Chapter 48 Assessment of the Cardiovascular System

Which teaching point will the nurse include when providing discharge instructions to the patient with a new permanent pacemaker?

"Avoid lifting heavy objects for as long as your physician prescribes

Following patient teaching regarding a scheduled minimally invasive direct coronary artery bypass (MIDCAB), the nurse determines the need when the patient states

"It frightens me to think that my heart will be stopped during surgery."

The 60-year-old female in the post-coronary care unit confides to the nurse, "My life is over. I'll never be able to care for my family, take a vacation, or work in my garden." Which response is most supportive?

"You sound a little down. Tell me what you think is going to keep you from those activities; we might be able to address the problems."

The nurse is providing patient teaching to a pregnant patient who works as a cashier in a grocery store. Which suggestion by the nurse will help most preventing varicose veins?

"march in place" while standing at the counter

The patient has been prescribed a low sodium diet. Which food omissions from the diet will indicate the patient has an adequate understanding of the recommended diet?

hot dogs

The endothelium lining of the heart chambers and valves is called the: a. endocardium b. epicardium c. myocardium d. pericardium

ANS: A The endocardium is made of endothelium cells that line the inside of the heart and valves and is continuous with the endothelial lining of the vessels of the circulatory system.

The nurse caring for a patient who is taking amiodarone (Cordarone) will plan to assess the vital signs carefully for which common side effect?

hypotension and fatigue

A client with deep vein thrombosis (DVT) may be asymptomatic or may have which of the following? a. a positive Homans' sign b. cyanosis of the entire leg c. mottling of the leg or foot d. cool temperature of foot

ANS: A The presence of hardened, brittle nails, skin ulcerations, or a positive Homans' sign (which may indicate deep vein thrombosis) should also be noted.

The nurse is preparing to administer a daily dose of digoxin [Lanoxin]. What is the priority nursing intervention?

Check blood pressure Below 60 do not give

Which of these normal heart sounds can BEST be heard on the left, fifth intercostal space close to the clavicle and occurs as the mitral and tricuspid valves close simultaneously? a. S1 b. S2 c. S3 d. S4

ANS: A There are two normal heart sounds heard on auscultation: S1 and S2. S1 is the sound of the mitral and tricuspid valves closing simultaneously ("lubb"), and S2 is the sound of the pulmonic and aortic valves closing simultaneously ("dubb").

The double-walled sac that surrounds the heart is called the: a. endocardium b. epicardium c. myocardium d. pericardium

ANS: D The pericardium consists of two layers: the outer layer (parietal) surrounds the heart and the inner layer (visceral) lines the great vessels.

Which of these terms refers to the volume of blood pumped by the ventricle with each contraction? a. cardiac output b. polar output c. pulmonary volume d. stroke volume

ANS: D The volume of blood pumped by the ventricle with each contraction or systole is called the stroke volume (SV). The amount ejected in 1 minute is the cardiac output.

The 85-year-old patient asks the nurse why he has a heart murmur now after all these years. What is the most likely cause of this patient's heart murmur?

insufficient valves

Blood leaves the heart through which of these structures? a. arteries b. capillaries c. veins d. vesicles

ANS: A Arteries carry oxygenated blood from the heart to the entire body.

If a positive Homans' sign is detected during assessment, the nurse should not perform this assessment again until a clot has been ruled out for which reason? a. It may cause an embolus. b. It may cause a thrombus. c. It would cause the client emotional distress. d. It would cause the client severe pain.

ANS: A Nursing management focuses on improving the client's tissue perfusion, reducing pain and anxiety, and monitoring vascular status. Once the client has a positive Homans' sign, the assessment should not be performed again, to decrease the risk of causing an embolus. Nurses should also be alert to the prevention of any type of phlebitis or thrombosis in high-risk clients (e.g., postoperative clients and those receiving intravenous therapy).

The nurse in a long-term care facility designs a teaching program for the residents to help prevent peripheral vascular disease (PVD) caused by age-related changes, ...

- loss of elasticity in vessel walls - atherosclerotic vessels - sedentary practices - weakened leg muscles

The nurse cautions the patient with uncontrolled hypertension that the consequences of the disease will include: (select all that apply)

- treat of a stroke - possible kidney failure - risk of heart attack - probability of congestive heart failure

The nurse reminds the 60 yr old moderately obese African American hypertensive diabetic male who smokes that he can modify his risk for heart disease by

-Smoking cessation -Controlling diabetes -Reducing weight -Exercising regularly -reducing blood pressure

The nurse outlines methods of prevention of peripheral vascular disease (PVD), which include: (select all that apply)

-relieving stress - controlling diabetes - maintaining appropriate weight - routinely exercising - stopping smoking

Which pulse point is used to auscultate a client's blood pressure? a. brachial b. apical c. radial d. ulnar

ANS: A The brachial pulse is found between the groove of biceps and triceps muscles at the antecubital fossa. It is used to assess lower arm circulation, and to auscultate blood pressure.

What are the major risk factors associated with cardiovascular disease? (Select all that apply.) a. gender b. age c. smoking d. dyslipidemia e. high blood pressure f. clotting time g. physical inactivity h. race

ANS: A, B, C, D, E, G, H Major risk factors associated with cardiovascular diseases are age, gender, heredity (including race), smoking, dyslipidemia (presence of increased total serum cholesterol and low-density lipoprotein [LDL]), high blood pressure, physical inactivity, overweight, obesity, and diabetes mellitus. An individual's response to stress may be a contributing factor. Additional contributing factors for women include menopause, use of birth control pills, and high triglyceride level.

Which of the following factors will influence a client's stroke volume and cardiac output? (Select all that apply.) a. the amount of pressure within the ventricles b. the strength of cardiac contraction c. resistance of blood ejection from the ventricles d. the amount of pressure within the atria e. the number of beats per minute

ANS: A, B, C, E The four factor that influence a client's stroke volume and cardiac output are preload (the amount of pressure within the ventricles), afterload (resistance of blood ejection from the ventricles), contractility (the strength of cardiac contraction), and heart rate (the number of beats per minute).

Depolarization of which heart chamber pumps blood into the aorta and out to the entire body? a. left atrium b. left ventricle c. right atrium d. right ventricle

ANS: B Contraction of the left ventricle pumps blood into the aorta and out to the entire body.

At a preoperative cardiac surgery appointment, the nurse is educating a client and his wife about the heart's ability to pump blood and the cardiac output. The nurse explains that the normal cardiac output is: a. 1-2 L/minute b. 4-6 L/minute c. 7-9 L/minute d. 10-12 L/minute

ANS: B Normal cardiac output is 4-6 L/minute.

All of the following are risk factors associated with cardiovascular disease. Which of these would be considered an alterable risk factor? a. menopause b. physical inactivity c. high blood pressure d. history of chest pain

ANS: B The nurse should recognize major cardiovascular risk factors for the client: age, gender, heredity, smoking, dyslipidemia, high blood pressure, physical inactivity, obesity, diabetes mellitus, and response to stress.

Which of these normally heard sounds is the simultaneous closing of the pulmonary and aortic valves and is heard on the right, second intercostal space? a. S1 b. S2 c. S3 d. S4

ANS: B There are two normal heart sounds heard on auscultation: S1 and S2. S1 is the sound of the mitral and tricuspid valves closing simultaneously ("lubb"), and S2 is the sound of the pulmonic and aortic valves closing simultaneously ("dubb").

A positive Homan's sign is assessed by which movement of the client's foot? a. pointing toes b. inversion of the foot c. dorsiflexion of the foot d. performing a foot circle

ANS: C A positive Homans' sign is present in some cases of deep vein thrombosis (DVT). To test for Homans' sign, dorsiflex the client's foot. If there is pain in the calf of the leg or behind the knee, the Homans' sign is positive and may indicate the presence of a venous clot.

Which of these factors, in combination with cigarette smoking, places a woman at greater risk for developing coronary artery disease? a. alcohol abuse b. a diet high in saturated fats c. use of oral contraceptives d. stress

ANS: C The nurse should recognize major cardiovascular risk factors for the client: age, gender, heredity, smoking, dyslipidemia, high blood pressure, physical inactivity, obesity, diabetes mellitus, and response to stress. Additional risk factors for women include menopause, use of birth control pills, and high triglyceride levels.

