MED SURG 324 Exam 2- Final Review

1. When a female client tells the nurse, “I always get pains in my legs when walking,” the nurse would question her about a. amount of activity required to cause pain. The extent of the disease can be gauged by the distance the client is able to walk without pain, or the “claudication” distance. 2. For a client admitted to the hospital with chronic venous disease, the nurse’s assessment of the client’s legs would most likely reveal b. erythema. Initial skin changes noted with chronic venous disorders may include erythema (redness), followed in later stages by lipodermatosclerosis (brawny, thick, darkly pigmented skin). Decreased pulses would indicate an arterial disorder. 3. A client with venous disease is scheduled for impedance plethysmography. Before the study the nurse would explain that c. venous blood flow quality will be measured. Impedance plethysmography is used to measure venous blood volume changes in the extremities. Electrodes and a pressure cuff are attached to an extremity. As the pressure cuff is inflated and electrical resistance increases, the quality of venous blood flow can be demonstrated. This non-invasive test does not use dye, does not require walking on a treadmill, nor is it uncomfortable. 4. To determine if a client with complaints of pain after walking 5 blocks is experiencing intermittent claudication, the nurse would ask b. “Does pain go away when you rest?” Initially the pain of claudication is consistent and develops after a fixed amount of activity (e.g., walking around the block) and disappears within 1-2 minutes of resting. 5. When assessing a client with arterial insufficiency, the nurse would expect b. cool, pale skin. Hallmarks of arterial insufficiency include decreased or absent pulses; possible systolic bruit over involved arteries; muscular atrophy; thin, shiny, hairless skin; thick, ridged toenails; cool skin temperature; and ulcers on pressure points of feet. 6. During lower extremity inspection of a client with early chronic venous disease, the nurse would expect to find lOMoARcPSD| 2 d. pitting edema of the lower extremities. lOMoARcPSD| In more severe forms of chronic venous disorders, lower extremity edema is the usual initial complaint. Pitting edema may be seen at first, but as the edema becomes more chronic, scarring develops and the pitting disappears. 7. The nurse tests the capillary refill on a client’s lower extremity and notes that it takes 4 seconds for the color to return to baseline. It would be most important for the nurse to then check for b. other indicators of peripheral perfusion. Capillary refill time is an evaluation of peripheral perfusion and cardiac output. Normal is up to 3 seconds; 4 seconds is too slow, so the nurse should do further assessments of peripheral perfusion. Certainly constrictive clothing might be a problem, but that would be considered as part of the peripheral perfusion assessment. Venous ulceration is also part of an assessment of peripheral perfusion. 8. A client is taking garlic and hawthorn supplements. The nurse would ask further questions to elicit information on a possible history of b. hypertension. Herbal preparations that are used to self-treat hypertension include garlic, hawthorn, kudzu, nettle, onion, purslane, reishi mushrooms, and valerian. 9. A client has a 30 mm Hg difference in blood pressures in the arms. For subsequent blood pressure readings, the nurse should use c. the arm with the higher reading. difference in blood pressure of 20 mm Hg or more may indicate other medical problems. This discrepancy should be documented. The nurse should use the arm with the higher reading for all subsequent blood pressure measurements. 10. A client has a suspected DVT. The nurse would prepare the client to undergo a d. ultrasonic duplex scan. The ultrasonic duplex scanner is used to localize vascular obstruction, evaluate the degree of stenosis, and determine the presence or absence of vascular reflux. It is also the most sensitive and specific noninvasive test for detecting DVT. 1. During a physical exam, the nurse asks the client about medical problems that can impact vascular health, including (Select all that apply) a. diabetes. lOMoARcPSD| b. heart disease. c. stroke or TIA. e. prior frostbite. The nurse should specifically question the client about hypertension, diabetes, stroke, TIAs, changes in vision, phlebitis, history of blood clots, pulmonary emboli, varicose veins, or a previous history of frostbite. 2. Age-related changes the nurse incorporates into interpreting the physical assessment for vascular disorders include (Select all that apply) b. dorsalis pedis and posterior tibial pulses may be more difficult to palpate. c. peripheral vascular disease is common among the elderly. Atherosclerosis and peripheral vascular disease are both more common in the elderly population. Also, the dorsalis pedis and posterior tibial pulses may be more difficult to palpate. Blood pressure readings should not be inaccurate in older people, and dependent rubor is not seen in older clients in the absence of venous disorders. 1. When a client diagnosed with primary hypertension asks the nurse what causes this disease, the nurse’s best response would be “High blood pressure is caused by b. a number of factors, not just one cause.” Primary hypertension results from an array of genetic and environmental factors. 2. The nurse would explain to a client that the most common cause of secondary hypertension is a. chronic renal disease. Chronic renal disease, mainly chronic glomerulonephritis and renal artery stenosis, is the most common cause of secondary hypertension. 3. A hypertensive client, age 55, is slightly obese, has a sedentary lifestyle, and smokes half a pack of cigarettes daily. For the behavioral change with the most immediate and positive impact on his blood pressure, the nurse would focus on d. weight reduction measures. lOMoARcPSD| The relationship between obesity and blood pressure has been clearly established from numerous studies. For many people with hypertension whose body weight is more than 10% over ideal, weight reduction of as little as 10 pounds can lower blood pressure. Also weight loss may improve the response to medication. 4. In advising a hypertensive client who is reluctant to give up smoking, the nurse would state that nicotine from smoking c. increases blood pressure immediately for a short time. Although smoking has not been statistically linked to the development of hypertension, nicotine causes peripheral vasoconstriction, which raises the blood pressure for a short time. It also increases the risk of cardiovascular disease, stroke, and cancer. 5. When a client tells the nurse, “I heard that potassium supplements are effective in treating hypertension,” the nurse’s most appropriate reply would be as follows: c. “You can achieve the same benefits from low-sodium, high-potassium foods.” Reducing intake of high-sodium, low-potassium processed foods and increasing intake of low-sodium, high-potassium natural foods may be sufficient to achieve the potential benefits. Potassium supplements are also too costly and potentially too hazardous for routine use. 6. The nurse working with hypertensive clients knows that what factor is most important in order for the client’s treatment plan to be successful? c. Long-term compliance and adherence to therapy Long-term compliance and adherence has emerged as the most essential element in reducing morbidity and mortality associated with hypertension. Noncompliance is often due to client beliefs and values that conflict with the treatment plan. The plan must be mutually designed by health care providers and the client. Referrals to the interdisciplinary team are important, as is provider willingness to change medications if side effects are intolerable, but the single most important determinant of success is compliance and adherence. 7. In conducting a health interview with a hypertensive client, the nurse would ask the client about the presence of the typical manifestations of the disorder, which are c. none unless the hypertension is sustained. Typically the hypertensive client has no manifestations, which contributes to noncompliance. If the disorder goes undiagnosed, eventually the blood pressure will rise high enough to cause persistent headaches, fatigue, dizziness, palpitations, flushing, blurred or double vision, or epistaxis. 8. An African-American male is being started on medication for hypertension, and the physician has prescribed a beta blocker as first-line therapy. The most appropriate action by the nurse is to lOMoARcPSD| a. consult with the physician about the choice of drug. African Americans respond less well than other ethnic groups to beta-adrenergic blockers alone or as firstline treatment. The nurse should consult with the physician regarding the drug of choice. 9. An important action the nurse can take that will most likely increase client compliance with a sodium- and fat-restricted diet is to c. refer the client for a consultation with a registered dietitian. While all options have some place in working with hypertensive clients, the intervention that would have the most positive outcome would be referring the client to a dietitian. A highly individualized approach to dietary counseling is crucial and the dietitian can help the client plan, taking into account lifestyle; preferences; and ethnic, social, cultural, and financial influences. Some clients might like a cooking class, but this does not relieve the nurse from responsibilities related to diet teaching. Verbal education should be supplemented with written information. And education about complications is important, but simply telling the client about complications that might occur if the diet plan is not followed may be perceived as threatening. 10. For a client who wants to walk for exercise to reduce hypertension, the nurse would offer the guideline to walk b. briskly for 30 to 45 minutes most days of the week. Blood pressure can be reduced with moderate-intensity physical activity, such as a brisk walk (at about to 3 miles per hour) for 30 to 45 minutes most days of the week. 11. The nurse would consider referring a hypertensive client for step-down therapy when the blood pressure has been effectively controlled for at least c. 1 year. Reducing the number and amount of antihypertensive medications should be considered once a client’s blood pressure has been controlled effectively for at least 1 year. 12. The nurse providing care to a client being treated for a hypertensive emergency would monitor the blood pressure to ensure that it is slowly reduced during the therapy to prevent c. renal ischemia. It is essential to avoid excessive falls in blood pressure, which can precipitate cerebral, renal, or coronary ischemia. 13. For a hypertensive client who reports being “really fired up” about losing weight, the nurse would recognize the need for more education on hearing the client’s plan to c. use over-the-counter appetite suppressants. lOMoARcPSD| Clients should avoid over-the-counter (OTC) appetite suppressants because these preparations often contain ingredients that increase blood pressure. 