Edge Circulation and Perfusion

A nurse is assessing lab values for a client admitted to rule out myocardial infarction. What is the most sensitive test that measures damage in the heart muscle? a. Troponin b. Myoglobin c. Hemoglobin d. Creatinine kinase-MB (CK-MB)

a. Troponin Rationale: Troponin measures a complex of proteins used to detect an MI. Troponin levels peak at 18 to 24 hours. b. Myoglobin Rationale: Myoglobin levels peak at approximately 2 to 4 hours and is a nonspecific marker for an MI. c. Hemoglobin Rationale: Hemoglobin levels are not used to detect damage to the heart muscle. Hemoglobin carries oxygen. d. Creatinine kinase-MB (CK-MB) Rationale: The MB isoenzyme is only present in the heart muscle. A serum measurement of the MB band is used to detect an MI. Levels rise with an acute MI within 4 to 8 hours.

Which questions should the nurse ask the client when assessing for peripheral vascular deficits? Select all that apply. a. do you have numbness in your hands or feet? b. are there any sores on your legs that never heal? c. Do you experience any chest pain upon exertion? d. do you feel dizzy when you change positions too fast? e. what makes the pain worse, elevating your legs or dangling them?

a. do you have numbness in your hands or feet? b. are there any sores on your legs that never heal? e. what makes the pain worse, elevating your legs or dangling them?

A client with a diagnosis of dysrhythmias questions the nurse about the need for so many medications. The nurse explains the need for an antiarrhythmic to regulate the heart rate and rhythm. Which complications should the nurse explain to the client that can occur with untreated dysrhythmias? Select all that apply. a. Number of Optionss b. Amplified risk of stroke c. Increased cardiac output d. Narrowed valves in the heart e. Decreased tissue oxygenation f. Noted audible cardiac murmur

. Number of Optionss Rationale: Number of Correct Answers Amplified risk of stroke Rationale: Dysrhythmias that are untreated can place a client at an increased risk for strokes. Increased cardiac output Rationale: Untreated dysrhythmias can cause a decrease, not an increase, in cardiac output. Narrowed valves in the heart Rationale: Heart valves are narrowed due to congenital damage or acquired damage. This is not related to untreated dysrhythmias. Decreased tissue oxygenation Rationale: Tissue oxygenation decreases in clients with untreated dysrhythmias. Noted audible cardiac murmur Rationale: The nurse would notice an audible cardiac murmur in a client with heart valve abnormalities.

A new nurse is learning how to set up telemetry monitoring for a new admission. Put the steps in the correct order. Expose the client's chest and shave the hair if dense. Connect the lead wires to the transmitter. Clean the client's skin with an alcohol pad. Remove the electrode backing. Insert a new battery into the transmitter. Attach the lead wires to the electrodes. Turn on the transmitter. Apply the electrodes to the sites. Place the transmitter in the pouch and the pouch strings around the client's neck. Secure the monitoring equipment.

0. insert new battery into transmitter 1. turn on transmitter 2. connect the lead wires to the transmitter 3. expose the chest and shave hair if dense 4. clean the client's skin with an alcohol pad 5. Remove the electrode backing 6. Attach the lead wires to the electrodes 7. Apply the electrodes to the sites 8. Secure the monitoring equipment 9. Place the transmitter in the pouch and the pouch strings around the client's neck

A nurse is reviewing lab data on a client with a BMI of 30.2 (obesity). What lab value would be most concerning? 1. A potassium level of 3.7 mEq/L 2. A total cholesterol level of 289 mg/dL 3. An HDL level of 47 mg/dL 4. An LDL level of 122 mg/dL

1. A potassium level of 3.7 mEq/L Rationale: A normal potassium level is between 3.5 and 5.1 mEq/L. This potassium level is normal. 2. A total cholesterol level of 289 mg/dL Rationale: A total cholesterol level should be less than 200 mg/dL. 3. An HDL level of 47 mg/dL Rationale: An acceptable HDL level is greater than 45 mg/dL. 4. An LDL level of 122 mg/dL Rationale: An acceptable LDL level is less than 130 mm/dL. Test Taking Tips: Obesity and high cholesterol are frequent causes of heart disease.

