Med-Surg Chapter 31
A patient presents to the emergency department reporting chest pain. The nurse recalls that what
component of the patient's blood work is most clearly indicative of an acute myocardial infarction (MI)? -
CORRECT ANSWER-Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and
specificity that exceed those of other markers. CK enzymes are found in a variety of organs and tissues.
Myoglobin elevation is a sensitive indicator of very early myocardial injury but lacks specificity for MI.
CRP levels are not used to diagnose acute MI; rather, an increased level has been linked with the
presence of atherosclerosis.
A 78-year-old patient experiences cardiac sinus dysrhythmias. The nurse recalls that a reduction in which
type of cells leads to this condition? - CORRECT ANSWER-A reduction in the number of pacemaker cells
in the SA node may account for sinus dysrhythmias in the older adult patient. Reductions in the number
of conduction cells in the internodal tracts, bundle of His, and bundle branches contribute to the
development of atrial dysrhythmias and heart blocks
The nurse provides information to a group of nursing students about cardiac output. What information
should be included in the teaching? - CORRECT ANSWER-Cardiac output is determined by multiplying the
patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a
one-minute period. Electrical activity of the heart and blood pressure are not direct components of
cardiac output.
A nurse is preparing a patient for a transesophageal echocardiogram (TEE). What intervention does the
nurse perform for this patient? - CORRECT ANSWER-While preparing a patient for a TEE, the nurse asks
the patient to remove the dentures and places a bite block in the mouth. This is done because an
ultrasound transducer will need to be swallowed and passed through the esophagus. When preparing
the patient for a chest x-ray, the nurse provides lead shielding to areas that are exposed to radiation. If
the patient is undergoing ambulatory ECG, then the nurse asks him to carefully observe possible
symptoms of skin irritation. The patient will receive IV sedation; general anesthesia is not used for the
procedure.
What initiates the action potential in the heart? - CORRECT ANSWER-The sinoatrial node is called the
pacemaker of the heart, and it initiates the electrical impulse, or action potential, in the heart. By way of
the Purkinje fibers, the action potential moves through the walls of ventricles, but it is not initiated at
this point. The action potential moves from the atrioventricular node through the bundle of His and the
right and left bundle branches, but it is not initiated at these points.
, The patient is admitted to the hospital with reports of awakening during the night with sudden shortness
of breath. How should the nurse document this assessment finding? - CORRECT ANSWER-Paroxysmal
nocturnal dyspnea is defined as "attacks of shortness of breath, especially at night," which awaken the
patient. Orthopnea is the need to sleep in an upright position. Atrial fibrillation is a conduction
abnormality of the heart. Intermittent claudication affects the muscles of the leg during exercise related
to decreased oxygen delivery to the muscle.
The nurse is reviewing the function of the vascular system. What portion of the vascular system
exchanges cellular nutrients and metabolic end products? - CORRECT ANSWER-The exchange of cellular
nutrients and metabolic end products takes place through the thin-walled capillaries, which connect the
arterioles and the venules. Exchange of cellular nutrients and metabolic end products does not occur in
the arteriole, arteries, or veins.
The nurse teaches a caregiver about the plan of care for an elderly patient with orthostatic hypotension.
Which action by the caregiver will be most beneficial to the patient? - CORRECT ANSWER-Orthostatic
hypotension, or postural hypotension, is low blood pressure that occurs in patients when they stand up
from sitting or lying down. Patients with orthostatic hypotension are at an increased risk of falls.
Therefore the caregiver should monitor for falls in the patient. The caregiver can encourage laughter
therapy and treadmill exercises, but these measures are not as beneficial as monitoring the patient for
falls. The caregiver can take the patient out for recreation, but it is not as beneficial as monitoring the
patient's risk of falls.
The nurse does not have information about a patient's typical systolic blood pressure. The nurse is
preparing to take the patient's blood pressure using a sphygmomanometer and a stethoscope. What
action should the nurse take? - CORRECT ANSWER-While measuring blood pressure with the
sphygmomanometer and a stethoscope, if systolic blood pressure is not known, then the nurse should
palpate the brachial pulse and inflate the cuff until the pulse ceases. Using a larger-sized cuff cannot give
accurate results for blood pressure. Applying extra pressure can increase the pressure on the brachial
artery, which can give inaccurate test results. When a blood pressure measurement is scheduled, the
nurse should be timely and take the patient's blood pressure, using the appropriate technique.
The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. The nurse
identifies that what age-related change contributes to this finding? - CORRECT ANSWER-An age-related
change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because
of the increasing resistance to flow, pressure is increased within the blood vessel and hypertension
results. Valvular rigidity of aging causes murmurs and decreased adrenergic sensitivity slows the heart
rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
A patient presents to the emergency department reporting chest pain. The nurse recalls that what
component of the patient's blood work is most clearly indicative of an acute myocardial infarction (MI)? -
CORRECT ANSWER-Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and
specificity that exceed those of other markers. CK enzymes are found in a variety of organs and tissues.
Myoglobin elevation is a sensitive indicator of very early myocardial injury but lacks specificity for MI.
CRP levels are not used to diagnose acute MI; rather, an increased level has been linked with the
presence of atherosclerosis.
A 78-year-old patient experiences cardiac sinus dysrhythmias. The nurse recalls that a reduction in which
type of cells leads to this condition? - CORRECT ANSWER-A reduction in the number of pacemaker cells
in the SA node may account for sinus dysrhythmias in the older adult patient. Reductions in the number
of conduction cells in the internodal tracts, bundle of His, and bundle branches contribute to the
development of atrial dysrhythmias and heart blocks
The nurse provides information to a group of nursing students about cardiac output. What information
should be included in the teaching? - CORRECT ANSWER-Cardiac output is determined by multiplying the
patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a
one-minute period. Electrical activity of the heart and blood pressure are not direct components of
cardiac output.
A nurse is preparing a patient for a transesophageal echocardiogram (TEE). What intervention does the
nurse perform for this patient? - CORRECT ANSWER-While preparing a patient for a TEE, the nurse asks
the patient to remove the dentures and places a bite block in the mouth. This is done because an
ultrasound transducer will need to be swallowed and passed through the esophagus. When preparing
the patient for a chest x-ray, the nurse provides lead shielding to areas that are exposed to radiation. If
the patient is undergoing ambulatory ECG, then the nurse asks him to carefully observe possible
symptoms of skin irritation. The patient will receive IV sedation; general anesthesia is not used for the
procedure.
What initiates the action potential in the heart? - CORRECT ANSWER-The sinoatrial node is called the
pacemaker of the heart, and it initiates the electrical impulse, or action potential, in the heart. By way of
the Purkinje fibers, the action potential moves through the walls of ventricles, but it is not initiated at
this point. The action potential moves from the atrioventricular node through the bundle of His and the
right and left bundle branches, but it is not initiated at these points.
, The patient is admitted to the hospital with reports of awakening during the night with sudden shortness
of breath. How should the nurse document this assessment finding? - CORRECT ANSWER-Paroxysmal
nocturnal dyspnea is defined as "attacks of shortness of breath, especially at night," which awaken the
patient. Orthopnea is the need to sleep in an upright position. Atrial fibrillation is a conduction
abnormality of the heart. Intermittent claudication affects the muscles of the leg during exercise related
to decreased oxygen delivery to the muscle.
The nurse is reviewing the function of the vascular system. What portion of the vascular system
exchanges cellular nutrients and metabolic end products? - CORRECT ANSWER-The exchange of cellular
nutrients and metabolic end products takes place through the thin-walled capillaries, which connect the
arterioles and the venules. Exchange of cellular nutrients and metabolic end products does not occur in
the arteriole, arteries, or veins.
The nurse teaches a caregiver about the plan of care for an elderly patient with orthostatic hypotension.
Which action by the caregiver will be most beneficial to the patient? - CORRECT ANSWER-Orthostatic
hypotension, or postural hypotension, is low blood pressure that occurs in patients when they stand up
from sitting or lying down. Patients with orthostatic hypotension are at an increased risk of falls.
Therefore the caregiver should monitor for falls in the patient. The caregiver can encourage laughter
therapy and treadmill exercises, but these measures are not as beneficial as monitoring the patient for
falls. The caregiver can take the patient out for recreation, but it is not as beneficial as monitoring the
patient's risk of falls.
The nurse does not have information about a patient's typical systolic blood pressure. The nurse is
preparing to take the patient's blood pressure using a sphygmomanometer and a stethoscope. What
action should the nurse take? - CORRECT ANSWER-While measuring blood pressure with the
sphygmomanometer and a stethoscope, if systolic blood pressure is not known, then the nurse should
palpate the brachial pulse and inflate the cuff until the pulse ceases. Using a larger-sized cuff cannot give
accurate results for blood pressure. Applying extra pressure can increase the pressure on the brachial
artery, which can give inaccurate test results. When a blood pressure measurement is scheduled, the
nurse should be timely and take the patient's blood pressure, using the appropriate technique.
The blood pressure of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. The nurse
identifies that what age-related change contributes to this finding? - CORRECT ANSWER-An age-related
change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because
of the increasing resistance to flow, pressure is increased within the blood vessel and hypertension
results. Valvular rigidity of aging causes murmurs and decreased adrenergic sensitivity slows the heart
rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
