrates; the ECG showed arrhythmias and ST-segment elevation; cardiac markers remained stable. C) An 80-year-old woman whose pain started at 6 AM shortly after awakening and was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose. D) A 61-year-old man whose pain started at 9 AM during a short walk and responded to nitrates, but not to rest; ECG and cardiac markers remained stable, but anginal pattern worsened.

Ans: C Feedback: The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other patients have angina of varying severity.

A 3-year-old child with right-sided heart failure has been admitted for worsening of his condition. Which of the following assessments would be considered one of the earliest signs of systemic venous congestion in this toddler? A) Breathlessness with activity B) Excessive crying C) Enlargement of the liver D) Increased urine output

Ans: C Feedback: With RV function impaired, systemic venous congestion develops. Hepatomegaly due to liver congestion often is one of the first signs on systemic venous congestion in infants and children.

The initial medical management for a symptomatic patient with obstructive hypertrophic cardiomyopathy (HCM) would be administering a medication to block the effects of catecholamines. The nurse will anticipate administering which of the following medications? A) Lisinopril, an ACE inhibitor B) Lasix, a diuretic C) Propranolol, a -adrenergic blocker D) Lanoxin, an inotropic

Ans: C Feedback: beta-Adrenergic blockers are generally the initial choice for persons with symptomatic HCM. Calcium channel blockers can also be used. ACE inhibitors, diuretics, or positive inotropics are not the first-line medications.

Which of the following changes associated with aging contributes to heart failure development in older adults? Select all that apply. A) Increased incidence of mitral stenosis B) Sludge buildup in the kidneys C) Elevated diastolic BP D) Increased vascular stiffness E) Inflammation in the joints due to arthritis

Ans: C, D Feedback: Changes with aging contribute to the development of HF in older adults. First is reduced responsiveness to -adrenergic stimulation. Second is increased vascular stiffness that contributes to ventricular hypertrophy. Third, the heart itself becomes less compliant with age. Fourth relates to altered myocardial metabolism at the level of the mitochondria. Older adults usually develop aortic stenosis and mitral regurgitation. Kidney stones do not contribute to HF. Increase in diastolic pressure compromises LV filling leading to increases in pressures predisposing to HF. Arthritis is not associated with heart failure.

Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is to A) have medical supply department bring up suction equipment. B) apply oxygen via nasal cannula at 3 lpm. C) page the respiratory therapist to come give him a breathing treatment. D) call for emergency assistance utilizing hospital protocol.

Ans: D Feedback: Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The patient needs the emergency responder team (including ICU nurses, physicians, respiratory therapist, etc.) to intervene. Applying O2 by mask will not increase his oxygen level fast enough, and he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course respiratory therapist will arrive with the emergency assistance team.

Which of the following situations related to transition from fetal to perinatal circulation would be most likely to necessitate medical intervention? A) Pressure in pulmonary circulation and the right side of the infant's heart fall markedly. B) Alveolar oxygen tension increases causing reversal of pulmonary vasoconstriction of the fetal arteries. C) Systemic vascular resistance and left ventricular pressure are both increasing. D) Pulmonary vascular resistance, related to muscle regression in the pulmonary arteries, rises over the course of the infant's first week.

Ans: D Feedback: One of the hallmarks of the transition from placental circulation is a rapid and then steady decrease in pulmonary vascular resistance. Answers A, B, and C relate normal physiological processes.

An 81-year-old male resident of a long-term care facility has a long-standing diagnosis of heart failure. Which of the following short-term and longer-term compensatory mechanisms are least likely to decrease the symptoms of his heart failure? A) An increase in preload via the Frank-Starling mechanism B) Sympathetic stimulation and increased serum levels of epinephrine and norepinephrine C) Activation of the renin-angiotensin-aldosterone system and secretion of brain natriuretic peptide (BNP) D) AV node pacemaking activity and vagal nerve suppression

Ans: D Feedback: Reassignment of cardiac pacemaking activities and suppression of the vagal nerve are not noted compensatory actions related to heart failure. Increased preload and sympathetic stimulation, increased levels of epinephrine and norepinephrine, and activation of the renin-angiotensin-aldosterone system and secretion of brain natriuretic peptide (BNP) are all noted compensatory mechanisms.

A number of clients have presented to the emergency department in the last 32 hours with complaints that are preliminarily indicative of myocardial infarction. Which of the following clients is least likely to have an ST-segment myocardial infarction (STEMI)? A) A 70-year-old woman who is complaining of shortness of breath and vague chest discomfort B) A 66-year-old man who has presented with fatigue, nausea and vomiting, and cool, moist skin C) A 43-year-old man who woke up with substernal pain that is radiating to his neck and jaw D) A 71-year-old man who has moist skin, fever, and chest pain that is excruciating when he moves but relieved when at rest

Ans: D Feedback: STEMI pain is not normally relieved by rest, nor would fever be a common symptom. Shortness of breath, vague chest discomfort, fatigue, GI symptoms, and radiating substernal pain are all associated with STEMI.

A 66-year-old obese man with diagnoses of ischemic heart disease has been diagnosed with heart failure that his care team has characterized as attributable to systolic dysfunction. Which of the following assessment findings is inconsistent with his diagnosis? A) His resting blood pressure is normally in the range of 150/90, and an echocardiogram indicates his ejection fraction is 30%. B) His end-diastolic volume is higher than normal, and his resting heart rate is regular and 82 beats/minute. C) He is presently volume overloaded following several days of intravenous fluid replacement. D) Ventricular dilation and wall tension are significantly lower than normal.

Ans: D Feedback: Systolic dysfunction is associated with increased ventricular dilation and wall tension. Hypertension, low ejection fraction, high preload, and volume overload are all commonly associated with systolic dysfunction.