A community health nurse is teaching CPR for a single rescuer of an adult victim collapse. Put the steps in order.

1. Establish Responsiveness 2. Call 911 3. Obtain an AED 4. Start CPR 5. Push hard and fast on the center of the chest 6. When the AED arrives turn on and apply the pads 7. Administer one shock per AED 8. Continue CPR until help arrives

The nurse is teaching a family about the reasons why someone has a pulmonary embolism. What should the nurse include with the teaching? Select all that apply. Fat Thrombus Tumor Amniotic fluid Air

Fat Rationale: A fat embolism most often occurs when there is a large bone fracture. Thrombus Rationale: A thrombus or blood clot is the most common reason someone has a pulmonary embolism. Tumor Rationale: Tumor pulmonary embolus is caused when tumor cells break off in the vascular system. Amniotic fluid Rationale: Amniotic fluid pulmonary embolus is fatal to the mother in two-thirds of the cases, with 70% of newborns surviving. Air Rationale: Air embolism most often occurs when there is a medical error. Test Taking Tips:Know the causes of an embolism.

The nurse is preparing to administer morning medications to a client. As the nurse reviews the electronic medication administration record, which medications require an assessment prior to administration? Select all that apply. Insulin Digoxin Antihistamine Bronchodilator Antihypertensive Chemotherapy drugs

Insulin Rationale: The nurse must assess blood glucose levels prior to administering insulin in order to prevent hypoglycemia. Digoxin Rationale: Digoxin is an antiarrhythmic medication. The nurse should always assess the client's apical pulse prior to its administration and hold the drug if the apical pulse is less than 60 beats per minute to prevent severe bradycardia. Antihistamine Rationale: The nurse does not need to perform an assessment prior to the administration of antihistamines. Bronchodilator Rationale: Bronchodilators are safe to give to a client without special assessments prior to administration. Antihypertensive Rationale: The client's blood pressure must always be obtained before the administration of any antihypertensive medication. This will protect the client from hypotension. Chemotherapy drugs Rationale: Chemotherapy drugs affect blood cell counts. Therefore, the nurse would need to assess the client's white blood cell, red blood cell, and platelet counts prior to administering these drugs. Test Taking Tips:Some medications require you to make a specific assessment to ensure that it is safe to administer the drug. You must document that assessment data on the MAR, along with the time of administration and other required information.

A patient has a positive D-dimer and has just returned from a positive spiral CT scan. What vital sign changes should the nurse anticipate? Select all that apply. Tachycardia Hypotension Hyperthermia Hypoxia

Tachycardia Rationale: Pulse increases because of hypoxemia. Hypotension Rationale: Blood pressure may decrease from baseline in cases of massive pulmonary embolism (PE) because of decreased left heart preload. Hyperthermia Rationale: Fever may develop because of inflammatory response. Hypoventilation Rationale: Tachypnea will occur due to decreased oxygenation and pain. Hypoxia Rationale: Hypoxia will occur from the ventilation/perfusion (V/Q) mismatch. Test Taking Tips:Look for assessment changes with a pulmonary embolism.

The nurse is educating a client regarding the cardiovascular effects of chronic alcohol abuse. Which information should the nurse include? Select all that apply. a. Leads to congestive heart failure b. Causes endocarditis of the heart c. Forms thrombi in the coronary arteries d. Produces hepatic encephalopathy of the brain e. Depresses cardiovascular centers of the brain

The nurse is educating a client regarding the cardiovascular effects of chronic alcohol abuse. Which information should the nurse include? Select all that apply. Leads to congestive heart failure Rationale: Congestive heart failure occurs from fluid volume overload and heart enlargement. This can occur from chronic alcohol abuse. Causes endocarditis of the heart Rationale: Endocarditis occurs from drug abuse, not alcohol. Forms thrombi in the coronary arteries Rationale: Chronic alcohol abuse can lead to thrombi formation in the coronary arteries. Produces hepatic encephalopathy of the brain Rationale: Hepatic encephalopathy occurs from chronic alcohol use, but it affects the brain, not the cardiovascular system. Depresses cardiovascular centers of the brain Rationale: Alcohol abuse affects the brain by depressing the cardiovascular centers of the brain.

When arriving to take a client's blood pressure, a nurse witnesses an argument between the client and spouse. Recognizing that stress can alter blood pressure, the nurse encourages the spouse to step out and get something to drink, giving the client an opportunity to calm down. The nurse returns later to take the client's blood pressure after the client has had time to settle down. What is true about this situation? Select all that apply. a. The nurse used theoretical knowledge by recognizing the argument would raise blood pressure. b. The nurse used ethical knowledge by returning to get an accurate reading instead of just assuming the client's blood pressure would return to normal. c. The nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading. d. The nurse used scientific basis to determine steps in applying the nursing plan for obtaining a blood pressure reading. e. The nurse was carrying out the planning part of the nursing process.

The nurse used theoretical knowledge by recognizing the argument would raise blood pressure. Rationale: Theoretical knowledge is used to describe clients, understand their health status, explain reasoning for choosing interventions, and predict client responses to interventions and treatments. The nurse used ethical knowledge by returning to get an accurate reading instead of just assuming the client's blood pressure would return to normal. Rationale: Ethical knowledge is based on moral principles and processes for making moral decisions and helps fulfill ethical obligations to clients and colleagues. The nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading. Rationale: Knowing what to do and how to do it is referred to as practical knowledge, which consists of processes and procedures. The nurse used scientific basis to determine steps in applying the nursing plan for obtaining a blood pressure reading. Rationale: Applying the nursing plan and obtaining the blood pressure reading is a component of the nursing process and implementation, not scientific basis. The nurse was carrying out the planning part of the nursing process. Rationale: The nurse was carrying out the evaluation part of the nursing process. Test Taking Tips:Nursing utilizes different types of knowledge basis to critically think about what, why, and how a client should be assessed.

The nurse is preparing to interview a client with an extensive cardiac history. Which questions would the nurse ask of a client in a focused assessment of the family history? Select all that apply. a. "How often do you experience chest pain?" b. "Did your parents smoke? If so, at what age?" c. "At what age did you begin to smoke cigarettes?" d. "Have any of your siblings experienced a heart attack or stroke?" e. "Who on your father's side of the family has heart disease?"

a. "How often do you experience chest pain?" Rationale: The nurse would ask the client about chest pain during the focused cardiovascular assessment. This does not fall under the family history. b. "Did your parents smoke? If so, at what age?" Rationale: Whether the client's parents smoke is not relevant family history. Those are modifiable risk factors and not genetic-related. c. "At what age did you begin to smoke cigarettes?" Rationale: The client's smoking history does not relate to the client's family history. d. "Have any of your siblings experienced a heart attack or stroke?" Rationale: Sibling cardiovascular health is relevant family history that the nurse should ask the client. e. "Who on your father's side of the family has heart disease?" Rationale: The nurse would ask the client about the parental history of cardiovascular disease in the family history.

A nurse is teaching a client how to promote venous circulation. Which statements by the client indicates understanding of the teaching? Select all that apply. a. "I will keep my legs elevated when I am sitting in the recliner." b. "I will take a walk around the block in the morning and afternoon." c. "I will only be able to perform range-of-motion exercises once per week" d. "It's ok if I sit with my legs crossed in the car." e. "I will drink at least six 8-ounce glasses of water every day." f. "I will attend a smoking cessation class at the YMCA."

a. "I will keep my legs elevated when I am sitting in the recliner." Rationale: The client should have the legs raised above the level of the heart. Gravity promotes venous return from the feet and legs. b. "I will take a walk around the block in the morning and afternoon." Rationale: Walking is encouraged to contract the leg muscles and to move venous blood upward against gravity. c. "I will only be able to perform range-of-motion exercises once per week" Rationale: Range-of-motion exercises should be done every day, not just once a week. d. "It's ok if I sit with my legs crossed in the car." Rationale: Clients should be taught not to cross their legs, as it interferes with blood flow back to the heart. e. "I will drink at least six 8-ounce glasses of water every day." Rationale: Adequate hydration keeps the blood from becoming viscous, as viscous blood can lead to clots more easily. Clients should be encouraged to consume approximately 2000 mL per day unless contraindicated. f. "I will attend a smoking cessation class at the YMCA." Rationale: Nicotine increases the risk of clots because it constricts the blood vessels. Test Taking Tips: Patients need to participate in activities that promote venous circulation.

A nurse is teaching a client who is started on digoxin before discharge. Which statements by the client indicate correct understanding of the teaching? Select all that apply. a. "I will take my pulse before every dose and contact my health-care provider for a pulse of less than 50." b. "I will notify my health-care provider if I have blurred, yellow vision." c. "I don't have to worry about my potassium level when taking digoxin." d. "My blood levels of digoxin should be between 0.2 and 0.5." e. "My blood levels will have to be checked every month."

a. "I will take my pulse before every dose and contact my health-care provider for a pulse of less than 50." Rationale: Clients and family members should be taught how to take a radial pulse for 1 minute and when to contact the health-care provider if below 50 beats/min. b. "I will notify my health-care provider if I have blurred, yellow vision." Rationale: This is a classic sign of digoxin toxicity and must be reported immediately to the health-care provider. c. "I don't have to worry about my potassium level when taking digoxin." Rationale: Potassium levels should also be monitored, as a level below 3.5 mEq/L may precipitate digoxin toxicity. d. "My blood levels of digoxin should be between 0.2 and 0.5." Rationale: The therapeutic blood level for digoxin is 0.8 to 2.0 ng/mL. e. "My blood levels will have to be checked every month." Rationale: Blood levels must be monitored closely to prevent toxicity. Levels greater than 2.0 are toxic.

The nurse is administering morning medications including a once-a-day aspirin to a client with cardiovascular disease and diabetes mellitus. The client asks the nurse why the health-care provider prescribed an aspirin when he or she has no pain. What is the nurse's best response? a. "The aspirin is used to prevent any pain from occurring." b. "We will hold the medication until I receive clarification." c. "This is a small dose of aspirin that I would not worry about it." d. "Your risk for heart attacks and strokes can be decreased by taking aspirin every day."

a. "The aspirin is used to prevent any pain from occurring." Rationale: If the health-care provider was using aspirin as a pain reliever, it would be prescribed PRN instead of once a day. b. "We will hold the medication until I receive clarification." Rationale: The nurse would not need to hold the medication because the nurse could explain why the medication was administered. c. "This is a small dose of aspirin that I would not worry about it." Rationale: This statement dismisses the client's concerns and does not answer the question. D. "Your risk for heart attacks and strokes can be decreased by taking aspirin every day." Rationale: The client has cardiovascular disease and diabetes mellitus. This places the client at a high risk for heart attacks and strokes. An aspirin a day can decrease the client's risk. Test Taking Tips:Aspirin can help to prevent cardiovascular disease.

A client is learning about anticoagulant therapy. Which statement indicates that the client understands this therapy? a. "There are no antidotes for heparin or Coumadin." b. "I will need weekly blood tests if I take apixaban." c. "If I am taking Coumadin, I will avoid green, leafy vegetables." d. "I can use a regular razor to shave my face."

a. "There are no antidotes for heparin or Coumadin." Rationale: There are antidotes for heparin and Coumadin. Heparin is protamine sulfate and the antidote for Coumadin is vitamin K. b. "I will need weekly blood tests if I take apixaban." Rationale: There are no weekly blood tests for dabigatran, apixaban, or rivaroxaban, and there are no antidotes. c. "If I am taking Coumadin, I will avoid green, leafy vegetables." Rationale: Green leafy vegetables like kale, spinach, Brussels sprouts, parsley, collard greens, mustard greens, chard, and green tea contain vitamin K and should be avoided so as to not interfere with Coumadin. d. "I can use a regular razor to shave my face." Rationale: Clients should be instructed to use an electric razor in order to prevent risk of cuts and bleeding. Test Taking Tips: Foods that contain vitamin K should be avoided.

A client is in the emergency room with complaints of chest pain and dyspnea. What would be the most important assessment data to report to the physician? a. A blood pressure of 168/94 in left arm b. A pulse oximetry reading of 91% on room air c. A heart rate of 112 beats/min d. An oral temperature of 98.9°F

a. A blood pressure of 168/94 in left arm Rationale: A normal blood pressure is < 120/< 80. If this client is having a cardiac event, the blood pressure would be elevated. This is a circulation problem. b. A pulse oximetry reading of 91% on room air Rationale: A normal pulse oximetry reading should be 95 to 100% on room air. This is the most important data to report because it is an oxygenation problem and needs to be treated immediately. c. A heart rate of 112 beats/min Rationale: A normal heart rate is 60 to 100 beats/min. This client's heart rate is elevated due to complaints but is not dangerously high. d. An oral temperature of 98.9°F Rationale: This temperature is within the normal range and does not require any treatment.

A nurse is teaching a group of clients about different cardiovascular medications. Which cardiac medications are considered vasodilators? Select all that apply. a. ACE inhibitors b. Diuretics c. Beta-adrenergic blockers d. Angiotensin II receptor blockers e. Nitrates f. Statins

a. ACE inhibitors Rationale: ACE inhibitors cause vessel dilation. Such medications include captopril, lisinopril, and enalapril. b. Diuretics Rationale: Diuretics remove sodium and water from the body via urine. Diuretics include HCTZ, furosemide, and spironolactone. c. Beta-adrenergic blockers Rationale: Beta-adrenergic blockers block the stimulation of beta receptors, which are located in the heart, to decrease heart rate, slow conduction of the AV node, and reduce myocardial contractility. Medications include metoprolol and propranolol. d. Angiotensin II receptor blockers Rationale: Angiotensin II receptor blockers (ARBS) relax blood vessels, decrease blood pressure, and ease workload of the heart. Medications include losartan and valsartan. e. Nitrates Rationale: Nitrates dilate the vessels during an episode of chest pain. Nitrates include nitroglycerin and Isordil. f. Statins Rationale: Statins are a class of drugs that protect against coronary artery disease by lowering triglycerides and reduce the production of cholesterol by the liver.

Which statement is accurate regarding electrocardiography (ECG)? a. An ECG includes placing two electrodes on the chest. b. An ECG monitors the mechanical activity of the heart. c. An ECG reflects what the nerves tell the heart muscle to do. d. An ECG is used in screening to determine the risk factors for cardiac disease.

a. An ECG includes placing two electrodes on the chest. Rationale: An ECG involves placing three to five electrodes on the chest. b. An ECG monitors the mechanical activity of the heart. Rationale: The ECG monitors the electrical, not mechanical, activity of the heart. c. An ECG reflects what the nerves tell the heart muscle to do. Rationale: The ECG is demonstrating what the nerves are telling the heart muscle to do. d. An ECG is used in screening to determine the risk factors for cardiac disease. Rationale: Current evidence states that ECGs should not be used to determine cardiac disease risk factors.

A nurse is reviewing clinical data on a client with a history of type 2 diabetes mellitus, hypertension, and tobacco use. What data is the most concerning? a. Blood pressure of 156/86 in left arm b. Fasting serum glucose of 168 mg/dL c. C-reactive protein of 3.2 mg/dL d. Total cholesterol of 205 mg/dL

a. Blood pressure of 156/86 in left arm Rationale: Although this blood pressure is elevated, it is not the most significant finding. b.Fasting serum glucose of 168 mg/dL Rationale: For a client with type 2 diabetes mellitus, this fasting blood sugar is not ideal but is not the most significant finding. c. C-reactive protein of 3.2 mg/dL Rationale: A C-reactive protein of 3.2 mg/dL indicates a high risk level for cardiovascular disease. CRP measures the amount of inflammation in the body and ideally should be less than 1.0 mg/dL. d. Total cholesterol of 205 mg/dL Rationale: Total cholesterol should be less than 200 mg/dL. Cholesterol levels can be managed with diet, exercise, or statins. Test Taking Tips: This would be the most reliable marker for arterial inflammation.

What would the nurse assess for in a client with stable angina? Select all that apply. a. Chest pain relieved by rest b. Chest pain unrelieved by medication c. Chest pain caused by cigarette smoking d. Chest pain that gets worse without relief e. Chest pain that leads to a myocardial infarction

a. Chest pain relieved by rest Rationale: Chest pain that is relieved by rest is stable angina. b. Chest pain unrelieved by medication Rationale: Chest pain that is not relieved by medication is considered unstable angina. c. Chest pain caused by cigarette smoking Rationale: Cigarette smoking that leads to chest pain in considered stable angina. d. Chest pain that gets worse without relief Rationale: A client who develops chest pain that gets worse without any relief is unstable angina. e. Chest pain that leads to a myocardial infarction Rationale: Chest pain that leads to a myocardial infarction is unstable angina. Test Taking Tips:Stable angina has predictable patterns.

What would the nurse assess for in a client with stable angina? Select all that apply. a. Chest pain relieved by rest b. Chest pain unrelieved by medication c. Chest pain caused by cigarette smoking d. Chest pain that gets worse without relief e. Chest pain that leads to a myocardial infarction

a. Chest pain relieved by rest Rationale: Chest pain that is relieved by rest is stable angina. c. Chest pain caused by cigarette smoking Rationale: Cigarette smoking that leads to chest pain in considered stable angina. b. Chest pain unrelieved by medication Rationale: Chest pain that is not relieved by medication is considered unstable angina. d. Chest pain that gets worse without relief Rationale: A client who develops chest pain that gets worse without any relief is unstable angina. e. Chest pain that leads to a myocardial infarction Rationale: Chest pain that leads to a myocardial infarction is unstable angina. Test Taking Tips:Stable angina has predictable patterns.

The nurse is examining a client who reports a history of peripheral venous abnormalities. What would the nurse expect to find during the examination? Select all that apply. a. Cool skin b. Stasis ulcers c. Poor capillary refill d. Lower extremity edema e. Brown skin discoloration

a. Cool skin Rationale: A client with peripheral arterial disease would present with cool skin due to insufficient oxygenation to the extremities. b. Stasis ulcers Rationale: Due to fluid leaking from capillaries, the client will have tissues that weep and cause venous stasis ulcers. c. Poor capillary refill Rationale: Poor capillary refill is an assessment finding in a client with peripheral arterial disease. d. Lower extremity edema Rationale: A client with venous vascular disease would have lower extremity edema due to an increase in oncotic pressure that causes fluid to leak from capillaries. e. Brown skin discoloration Rationale: Due to vascular congestion, a client with peripheral venous disease would have a brown skin discoloration in the lower extremities.

There are various cardiovascular medications that lower cholesterol. Which medication category lowers LDL cholesterol levels? a. Diuretics b. Vasodilators c. Statins d. Positive inotropes

a. Diuretics Rationale: The purpose of diuretics is to increase the elimination of sodium and water from the body by increasing urinary output. b. Vasodilators Rationale: The purpose of vasodilators is to dilate the vessels, which eases the work of the heart. c. Statins Rationale: The purpose of statins is to decrease elevated LDL cholesterol levels. d. Positive inotropes Rationale: The purpose of positive inotropes is to increase cardiac contractility.

Cardiac dysrhythmias have the potential to decrease cardiac output. Which type of dysrhythmia is located in the AV node? a. Ectopy b. Supraventricular c. Ventricular d. Junctional

a. Ectopy Rationale: Ectopy occurs when there are extra beats in the cardiac cycle. b. Supraventricular Rationale: Supraventricular cardiac dysrhythmias occur above the ventricles. c. Ventricular Rationale: Ventricular cardiac dysrhythmias occur within the ventricles. d. Junctional Rationale: Junctional dysrhythmias occur within the AV (atrioventricular) node.

The NHLBI panel of experts recommended that children between 9 and 11 years be screened for cardiovascular risk factors. What is the most important screening for this age group? a. Height and weight to calculate BMI b. Select lipid profile c. An EKG d. A chest x-ray

a. Height and weight to calculate BMI Rationale: BMIs are important in this age group but not the most specific indicator for cardiovascular disease. b. Select lipid profile Rationale: A select lipid profile for baseline is recommended in this age group, regardless of family history. c. An EKG Rationale: An EKG is not indicated for this age group unless there is clinical data to support this procedure. Most children do not require an EKG unless there is underlying disease to indicate one. d. A chest x-ray Rationale: A chest x-ray is not necessary as a screening tool for this age group and is not related to cardiovascular disease. Test Taking Tips: Childhood obesity is on the rise and can lead to heart disease.

The nurse is assessing a client with a potential deep vein thrombosis (DVT). What sign does the nurse use by dorsiflexing the toes? a. Homan's sign b. Pratt's sign c. Kernig's sign d. Brudzinski's sign

a. Homan's sign Rationale: The Homan's sign is elicited when the provider dorsiflexes the toes/foot of the affected leg. If there is pain on dorsiflexion, this is considered a positive Homan's sign. b. Pratt's sign Rationale: The Pratt's sign is similar to the Homan's sign, but it is elicited by squeezing the calf of the affected leg to produce pain on the clot. c. Kernig's sign Rationale: The Kernig's sign is a diagnostic sign for meningitis marked by a loss of the ability of a supine client to completely straighten the leg when it is fully flexed at the knee and hip. Pain in the lower back and resistance to straightening the leg constitutes a positive Kernig's sign. d. Brudzinski's sign Rationale: The Brudzinski's sign is an involuntary flexion of the hip and knee when the neck is passively flexed. It can occur in clients with meningitis. Test Taking Tips:Although this sign cannot be used for diagnosis, it can be used with other signs and symptoms to confirm DVT.

The nurse is educating a client regarding the cardiovascular effects of chronic alcohol abuse. Which information should the nurse include? Select all that apply. a. Leads to congestive heart failure b. Causes endocarditis of the heart c. Forms thrombi in the coronary arteries d. Produces hepatic encephalopathy of the brain e. Depresses cardiovascular centers of the brain

a. Leads to congestive heart failure Rationale: Congestive heart failure occurs from fluid volume overload and heart enlargement. This can occur from chronic alcohol abuse. b. Causes endocarditis of the heart Rationale: Endocarditis occurs from drug abuse, not alcohol. c. Forms thrombi in the coronary arteries Rationale: Chronic alcohol abuse can lead to thrombi formation in the coronary arteries. d. Produces hepatic encephalopathy of the brain Rationale: Hepatic encephalopathy occurs from chronic alcohol use, but it affects the brain, not the cardiovascular system. e. Depresses cardiovascular centers of the brain Rationale: Alcohol abuse affects the brain by depressing the cardiovascular centers of the brain.

Which diagnostic tests would the nurse expect the health-care provider to prescribe to determine a client's risk for cardiovascular disease? Select all that apply. a. Lipid panel b. Cholesterol level c. Arterial blood gas d. C-reactive protein e. Basic metabolic panel

a. Lipid panel Rationale: A lipid panel is used to determine a client's cardiovascular risk. b. Cholesterol level Rationale: The heath-care provider would prescribe a cholesterol level for a client to determine cardiovascular risk. c. Arterial blood gas Rationale: Arterial blood gases are prescribed to determine oxygenation. It does not assess risk factors. d. C-reactive protein Rationale: A C-reactive protein test assesses for the presence of arterial inflammation and is used to determine cardiovascular risk. e. Basic metabolic panel Rationale: A basic metabolic panel measures electrolytes, renal function, and glucose level. It does not measure a person's cardiovascular risk.

A client with a diagnosis of dysrhythmias questions the nurse about the need for so many medications. The nurse explains the need for an antiarrhythmic to regulate the heart rate and rhythm. Which complications should the nurse explain to the client that can occur with untreated dysrhythmias? Select all that apply. a. Number of Options b. Amplified risk of stroke c. Increased cardiac output d. Narrowed valves in the heart e. Decreased tissue oxygenation f. Noted audible cardiac murmur

a. Number of Options Rationale: Number of Correct Answers b. Amplified risk of stroke Rationale: Dysrhythmias that are untreated can place a client at an increased risk for strokes. c. Increased cardiac output Rationale: Untreated dysrhythmias can cause a decrease, not an increase, in cardiac output. d. Narrowed valves in the heart Rationale: Heart valves are narrowed due to congenital damage or acquired damage. This is not related to untreated dysrhythmias. e. Decreased tissue oxygenation Rationale: Tissue oxygenation decreases in clients with untreated dysrhythmias. f. Noted audible cardiac murmur Rationale: The nurse would notice an audible cardiac murmur in a client with heart valve abnormalities.

Which part of the ECG complex represents the SA node firing and conducting the impulse through the atria? a. P wave b. QRS complex c. T wave d. U wave

a. P wave Rationale: The P wave represents the firing of the SA node and the impulse moving through the atria. b. QRS complex Rationale: The QRS complex reflects ventricular depolarization and causes the ventricles to contract. It is not related to the SA node. c. T wave Rationale: The T wave occurs when the ventricles return to a resting state. This does not involve the SA node. d. U wave Rationale: The U wave is usually not detected unless the client has an electrolyte imbalance and is unrelated to the SA node. Test Taking Tips:In the healthy heart, this leads to atrial contraction.

Which finding would the nurse expect to note when assessing a client with right-sided heart failure? a. Peripheral edema b. Shortness of breath c. Decreased urinary output d. Crackles in the lung fields

a. Peripheral edema Rationale: A client with right-sided heart failure will experience peripheral edema due to fluid backing up in the extremities. b. Shortness of breath Rationale: Shortness of breath would be noted in a client with left-sided heart failure as blood backs up into the lungs. c. Decreased urinary output Rationale: Urinary output decreases in left-sided heart failure due to decreased blood supply to the kidneys. d. Crackles in the lung fields Rationale: The nurse would notice crackles in the lung fields in a client with left-sided heart failure due to inefficient pumping of the left side of the heart. This causes fluid to back up in the lungs, leading to crackles.

A nurse is assessing a client with cardiac pain. What is the difference between cardiac pain and pleuritic pain? Select all that apply. a. Pleuritic pain is unrelieved with nitrates. b. Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety. c. Pleuritic pain is the result of a pulmonary emboli. d. Cardiac pain typically does not change with inhalation or exhalation. e. Pleuritic pain is diagnosed with cholesterol, lipid panel, C-reactive protein, and glucose testing.

a. Pleuritic pain is unrelieved with nitrates. Rationale: Pleuritic pain may present as cardiac pain but is usually well localized in the chest wall, without radiation and with dyspnea on exertion. There may be evidence of inflammation and intercostal retractions. b. Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety. Rationale: Classic signs of cardiac pain occur in the center/left side of the chest, and the pain radiates to the left arm and lasts several minutes. It may subside and return. c. Pleuritic pain is the result of a pulmonary emboli. Rationale: A pulmonary emboli (PE) does not present with pleuritic pain. A PE presents with sudden chest pain, tachycardia, tachypnea, and hemoptysis. A complete assessment will differentiate this diagnosis. d. Cardiac pain typically does not change with inhalation or exhalation. Rationale: A nursing assessment includes location, duration, frequency, radiation, and quantity. When the heart muscle is infarcted, it will be constant and not change with respirations. e. Pleuritic pain is diagnosed with cholesterol, lipid panel, C-reactive protein, and glucose testing. Rationale: A cardiovascular assessment includes cholesterol, lipid panel, C-reactive protein (CRP), and glucose lab testing. The CRP is the most reliable marker for arterial inflammation.

The heart is regulated by the autonomic nervous system (ANS) and control centers in the brainstem. Where do the parasympathetic fibers innervate the heart? a. The baroreceptors b. The chemoreceptors c. The trigeminal nerve d. The vagus nerve

a. The baroreceptors Rationale: Baroreceptors are located in the walls of the heart and blood vessels and are sensitive to pressure changes. b. The chemoreceptors Rationale: Chemoreceptors are located in the aortic arch and carotid arteries and are sensitive to chemicals in the blood pH, oxygen, and carbon dioxide. c. The trigeminal nerve Rationale: The trigeminal nerve (cranial nerve V) receives sensation from the face and innervates the muscles of mastication. d. The vagus nerve Rationale: The vagus nerve (cranial nerve X) is both a sensory and motor (mixed) nerve in the heart.

Which diagnostic tests would the nurse expect the health-care provider to prescribe to determine a client's risk for cardiovascular disease? Select all that apply. a. Lipid panel b. cholesterol level c. arterial blood gas d. c-reactive protein e. basic metabolic panel

a. lipid panel b. cholesterol level d. c-reactive protein (assesses for the presence of arterial inflammation and is used to determine cardiovascular risk)

Which symptoms would the nurse expect to find in a female client experiencing a heart attack? Select all that apply. a. nausea b. jaw pain c. shortness of breath d. radiating left arm pain e. disappearance of chest pain with exhalation

a. nausea b. jaw pain c. shortness of breath