What prevents blood from flowing back into the ventricles from the pulmonary artery and aorta during repolarization? a. tricuspid and mitral valves b. papillary muscles c. pulmonic and aortic valves d. chordae tendinae

ANS: C The pulmonic and aortic valves prevent blood from flowing back into the ventricles from the pulmonary artery and aorta during repolarization.

What part of the heart is capable of conducting electrical impulses from one part of the heart to another? a. atria b. ventricles c. specialized cardiac muscle cells d. arterial system

ANS: C The specialized cardiac muscle cells are capable of conducting electrical impulses from one part of the heart to another. For the heart to beat regularly in a rhythmic sequence, electrical impulses follow a set pattern through the conduction system of the heart.

In the peripheral vascular system, what carries deoxygenated blood back to the right side of the heart? a. arteries b. capillaries c. veins d. venules

ANS: C Veins carry deoxygenated blood back to the right side of the heart.

While assess a client's lower extremities, the nurse notices an inflammation of the skin around the ankle area. The nurse notes which of the following on the client's assessment form? a. mottled skin b. ulceration c. pruritis d. stasis dermatitis

ANS: D An inflammation of the skin caused by decreased circulation is called stasis dermatitis. Waste products that normally are carried away by the circulatory system remain in the tissues, causing pruritus and irritation of the skin. At first, the ankle area is reddened and edematous, and then vesicles form and start oozing. The skin becomes crusted, thickened, and brown.

The nurse notes a client's neck veins are distended when sitting upright. This finding is indicative of which of these conditions? a. ascites b. decreased renal output c. pulmonary hypertension d. right-sided heart failure

ANS: D Objective data for a client who has cardiovascular symptoms include a head-to-toe assessment of the skin; observation of neck veins, respirations, heart sounds, abdomen, and extremities; and observation of peripheral pulses, ascites, cold or mottled extremities, or edema in the feet, ankles, or legs. Distention of the neck vein when sitting may be indicative of right-sided heart failure.

A client reports awakening suddenly, sweating profusely, and having difficulty breathing. Which of these terms should the nurse record in the client's health history? a. apnea b. dyspnea c. orthopnea d. paroxysmal nocturnal dyspnea

ANS: D The nurse should determine the type of dyspnea, such as dyspnea when engaged in physical activity (exertional), difficulty breathing when lying down (orthopnea), or dyspnea when awakening after several hours of sleep accompanied by sweating (paroxysmal nocturnal dyspnea).

Which of the following is a primary nursing goal when obtaining a health history from a client? a. to determine why the client continues to participate in activities that are unhealthy b. to incorporate the family into the client's care c. to obtain psychosocial information about the client and family d. to identify present and potential health problems

ANS: D When a nurse obtains the health history of a client who has cardiovascular disease, the goals are to identify present and potential health problems, identify possible familial and lifestyle risk factors, and involve the client in planning long-term health care.

The nurse is caring for a patient with congestive heart failure (CHF). Which intervention should the nurse include in the plan of care?

Alternate rest with activity

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.

Atrial fibrillation

If there are several tiny spikes in place of P waves on the ECG, the nurse recognizes the arrhythmia

Atrial flutter/fibrillation

Furosemide and digoxin have been prescribed for a person who is admitted in heart failure what should the nurse do to determine if the drugs are effective?

Auscultate the chest

The patient in the emergency room with a MI becomes pale, diaphoretic, and hypotensive and complains of feeling cold. The nurse recognizes that these signs are which post-MI complication?

Cardiogenic shock

The patient who is taking digitalis for his heart condition becomes extremely dehydrated and has scant urine output. The nurse will assess regularly for the complaint of:

Blurred vision

Following a cardiac catheterization with coronary angiography, the physician writes an order to increase the patients fluid intake. The nurse knows that increasing the fluid intake

Diluting urine to prevent kidney damage

The nurse would anticipate that the patient with right sided heart failure would exhibit

Edema

The nurse is aware that a positive diagnosis of a myocardial infarction (MI) is based on which diagnostic test finding(s)? (Select all that apply.)

Electrocardiographic changes Elevation of troponin levels

The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?

Elevate the head of the bed

Heart disease in women is manifested by a variety of subtle signs. Which sign is typically seen in women?

Fatigue

The nurse outlines behaviors that aid on the prevention of cardiovascular disease which are

HDL greater that 50 mg/dl refrain from smoking Obtain and maintain healthy weight Regular physical activity at least 30 minutes a day

the adult male has angina pectoris which statement the client makes indicates he understands the necessary modifications to prevent attacks?

I will walk more slowly and rest often to avoid the angina

The nurse evaluates the need for further instruction on reduction of caffeine when the patient who has an arrhythmia says

I've switched from 5 cups of coffee to 5 cups of tea

The nurse clarifies that the MONA protocol for drug administration in the emergent stage of a myocardial infarction (MI) involves the use of which therapies?

Morphine Oxygen Nitrates Aspirin

The nurse assesses a friction rub in a patient who is 2 days post-myocardial infarction (MI). The nurse recognizes this finding indicates which problem?

Pericarditis

The nurse is taking care of a patient with cardiac catheterization. The left femoral vessel was used as the access site. The patient should remain on bed rest and in which position?

Supine with head of bed elevated no more than 15 degrees

The nurse adds an intervention to the care plan of a patient who has just been prescribed a thiazide diuretic, which is to increase:

intake of foods containing potassium

The patient was admitted with chest pain to rule out a myocardial infarction (MI). Which cardiac enzyme test is most indicative of an MI?

Troponin

A nurse is caring for a client who has just been diagnosed with angina pectoris. The client tells the nurse that he is afraid of dying from a heart attack during sex. Which of the following is an appropriate nursing response?

Try different positions that require less energy

The nurse is aware that some of the arrythmias may be the result of

Valvular prolapse Infarct damage Hyperkalemia Excess fluid Defective sinoatrial node

The nurse explains that the calcium channel blocker verapamil assists to correct an arrhythmia by:

Verapamil blocks calcium from the cardiac cells, inhibiting the transmission of the impulse from the AV node

The nurse is caring for a patient with Raynaud disease who is employed as a construction worker, has hypertension, and smokes one-half to one pack of cigarettes per day. What teaching points should ...

Wear gloves when handling cold items. Wear insulated socks when working in cool weather. Attend a smoking program. Use a heating pad to stay warm.

A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect?

Weight gain of 2 to 3 lbs in a few days

The patient states that he had a cardiac catheterization 10 years ago and wonders if any of the post procedure care has changed. Which response by the nurse is most accurate?

You will most likely be able to ambulate within a few hours if your doctor uses an arterial closure device at the catheter insertion site

The nurse recognizes the disorganized ECG pattern of the most fatal of all arrhythmias as.

a ventricular fibrillation

The patient is instructed that the most common and effective antiplatelet aggregation agent is:

aspirin

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?

assess the clients breath sounds

The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm. The patient is complaining of intense abdominal pain and lightheadedness. The patient's blood pressure has dropped and pulse is rising. What is the priority nursing intervention?

contact the physician immediately

The nurse instructs a patient that the pain of angina is due to

exertion, emotional excitement, eating heavy meals exposure to cold

the post myocardial infarction patient is placed on a low fat diet as well as daily simvastatin. the nurse instructs that while on this drug

have blood work every 2 months to check for liver damage

The independent interventions the nurse may employ when the 80-year-old patient in the long-term health care facility develops acute pulmonary edema are to: (Select all that apply.)

high Fowler position administering oxygen 2L/min Give diuretics Give morphine

The patient on a low-fat diet following a myocardial infarction (MI) states he can eat fish to help lower cholesterol because of its high content of:

omega-3 fatty acids

Which statement(s) accurately describe(s) characteristics of normal sinus rhythm (NSR)? (Select all that apply.)

one atrial contraction (P wave) one ventricular contraction (QRS complex) one T Wave heart rate 60 to 100

A nurse is reinforcing discharge instructions to a client during the fifth hospitalization for pulmonary edema caused by congestive heart failure exacerbation. Which statement by the client indicates that further teaching is required?

potato chips are acceptable snack in moderation

Following an angiogram, the nurse will assess and record

presence and strength of pedal pulses

The nurse suggests to the patient with angina that a daily dose of 81 mg of aspirin is an inexpensive therapy to ...

reduce clotting

Which modifiable risk factors increase a patient's risk for heart disease? (Select all that apply.)

smoking obesity sedentary lifestyle