EXAM 3 patho quiz 10
A client's electrocardiogram rhythm shows normal sinus rhythm followed by a complex of six premature ventricular contractions with a return to normal sinus rhythm. Which interpretation should the nurse document in the medical record?
Nonsustained ventricular tachycardia
A client in the nursing home wonders why he is having these signs and symptoms of left-sided heart failure. Which explanation will the nurse give the client?
"The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs."
For which consequences of cardiogenic shock will the nurse monitor a trauma client? Select all that apply. Decreased preloading Decreased blood volume Increased afterloading Decreased cardiac output Decreased stroke volume
-Decreased stroke volume -Decreased cardiac output -Increased afterloading
A client admitted to the emergency department is experiencing sinus tachycardia. What can cause this dysrhythmia that the nurse should monitor for? Select all that apply. -Pain -Blood loss -Hyperthyroidism -Insomnia -Fever
-Pain -Blood loss -Hyperthyroidism -Fever
In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which level indicates inadequate renal perfusion?
20 mL/hour
The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:
20 mL/hour
A client is transported to the emergency department in respiratory distress after eating peanuts. The following interventions are ordered by the health care provider. Which intervention should the nurse complete first?
Administer epinephrine (adrenaline).
A client is rushed to the emergency department with assessment findings of urticaria, wheezing, chest tightness, and difficulty breathing. The client is most likely experiencing which type of shock?
Anaphylactic
Coronary artery bypass grafting (CABG) is a treatment modality for which disorder of cardiac function?
Atherosclerosis and unstable angina
A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing?
Obstructive shock
The nurse is caring for a client who has just experienced an acute myocardial infarction. Which type of shock is this client likely to experience?
Cardiogenic
A nurse is monitoring a client with a consistent and regular heart rate of 128 beats/min. Which physiologic alteration would be consistent with this finding?
Decrease in ventricular filling time and blood pressure
A client is immobilized following a hip injury. The client has developed lower leg discoloration with edema, pain, and tenderness in the midcalf area. How should the nurse document these clinical findings?
Deep vein thrombosis
A client's electrocardiogram monitor begins to sound an alarm and shows sustained ventricular fibrillation. The client is unconscious and without a pulse. Which priority intervention should the nurse take?
Defibrillate the client
All of the following interventions are ordered STAT for a client stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first?
Epinephrine
A 20-year-old college student has a pelvic fracture and a severed leg from a motorcycle accident. She lost several units of blood. When the student arrived in the emergency department, her blood pressure was very low, her pulse was high, and her skin was pale. The nurse knows that this client has developed which type of shock?
Hypovolemic
The nurse is assisting a client who had a myocardial infarction 2 days ago during a bath. The client suddenly lost consciousness and the nurse was unable to feel a pulse. Cardiopulmonary resuscitation was begun and the client was connected to the monitor with a gross disorganization without identifiable waveforms or intervals observed. What is a priorityintervention at this time?
Immediate defibrillation
Anaphylactic shock is the most severe form of systemic allergic reaction. Immunologically medicated substances are released into the blood, causing vasodilation and an increase in capillary permeability. What physiologic response often follows the vascular response in anaphylaxis?
Laryngeal edema
The nurse is interpreting an electrocardiogram of a 65-year-old woman. Which should the nurse recognize as representing ventricular depolarization?
QRS complex
Considering the PQRST complex of an electrocardiogram (ECG), which letter designation represents atrial depolarization?
P wave
A client experiencing a sinus arrest would demonstrate which symptom or finding?
Prolonged periods of asystole demonstrated on an electrocardiogram
What is the correct sequence for the generation of electrical impulses in the heart causing ventricular contraction?
SA node - AV node - bundle of His - bundle branches - Purkinje fibers
A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF (40°C) in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this client most likely is experiencing which type of shock?
Septic
Which of the following is called the pacemaker of the heart?
Sinoatrial (SA) node
A 28-year-old marathon runner comes to the clinic to obtain a physical exam for a new job. The nurse assesses a regular pulse rate of 52 beats per minute (bpm). Which common dysrhythmia is the nurse aware this client most likely has related to maintaining a large stroke volume?
Sinus bradycardia
An older adult client with a past medical history of diabetes type II and myocardial infarction (MI) is admitted with sudden shortness of breath, palpitations, irregular apical pulse with no pattern, heart rate of 130 and blood pressure of 100/60. The nurse suspects atrial fibrillation (AF) for which reasons? Select all that apply. Tachycardia Hypotension Flutter waves on the ECG Palpitations Irregular rhythm
Tachycardia Palpitations Irregular rhythm
Which client is at the greatest risk of developing rheumatic heart disease?
Teenager with untreated strep throat
Which client will the nurse prioritize to assess first?
The client with sinus arrest
The health care provider is reviewing lab results of a client diagnosed with heart failure. The provider notes that the client's ANP and BNP levels have been increasing and remain significantly elevated. These results would be interpreted as:
The condition is getting progressively worse.
A client is believed to be in cardiac arrest and defibrillation is being performed. What is an aspect of the rationale and physiology of defibrillation treatment?
The goal is to depolarize the entire heart during the passage of current.
A client comes to the emergency room with all the symptoms of a myocardial infarction. Which lab value, known to have a high specificity for myocardial tissue considered the primary biomarker test for diagnosing an MI, does the nurse suspect the physician will order?
Troponin assays
Which dysrhythmia is considered to be the most fatal and requires immediate treatment?
Ventricular fibrillation
A client presents with uncharacteristic chest pain, and his ECG reveals T-wave elevation. This finding suggests an abnormality with which aspect of the cardiac cycle?
Ventricular repolarization
A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of:
hypovolemic shock due to acute intravascular volume loss.
The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be:
improving quality of life by relieving symptoms.
A client has been diagnosed with deep vein thrombosis (DVT). The nurse is planning care and recognizes that the client is most at risk for:
pulmonary embolism
Which serum biomarker is highly specific for myocardial tissue?
troponin
Anaphylactic shock is directly associated with:
type I hypersensitivity response.
A 30-year-old client arrives with these vital signs: Blood pressure 50/30 mm Hg, pulse 100 beats/min, respiratory rate 12 breaths/min, temperature 101°F (38.3°C). The nurse interprets these results as the client being in shock based on which reading?
Low blood pressure