14. To reduce the risk of orthostatic hypotension in a client prescribed a diuretic antihypertensive medication, the nurse would teach the client to a. increase fluid intake. A slow approach to standing and ambulation will reduce falls caused by orthostatic hypotension. 15. In an exercise program for weight reduction in a hypertensive client, the nurse would discourage the use of heavy weights because this may cause d. vasovagal response. Blood pressure rises, sometimes to very high levels, with the vasovagal response that occurs during intense isometric muscle contraction. Therefore using light weights is a better option for the client who wishes to include weight lifting in an exercise program. 1. The nurse would realize that outcomes for the diagnosis Ineffective Health Maintenance have been partly met when the client (Select all that apply) a. begins and maintains an exercise program. b. has ideas for incorporating medications into lifestyle. c. helps design a diet modification. e. shows the nurse the correct way to take the pulse. Many aspects of hypertension set the stage for noncompliance. The client must be an active part in designing and adhering to a plan for treatment. The correct options all show the client taking an active role in health maintenance. Option d is the option most likely associated with noncompliance because the client is not involved in making choices. 2. A client has two BP readings of and at a community screening event. The client smokes and has “some sort of eye disease like my grandma had” plus the client states, “I might have high sugar.” The most appropriate action by the nurse would be to (Select all that apply) lOMoARcPSD| c. inform the client about the high risk of developing hypertension. e. work with the client to identify risk factors and create a plan to address them. This client’s BP readings fall into the pre-hypertensive state. However, the client has several risk factors for target organ damage, including eye disease, which may be a retinopathy, and the possibility of diabetes. For this client, the risk of developing full-blown hypertension is twice the risk of someone whose readings are in the normal range. The nurse should work with the client to identify risk factors for hypertension and develop a plan to address them. Instead of returning to the screening the next day, the nurse should encourage the client to find a primary care provider or to see a primary care provider the client already knows. The client does not need urgent care. 1. The nurse teaches the client with intermittent claudication that the pain results from a. lactic and pyruvic acid buildup. Waste produced by lactic and pyruvic acid builds up quickly in oxygen-deprived muscles. 2. The nurse is caring for a client who is taking warfarin sodium (Coumadin) for a history of DVT. Before administering the medication, the nurse should assess the client’s b. PT, INR. The PT and INR are used to monitor therapy with warfarin. The PTT is used to guide heparin therapy. The Homan’s sign is not considered a very reliable assessment for DVT. The nurse administering either warfarin or heparin should know the results of the latest monitoring test before giving the client the drug in order to prevent possible complications if the level is too high. 3. The nurse would inform a client diagnosed with a 2-cm aneurysm that such aneurysms usually require d. semi-annual ultrasound. Aneurysms less the 4 cm are usually not surgically repaired, but instead are assessed twice a year by ultrasound to assess changes. Antihypertensive medications are prescribed if indicated. 4. When teaching foot care to a client with chronic arterial occlusive disease, the nurse would tell the client to avoid c. wearing canvas shoes. Instructions for clients with chronic arterial occlusive disease include (a) dust feet lightly with cornstarch if they sweat; (b) use clippers, not scissors, to cut toenails; (c) wear cotton socks for absorbency; and (d) avoid shoes that cause feet to perspire (e.g., canvas shoes, rubber boots). lOMoARcPSD| 5. In the exercise teaching plan for a client with chronic arterial occlusive disease, the nurse would caution the client to c. not walk if an open ulcer forms. Although exercise helps most clients with vascular disorders, some clients must not exercise, such as those with leg ulcers, pain at rest, cellulitis, deep vein thrombosis, or gangrene. 6. A client is scheduled to have a femoral-popliteal bypass with a synthetic graft. The nurse’s preoperative teaching would include information about preoperative a. antibiotics. Broad-spectrum antibiotics normally are prescribed for bypass clients preoperatively. Other common preoperative measures include administration of IV fluids, inserting a urinary catheter, and weighing the client. 7. A client is scheduled for a guillotine amputation and is crying, stating that he/she cannot live with “such an ugly leg.” The information from the nurse that would best help the client cope with the upcoming surgery is to tell the client that a. in another operation, the stump edge will be covered with a skin flap. The major indication for guillotine amputation is infection. The surgeon does not close the stump with a skin flap immediately but leaves it open, allowing the wound to drain freely. Antibiotics are used. Once the infection is completely eradicated, the client undergoes another surgery for stump closure. 