Critical Care - Chapter 13: Cardiovascular Alterations

17. A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse should verify whether the patient has taken medications prior to admission for which condition? a. Erectile dysfunction b. Prostate enlargement c. Asthma d. Peripheral vascular disease

ANS: A A history of the patient's use of sildenafil citrate (Viagra) or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies.

13. The patient presenting to the ED with severe chest discomfort is taken for cardiac catheterization and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. Coronary artery bypass graft surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization

ANS: A Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%). None of the other options are relevant to this cardiac problem.

24. What aspect of teaching is essential in preventing recurrence of heart failure? a. Notifying the physician if a 2-lb weight gain occurs in 24 hours. b. Compliance with diuretic therapy. c. Taking nitroglycerin if chest pain occurs. d. Assessment of an apical pulse.

ANS: B Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure. None of the other options have the impact diuretic therapy has on managing heart failure.

16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction with symptoms that began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels at least 88% d. Maintain heart rate above 100 beats/min

ANS: A Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Since interventional cardiology is not available, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

1. The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels

ANS: A ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.

4. A patient presents to the emergency department (ED) with chest pain occurring for the past 2 hours. The patient is nauseous and diaphoretic with skin that is dusky in color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery

ANS: A The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

12. A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 16 hours ago. The patient delayed coming to the ED hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is one possible treatment. Based on these data, the nurse correctly comes to what conclusion? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.

ANS: A To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours.

20. The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse should provide what response? a. "It will be worth it to have him healthy, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "As long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then just let the children eat whatever they want."

ANS: B Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease.

23. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions

ANS: B Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

22. Which comment by the patient indicates a good understanding of the diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"

ANS: B Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion.

18. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option

ANS: B LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

26. The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse should provide what explanation to her? a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."

ANS: B Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

27. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "My back is killing me!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"

ANS: B The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. Severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be discontinued, and volume expanders or coagulation factors, or both, are administered.

9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. Murmur c. S1 heart sound d. S3 heart sound

ANS: B The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

25. The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. What explanation should the nurse provide? a. "The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems." b. "The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year." c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." d. "The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husband's symptoms."

ANS: C A successful angioplasty procedure is one in which the stenosis is reduced to less than 50% of the vessel lumen diameter, although most clinicians aim for less than 20% final diameter stenosis.

10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

ANS: C Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches.

6. A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta-blockers d. Statins, bile acid, and nicotinic acid

ANS: C Conservative intervention for the patient experiencing angina includes nitrates, beta-blockers, and oxygen.

7. A patient diagnosed with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study

ANS: C Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers.

19. The primary care provider orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. dopamine b. dobutamine c. adenosine d. atropine

ANS: C If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed.

2. The nurse is assessing a patient diagnosed with left-sided heart failure. Which symptomwould the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting

ANS: C In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.

5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery

ANS: C In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy.

3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia

ANS: C Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines, which causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement

ANS: C Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway.

11. A 72-year-old woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent myocardial infarction d. Unstable angina

ANS: C Some individuals may have ischemic episodes without knowing it, thereby having a "silent" infarction. These can occur with no presenting signs or symptoms. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients.

15. The patient presents to the ED with sudden severe sharp chest discomfort radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, what should the nurse do in addition to informing the primary care provider? a. Report the cardiac enzyme results. b. Prepare the patient for thrombolytic therapy. c. Begin prepping the patient for emergency surgery. d. Give the patient aspirin and heparin.

ANS: C These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of an acute myocardial infarction (AMI) or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia. The other options relate to cardiac issues.

21. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery

ANS: D Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins

ANS: D The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs.