Med Surg Test 3

A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response?

"A heart attack evolves over several hours. We won't know the extent of the damage immediately."

A patient is admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF). The patient states, "I feel fine, this rhythm won't hurt me." Which nursing response is appropriate?

"Atrial Fibrillation can cause clots to form from the irregular blood flow in the heart."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

MI clinical manifestations:

- Chest pain - Arm pain (more on the left) - Jaw & tooth pain - Shoulder blade pain - Upper back pain - Shortness of breath - Nausea & vomiting - Sometimes color changes; pale or grayish color b/c of - decreased CO - Diaphoretic - Generalized fatigue

How to treat myocardial infarction:

1.) Administer oxygen 2.) Give a SL nitroglycerin tablet (if pain is not controlled with 3 doses in 5 minute intervals → IV nitroglycerin) 3.) Give aspirin 4.) Administer pain medication like Morphine sulfate if nitroglycerin doesn't relieve pain (w/ caution)

if a pt had a thrombolytic infusion, how many hours should you wait before beginning administration of any anticoagulant or antiplatelet medications?

24 hours

in order for patients to receive TPA, patients must present within ____ hours of stroke symptom onset.

3

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

Your patient requires immediate cardioversion, which is defined as which of the following?

A controlled electrical shock that is triggered by and fires on the R wave

The nurse notes an ECG rhythm on the monitor that may be the cause of Tom's stroke. Which rhythm leads the nurse to believe this?

Atrial fibrillation

During the first 24 hours after receipt of Activase (tPA), the primary concern is controlling:

Blood pressure (to monitor for post-CVA hypertension)

in this procedure: - Patient is under general anesthesia for this procedure - May be performed with/without cardiopulmonary bypass(CPB) - Blocked coronary vessels are bypassed using arteries/veins from arms/legs/chest

Coronary Artery Bypass Graft (CABG)

The nurse knows that close monitoring of serum electrolyte levels, especially sodium, is important because hyponatremia raises the risk of which stroke complication?

Cumulative fluid imbalance

Antiplatelet agents (i.e. Aspirin, plavix)

Decreases platelet aggregation & help clots not become any larger

The nurse is caring for a patient who is being transported to the emergency department with clinical manifestations of stroke. Which is the priority action upon arrival to the hospital?

Establish the time that the patient was last known to be without symptoms.

CT angiography

I.V. injection of a contrast dye; used to evaluate the cerebral vasculature

myelography

Invasive test; lumbar puncture & injection of contrast medium around the spinal cord area & X-rays are taken to visualize the spinal cord

Cerebral Angiography

Invasive; it's an intra arterial type test typically using the femoral artery to get a better view of the cerebral vessels

biopsy

Invasive; used to obtain tissue samples to identify possible problems w/in the spinal cord or brain

EEG

Look at the electrical activity of the brain & electrical responses in the brain

Ct scan

Looks at cross sectional images; used to assess for bleeding, edema, or masses

MRI

Non-invasive; type of imaging study to get very good detail for small structures

A patient is experiencing severe hypotension after a spinal cord injury. Which medication should the nurse anticipate will be ordered?

Norepinephrine

Based on these findings, what heart waveform is this: Heart rate: 60 to 100 bpm Heart rhythm: Will be regular P waves: present and consistent PR interval: 0.12 - 0.20 seconds and constant QRS duration: 0.06 - 0.10 seconds and 1-3 small boxes

Normal Sinus Rhythm

The nurse receives hand-off report on each of these patients. Which one should the nurse see *first*? A. Pt 1 hour after returning from cardiac catheterization, right groin dressing intact w/ dime size area of blood, distal pulses intact B. Pt w/ elevated troponin & CK-MB, chest pain of 3 out of 10 C. Pt w/ crackles bilaterally in the bases, Sp02 of 94% on 2L of 02 per nasal cannula, BNP elevated D. Pt going for stress test in 2 hours & needs teaching.

Patient w/ elevated troponin & CK-MB, chest pain of 3 out of 10

The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium?

Romberg test

What EKG changes will be seen for a patient with an acute MI?

ST segment elevation + T wave inversion

PET scan

Semi-invasive; Administration of a radioactive substance to detect increase metabolic activity in the body

What are the main goals in treating an ischemic stroke?

TPA (golden standard treatment of ischemic stroke) → dissolves the clot and restores blood flow

The nurse has just received a report on assigned patients. Which of the following patients should be assessed first? A. The patient with indigestion and increased troponin levels B. The patient with indigestion and increased CK levels C. The patient admitted 2 days ago with a BNP of 75 pg/mL D. The patient admitted 2 days ago with increased LDLs and C-reactive protein

The patient with indigestion and increased troponin levels

The nurse is assessing a patient who is experiencing chest pain. Which laboratory result may differentiate between myocardial injury and another cause?

Troponin 1ng/mL (troponin is specific to myocardial infarction)

MRA

Uses radioactive signals to look at blood flow & get a better picture of the blood vessels

The primary healthcare provider orders IV recombinant tissue plasminogen activator (rt-PA) therapy for a patient. Which is the most likely condition of the patient?

acute ischemic stroke

The nurse notes neglect, or inattention, to one side of the body in a patient who recently had a stroke. Which describes this condition in the patient?

agnosia (hemiparesis)

Any catheter placement into a blood vessel is associated with a risk of...

bleeding

Which of the following is NOT an appropriate intervention for *all* atrial dysrhythmias?

cardioversion

after a percutaneous coronary angioplasty (PCTA) what assessment should most concern the nurse? A. Back discomfort B. Chest pain C. Capillary refill of less than 3 seconds D. Hypoactive bowel sounds

chest pain

thrombolytics (TPA)

clot busters; dissolve clots

This is the gold standard for the diagnosis of flow-limiting coronary artery disease.

coronary angiography

A patient has VF. The nurse understands that the most effective treatment besides CPR is which of the following?

defibrillation

Transcutaneous pacing is through?

defibrillator pads

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:

depression

this is a disruption of the cardiac conduction pathway

dysrhythmia

This uses sound waves to map out the structures of the heart; the heart chambers, heart valves, and wall motion of the heart

echocardiography

what are the main goals in treating hemorrhagic stroke?

focus is on managing the bleed and reducing intracranial pressure caused by excess fluid -Aneurysm clipping or coiling → both reduce blood flow into the area

What information should be included in the teaching plan for a 76 year old patient after a physical?

report any new or excessive fatigue

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

risk for aspiration

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?

risk for falls

During this procedure: - The heart will be given a shock of electricity; it's done in synchronization w/ the R wave (controlled specific time) --> Hopefully this will cause the S A node to pick up function as it normally should (Done w/ patients who are alive + have a pulse)

synchronized cardioversion

_____________ is an enzyme specific to myocardial infarction

troponin

______________ ___________ refers to chest pain that can occur at rest. This is the most concerning form of angina. It's identified as the initial phase of ACS.

unstable angina

The nurse receives a report on a patient in the ICU with an SAH & clarifies that the date of the patient's initial bleed was 4 days before. The nurse needs this information to gauge the patient's risk of which complication of SAH?

vasospasm

Which dysrhythmia requires defibrillation?

ventricular fibrillation

Which of the following dysrhythmias requires defibrilation? A. atrial tachycardia B. Atrial fibrillation C. Ventricular tachycardia with a pulse D. Ventricular fibrillation

ventricular fibrillation

Which are true regarding the QRS wave?

- the QRS wave represents ventricular depolarization - wide QRS waves may indicate there is a block in the ventricles - QRS waves can take on many forms

What is the most likely procedure to determine the cause of severe chest pain in the patient newly admitted to the hospital?

coronary angiography

(diagnostic) antiarrythmatic (adenosine)

slows down the HR temporarily to allow for better visualization of the rhythm

antiarrythmatic (amiodarone)

slows the cardiac action potential --> slowing the HR (use for vtach, vfib, & afib)

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:

speech

What are some problems following a stroke?

- Further neurologic damage and decline - *Cerebral hemorrhage* - Cerebral edema - Sensory and motor disturbances - Hyponatremia (due to SIADH) - Aspiration

As the nurse, you should know that the following can cause rhythm disorders:

- electrolyte imbalances - myocardial hypertrophy - myocardial damage

The nurse looks at the electrocardiogram (ECG) monitor and sees a ventricular fibrillation rhythm. What action should the nurse take *first*?

1.) Determine unresponsiveness 2.) Assess for a pulse 3.) If no pulse, initiate CPR

A patient returning from heart catheterization has a slight increase in serum creatinine from 1.0 to 1.2 mg/dL and a blood urea nitrogen (BUN) of 30 mg/dL (previously 22 mg/dL). The nurse anticipates an order for which medication?

IV Fluids (Rationale: Contrast induced nephropathy is a potential complication of heart catheterization. It is evidenced by increased Cr/BUN and requires IV hydration to augment flow to the kidneys to flush out the dye.)

- This is chaotic ventricular activity on the EKG - Originate somewhere w/in the ventricles - the QRS wave will look wide and bizarre (b/c the impulse is coming from the ventricles) - Typically you won't see a P wave - Typically the QRS will be wider than 0.12 seconds (wider than 1-3 little boxes)

Premature ventricular contractions (PVC)

Inotropes (I.e. Digoxin)

helps increase the force of contraction in the heart

Anticoagulants (Wafarin, Heparin, etc.)

inhibits clot formation (use for afib)

Tom goes for an emergency CT scan to check for intracranial hemorrhage. No intracranial hemorrhage is noted on the scan. The healthcare provider is evaluating Tom's eligibility for plasminogen activator (rt-PA) to dissolve the blood clot that is present. What would make Tom ineligible for rt-PA?

He is taking warfarin (Coumadin) with an INR of 2.0 (this in combination w/ TPA increases risk for intracranial hemorrhage)

this is a procedure to treat hemorrhagic stroke; platinum coils are inserted into the aneurysm to reduce blood flow into that area

aneurysm coiling

Vasodilators (I.e. Nitroglycerin)

helps open up the coronary arteries to get more blood flow through them so that more oxygen gets to the myocardial tissue

The nurse suspects lower cranial nerve dysfunction in a patient with hemorrhagic stroke. Which diagnostic characteristic supports the nurse's suspicion?

impaired swallowing

the most significant risk with associated with I.V. TPA administration is?

intracranial bleeding

Cardiac Glycoside (Digoxin)

slows conduction, improves cardiac contractility (use for afib)

What is true of the electrical conduction system of the heart?

it's reflected in the waveforms on the electrocardiogram

evoked potential

looks at spontaneous activity the other looks at response to specific stimuli

this is a very invasive test; to obtain a sample of cerebrospinal fluid

lumbar puncture

The nurse is caring for a patient in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the patient's face and torso. The nurse would provide further instruction after seeing that the nurse aide:

moved the patient's head to clean behind the ears

The nurse is reviewing the laboratory results of her patient and notes that a cardiac troponin level was drawn. This test was drawn to determine which diagnosis?

myocardial infarction

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to:

reduce the chance of blood clot formation

Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply. a. Currently on Coumadin with an INR of 2.4 b. Major surgery in the last 14 days c. Systolic BP of 150 d. Platelet count of less than 100,000 e. Blood glucose of less than 50 mg/dL f. History of myocardial infarction 1 year ago g. Improving neurologic status

- Currently on Coumadin with an INR of 2.4 (INR can't be higher than 1.7) - Major surgery in the last 14 days - Platelet count of less than 100,000 - Blood glucose of less than 50 mg/dL - Improving neurological status

Key patient points for AF include which of the following?

- medications for HR control - bleeding precautions - s/s of AF with RVR - cardioversion

What is the function of cerebrospinal fluid (CSF)?

it cushions the brain & spinal cord

Calcium Channel Blocker (Diltiazem)

lowers blood pressure, slows conduction, increases blood flow through the coronaries (use for use for afib)

Which nursing diagnosis statements are matched with appropriate interventions for a client with a stroke? Select all that apply.

- Impaired swallowing: Provide a pureed diet. - Disturbed sensory perception: Stand on the client's unaffected side. - Impaired verbal communication: Repeat words and instructions.

What is the composition of the heart?

4 chambers with 4 valves that control flow through the heart & lungs through changes in pressure

In this procedure, a catheter with a small balloon on its tip is advanced under fluoroscopy through a suitable artery (usually the femoral artery or radial artery) to the area with athersclerotic plaque → The balloon is then inflated & deflated to open the lumen of the artery. Once the lumen is open, a stent may be advanced to the location to hold the artery open & maintain adequate blood flow. The procedure most commonly performed to relieve symptoms caused by athersclerotic changes in the coronary vessels. Pt receives monitored anesthesia ("conscious sedation")

Percutaneous Transluminal Coronary Angioplasty (PTCA)

signs of decreased cardiac output include:

- Palpation - Hypotension - Diaphoresis - Shortness of breath - Syncope

A client is following up after a visit to the emergency department where testing indicated that the client had suffered a transient ischemic attack. To prevent the occurrence of a stroke, which of the following should the nurse expect the neurologist to prescribe? Select all that apply.

- Smoking cessation - blood pressure control - weight loss - antiplatelet or anticoagulant therapy - alcohol intake modification

Tom is admitted to the intensive care unit after a stroke. The nurse receives the hand-off report from the emergency room nurse. Which priority assessments are appropriate for the nurse to perform?

- baseline neurological assessment - serial neurological assessment every 1-2 hours - Vital sign assessment every 1-2 hours

The nurse assesses a patient's blood pressure when lying and sitting, noting a significant drop in the blood pressure with the position change. What *priority* assessment should the nurse make *next*? A. Ask if the patient is dizzy B. Auscultate the lungs C. Check the radial pulse D. Ask if the patient is short of breath

Ask if the patient is dizzy

Anticholinergic (Atropine)

Increases SA node stimulus & increases conduction through the AV node (use for sinus bradycardia)

The nurse is preparing a patient for a coronary angiography. Which laboratory report is most concerning and should be reported to the provider? A. Hemoglobin of 13.6 B. Serum Creatinine of 2.6 C. C-Reactive protein 0.9 D. Triglycerides of 254

Serum Creatinine of 2.6 (Normal Creatinine: 0.5-1.2; in coronary angiography dye is used to visualize the vessels. This dye may cause impaired kidney function.)

Based on these findings, what heart waveform is this: Heart rate: will be <60 BPM Heart rhythm: Will be regular P waves: present and consistent PR interval: 0.12 - 0.20 seconds and constant QRS duration: 0.06 - 0.10 seconds and 1-3 small boxes

Sinus Bradycardia (Everything looks normal but its too slow)

The nurse recognizes that which patient is at greatest risk for death secondary to stroke? A. a 36 year old caucasian male B. a 45 year old asian male C. a 56 year old african american female D. a 62 year old hispanic female

a 56 year old african american female

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

a smoke detector

A nurse is caring for a patient with a diagnosis of MI. The patient calls the nurse because he is experiencing chest pain. The nurse administers an SL nitroglycerin tablet as prescribed. After 5 minutes, the chest pain is unrelieved by the nitroglycerin. The next nursing action is..

administer another nitroglycerin tablet

The nurse is caring for a client who is scheduled for a neurologic examination that uses a radiopaque dye. Before the test, the nurse assesses the allergy history of the client and find the client is allergic to seafood. What does the nurse relate the allergy to seafood as?

an allergy to iodine

this procedure is a treatment for hemorrhagic stroke; a device "clip" is placed around the aneurysm / vessel that's ballooned out to control bleeding into the aneurysm so that it doesn't further rupture

aneurysm clipping

_________________ medications are crucial for patients w/ atrial fibrillation. since the atria aren't contracting properly (just quivering) this can cause blood build up in the heart and can cause lethal clots to break loose & travel

anticoagulant

- No measurable electric activity - Without electrical impulses, the heart muscles can't squeeze or contract, they can't do anything - Heart rate: absent - Heart rhythm: absent - P waves: absent - PR interval: absent - QRS Complex: absent

asystole

A nurse finds the patient is unresponsive with no pulse or blood pressure. Which dysrhythmia does the nurse anticipate?

asystole

While assessing the electrocardiogram (ECG) report of a patient, the nurse observes that there is an absence of P waves and the QRS complex is narrow with irregular RR intervals. Which dysrhythmia is the patient experiencing?

atrial fibrillation

What is an important nursing action following a cardiac catheterization intervention?

bedrest to avoid stress on cannula insertion site

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control

this is the gold standard for diagnosing CAD Type of cardiac catheterization; they put a catheter in place & can determine the flow of the dye to see various blockages w/in the coronaries

coronary angiography

Assessing vision and smell is done during what part of the neurological assessment?

cranial nerve assessment

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

face the patient & establish eye contact

A patient with a neurological disorder has difficulty swallowing. The nurse should take special care with the patient's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the patient's diet allows for easy swallowing?si

help the patient sit upright when eating & feed slowly

While reviewing the diagnostic test reports of a patient suspected of having a basilar skull fracture, the primary healthcare provider finds blood is collecting between the skull and the dura mater. Which is the patient most likely experiencing?

hematoma

A patient with hypertension has what physical symptom?

increased resistance which may decrease cardiac output

Which of the following is an age-related change in the nervous system?

loss of neurons in the brain

The nurse receives the latest laboratory report. Which finding is most concerning for Tom? (stroke patient)

low sodium level (Close monitoring of serum electrolytes, particularly sodium, is necessary to identify disorders of salt and water imbalance resulting in hyponatremia, which places patients who have suffered a stroke at high risk for cerebral edema and neurological deterioration.)

Because of Tom's current condition (post-stroke), what action is a *priority* for the nurse? A. Begin nutritional supplement to prevent malnutrition B. Position to prevent aspiration C. Place antithrombotic devices to prevent clots D. Orient to person, place, & time

position to prevent aspiration

Vasopressor (Epinephrine)

produces vasoconstriction (use for vtach or vfib)

Statins (atorvostatin)

reduce total cholesterol (when used for long periods)

ACE inhibitors & ARBs

reduces blood pressure --> decreases workload & oxygen demands

A nurse is completing discharge teaching for the patient who has left-sided hemiparesis following a stroke. When investigating the patient's home environment, the nurse should focus on which nursing diagnosis?

risk for injury

Cerebral blood vessels may be opened using I.V. __________ which allows a blood clot to be dissolved at the site & restores blood flow to ischemic neuronal tissue.

rt-PA (recombinant tissue plasminogen activator) (TPA)

Beta Blockers (atenolol, mtoprolol, carvedilol, etc.)

slows down HR, decreases cardiac workload & oxygen consumption (use for afib)

__________ ____________ is chest pain or discomfort that is associated with physical activity.

stable angina

this is a procedure to treat an ischemic stroke; it involves utilizing cerebral angiogram & inserting a clot retrieval device w/ a stent to go in & pull out/retrieve the clot or thrombus from the vessel

thrombectomy

Cardiac biomarkers: _____________ & ____ - ____ levels rise when the heart sustains acute injury--can help differentiate between angina & MI pain.

troponin; CK-MB

- This is chaotic ventricular activity on the EKG - Quivering of the ventricles - Most serious type of waveform; the heart isn't actually beating - there's no cardiac output - A lot of pts who have cardiac arrest are experiencing this - no specific, definitive waveform - Heart rate: absent - Heart rhythm: Will be chaotic or irregular or undetectable - P waves: absent - PR interval: absent - QRS Complex: absent

ventricular fibrillation

- This is continuous ventricular activity on the EKG - The cardiac output drops drastically - Symptoms: chest pain, palpitations, syncope - May or more not have a pulse - Heart rate: >150 bpm - Heart rhythm: Will be variable - P waves: absent (b/c the ventricle is taking over and firing so rapidly) - QRS Complex: wide and bizarre

ventricular tachycardia

The nurse is evaluating an older adult for symptoms of cardiovascular problems. Which symptoms are most concerning?

- Mental status changes (indicate perfusion problems) - Agitation - Frequent falls (orthostatic hypotension) - Impaired kidney function (the kidneys are sensitive to perfusion changes)

The nurse is caring for a client who is receiving anticoagulants post-stroke. The nurse would implement which precautions for clients receiving anticoagulants?

- Monitoring for presence of bleeding - Implementing fall precautions - Monitoring for stroke-related weakness

What are some causes of dysrhythmias?

- decreased blood flow to the heart; (anything that causes a drop in perfusion to the heart muscle itself or the myocardium or the cardiac tissues) - Electrolyte disturbances - Problems w/ gas exchange - pts with respiratory problems can develop dysrhythmias (anything that affects oxygenation of the tissues can cause dysrhythmias) - Age - Older adults (oftentimes have a loss of normal pacemaker cells in the SA node → can lead to dysrhythmias) - Various medications - Various procedures (irritability of the heart)

As a nurse caring for a patient on a cardiac monitor you understand that which of the following steps are necessary to correctly identify the rhythm?

- determine the rate - determine the regularity - determine if there's a QRS for every P wave - determine if there's a P wave for every QRS

what are some clinical presentations of a stroke?

- face drooping; usually one side of face - arm weakness - speech difficulty; slurred

Signs or symptoms of symptomatic ventricular dysrhythmias include which of the following?

- hypotension - dizziness - shortness of breath

After an extended hospital and rehabilitation stay, Tom is ready for discharge. What discharge instructions should the nurse include for Tom and his wife? (stroke pt)

- identifying the symptoms of stroke - the importance of smoking cessation - compliance with medications - following up with provider as directed

What are some expected changes in the elderly related to neurologic function?

- motor changes - sensory changes - cognitive changes - vascular changes

A nurse is providing care for a patient newly diagnosed with heart disease. Which dietary, activity, or lifestyle modifications should be included in the plan of care?

- stopping smoking - limiting sedentary lifestyle - limiting alcohol intake

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? (Select all that apply).

- unequal pupils - pinpoint pupils - absence of pupillary response

The nurse understands that rhythms originating in the ventricle have which of the following characteristics?

- wide QRS complexes - only QRS complexes

The nurse is preparing to assist with a chemical stress test for an immobile patient. Which medication should the nurse prepare for administration?

Dobutamine (dobutamine is administered to a pt who can't perform the activity during a stress test. This medication mimics the effect of exercise on the heart & increases HR)

What are your responsibilities during the administration of Activase (tPA)?

During the infusion: - perform frequent neurological checks - assess vital signs (esp. BP) - inspect the infusion site for bleeding (every 15 minutes for the first hour, every 30 minutes for the next 2 hours, & then hourly for 24 hours) - Place pt on an EKG monitor - initiate bleeding precautions - keep the arm with the tPA infusion IV site still and straight.

a 68 year old male presents to the emergency department with complaints of crushing chest pain that radiates to the left shoulder. The patient is diagnosed with AMI. Admission orders include oxygen 2L via nasal cannula, blood work, chest x-ray, 12-lead EKG, & SL nitroglycerin. What should bee the nurse's *first* action?

apply oxygen