8. .Before a client’s amputation, the nurse would counsel that the client may experience “phantom sensation” after surgery, which is a. the sensation that the leg is still there. Phantom sensations are caused by intact peripheral nerves proximal to the amputation site that carried messages between the brain and the now amputated part. These sensations are normal, and the client should be prepared for them. Phantom sensations often are felt immediately after surgery and gradually decrease over the next 2 years. “Phantom pain” is the sensation of pain from the same nerves. 9. For the first 24 hours after a client’s leg amputation, the nurse would place the stump b. elevated on a pillow. Edema is controlled by elevating the stump for the first 24 hours after surgery. After this time, the stump is placed flat to avoid hip contracture. Placing the stump below the level of the heart would impede venous flow and would increase edema. Placing the stump in external rotation would not help with edema control either. 10. To prevent skin breakdown of a client’s stump, the nurse teaches the client to lOMoARcPSD| c. wash the stump daily with mild soap, and then rinse and dry it. The nurse should wash the stump with a mild soap, then carefully rinse and dry it. Nothing is applied to the stump after it is bathed. Alcohol dries and cracks the skin. Woolen stump socks should be used. The prosthesis should be adjusted professionally if it causes discomfort. 11. The nurse would explain to a client that anticoagulant therapy is used in the treatment of thromboembolic disease because anticoagulants can c. inhibit the synthesis of clotting factors. Anticoagulant therapy is based on the premise that the initiation or extension of thrombi can be prevented by inhibiting the synthesis of clotting factors or by accelerating their inactivation. The anticoagulants heparin and warfarin do not induce thrombolysis but effectively prevent clot extension. 12. For a client with deep vein thrombosis (DVT), the nurse would include in the plan of nursing care the intervention of c. raising the foot of the bed 6 inches. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain in the client with DVT. Warm compresses can be comforting. Restricting fluids is not in the plan of care. 13. When a client complains of heaviness, aching, and itching of both legs for the past year, the nurse recognizes these complaints as being most suggestive of d. varicose veins. Clients with varicose veins complain of aching, a feeling of heaviness, itching, moderate swelling, and the often unsightly appearance of their legs. 14. An appropriate nursing diagnosis to guide self-care teaching for a client who has lymphedema is d. Risk for Infection. The client with lymphedema is at high risk for infection. 15. A client is scheduled for computed tomography (CT) of the abdomen because of a suspected abdominal aortic aneurysm. The nurse would assess this client for d. pulsating abdominal mass. The most common clinical manifestation is awareness of a pulsating mass in the abdomen, with or without pain, followed by abdominal pain and back pain. lOMoARcPSD| 16. For a client admitted with a history of chronic arterial insufficiency, the nurse would anticipate that physical assessment will reveal c. diminished pedal pulses. Objective data associated with arterial insufficiency include weak or absent peripheral pulses, dependent rubor, pallor with elevation, hypertrophied toenails, tissue atrophy, ulceration, and gangrene. 17. A female client with Raynaud’s disease asks the nurse why she is taking the same calcium channel blocker that her brother-in-law takes for a heart condition. The nurse’s response would include information that the calcium channel blocker will relieve some clinical manifestations of Raynaud’s disease by a. decreasing vasospasm. Calcium antagonists, such as nifedipine and verapamil, are the drugs of choice because they can decrease the frequency, duration, and intensity of vasospastic attacks. 18. A client is wearing sequential compression devices (SCDs) on the bilateral lower legs. Nursing care for these devices includes c. removing them twice a day to inspect skin. SCDs are used to prevent DVTs in high-risk clients. They need to be removed twice a day to allow perspiration to dry, for bathing, and to inspect the skin. The devices do not prevent a client from ambulating, although they need to be removed first. Many clients with SCDs will be on bed rest, however. There is no need to pre-wrap the legs or to turn the machine on and off. 19. The nurse explains to a client started on daily doses of Plavix after femoral bypass surgery that the purpose of this regimen is to a. decrease platelet aggregation. Medications that decrease platelet aggregation, such as aspirin and clopidogrel (Plavix), are used to increase the length of graft patency. 20. Immediately after a client’s revascularization surgery, the nurse would position the client with the d. operative leg totally flat. The operated leg should be kept straight to prevent occlusion of the vessels. The legs do not need to be separated with pillows. . The legs do not elevated or legs flexed with the knee gatch up because it would increase the risk of vessel occlusion. lOMoARcPSD| 21. A client is recovering from a leg amputation and is doing well. However, the nurse still cautions the client to b. call for help when getting out of bed. A client with an amputation has to learn to adapt to a new center of gravity, making transfers and ambulation potentially difficult. Until the client has completely adapted, he/she will need assistance with ambulation and transfers, even if just going from bed to chair, to prevent injury. