Ch22-25
fen-phen diet
the client has been diagnosed with aortic regurgitation. Which nursing data is most significant in identifying cause for this disorder?
stiffness of heart valves
the nurse identifies a heart murmur in an adult client. Which of the following age-related changes would be the most likely cause?
a grayish cast to the skin
the nurse is assessing an African American client for signs of cyanosis. Which assessment finding is documented as cyanosis?
edema
the nurse is assessing the client newly prescribed Lasix 20mg daily for 3+ pitting edema. To evaluate the effectiveness of diuretic therapy, which of the following would be documented?
assess the client
the nurse is caring for a client on a monitor Telemetry unit. During morning assessment, the nurse notes abnormal ECG waves on the Telemetry monitor. Which action would the nurse do first?
report any numbness, tingling, or sharp pain in the extremity
your discharging a client after a cardiac catheterization. What would you include in your discharge teaching?
tell me what concerns you most
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirm diagnosis of acute myocardial infarction. The client is overly anxious and crying. Which response by the nurse is most appropriate?
coronary artery disease
a client comes to the emergency department complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client?
decreased cardiac output
a client diagnosed aortic stenosis is exhibiting fatigue, shortness of breath on exertion, and systolic murmur. Which of the following would the nurse list as the most concerning nursing diagnosis?
Prothrombin time PT or International normalized ratio INR
a client has had oral coagulation ordered. What should you monitor for when your client is taking oral anticoagulation?
pallor
a client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?
exercise, keep your cholesterol in check, and manage your stress
a client with a strong family history of coronary artery disease ask the nurse how to reduce the risk of developing this disorder. Which is the best response by the nurse?
pulmonary edema
a client with mitral stenosis develops a productive cough with pink frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
lower the legs
a client, who is resting in bed, presents with symptoms of poikilothermy, bilateral lower extremity edema, and paller. which is the best nursing measure to initiate?
improve venous return
a girl a client with venous insufficiency is instructed to exercise, apply elastic stockings, and Elevate the extremities. Which is the primary benefit for this nursing management regime?
thready pulse
a nurse is caring for a dying client following myocardial infarction. The client is experiencing apnea with a falling blood pressure of 60 / palpation. Which documentation of pulse quality does the nurse anticipate?
the SA node
a patient needs additional information about her heart condition. The patient states to the nurse, "what is considered the pacemaker of the heart?"
fatty deposits in the Lumen of arteries
a patient presents to the emergency room with characteristics of atherosclerosis. What characteristics would the patient display?
administer the digoxin
before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate of 62 beats per minute. The client usual rate ranges between 66 to 72 beats per minute. Which is the best action for the nurse to take?
to decrease workload of the heart
in the treatment of coronary artery disease, medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta adrenergic blockers in the nursing management of CAD?
right sided heart failure
one of your students asked what the consequences of uncorrect left-sided heart failure would be. What would be your best response?
morphine sulfate
severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer?
irregular heart rate
the nurse is caring for a client who is diagnosed with an infarction of the posterior wall of the right atrium. Which assessment finding with the nurse anticipate relating to the infarction location?
lung sounds
the nurse is caring for a client with a deep vein thrombosis in the popliteal vein. Which component of a head-to-toe assessment is crucial?
take the clients apical pulse
the nurse is caring for a client with a valvular disorder of the heart. What intervention should the nurse perform before administering the prescribed beta-blockers to clients with valvular disorder of the heart?
measure urine output
the nurse is caring for a client with a valvular disorder. The client is at risk for decreased cardiac output. What nursing intervention should the nurse perform for this client?
heart failure
the nurse is caring for a client with cardiac compromise related to mitral valve and impairment. Which outcome of the erosion of the mitral valve is most significant?
"you will be vulnerable to infective endocarditis for the rest of your life."
the nurse is caring for a client with infective endocarditis. The nurse teaches the client that he will have to take antibiotics for the rest of the client's life. The client wants to know why. What would be the nurse's best answer to the client?
dressing assessment
the nurse is caring for a post cardiac catheterization client in the recovery room. Which of the following is a priority nursing consideration?
use clean technique or sterile technique, when applicable, for any invasive procedure
the nurse is planning care for a client with history of rheumatic carditis. Which nursing intervention would be most helpful in preventing further complications?
orthostatic hypotension
the nurse is providing discharge instructions to a client with unstable angina. The client is ordered Nitrostat 1 / 150 every five minutes as needed for angina. Which side effect, emphasized by the nurse, is common especially with the increased dosage?
positive blood culture
the nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms this diagnosis?
amoxicillin
the nurse is reviewing the results of a client's diagnostic tests indicating a positive strep culture. Which prescription medication does the nurse anticipate?
relief of pain when sitting up
the nurse is working on a Telemetry unit at a local hospital. The nurse obtains report on a client with symptoms of sharp chest pain and tachycardia. The nurse begins to collect and critical think through assessment data. Which client symptom distinguishes between a myocardial infarction and myocarditis?
avoid straining during bowel movements and coughing
the nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
it may indicate a problem with oxygenation
the nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?
the inflammatory response is caused by accumulated waste products in the blocked vessel
the nursing instructor is teaching a class on thrombophlebitis. what should the nurse tell the students about the inflammatory response in thrombophlebitis?
obtaining a throat culture
the school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following?
hypertension
understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the development of the disorder and an outcome?
transthoracic echocardiogram
what is the best technique to identify a structural changes in the mitral valve?
abdomen bruit
which assessment finding by the nurse is the most significant findings suggestive of aortic aneurysm?
rheumatic fever
which historical fact is an greatest value to a nurse who is interviewing a client being admitted for possible mitral regurgitation?
withhold anticoagulant therapy
which nursing action would be a greatest importance in the management of a client preparing for angioplasty?
acute pain
which nursing diagnosis is most significant in planning the care for a client with Raynaud's disease?
employed as over-the-road truck driver
which of the following factors would the nurse identify as a modifiable risk factor for the development of varicose veins?
examine the legs for color, capillary refill time, and tissue integrity
you are caring for a client address for thrombosis. What is an appropriate nursing action when evaluating this client?
assess the characteristics of chest pain
you are caring for a client with coronary artery disease. What is an appropriate nursing action when evaluating a client with CAD?
using accessory muscles during respiration
you are caring for a client with right sided heart failure. When assessing the respiratory rate of this client, what is an indication that the client is having difficulty breathing?
chest pain and dyspnea
you're caring for a client with thrombophlebitis. When assessing this client what would be the most important to assess for?
echocardiography is a way of determining the function of the left ventricle of your heart.
your client is being prepared for echocardiography when he asked you why he needs to have this test. What would be your best response?
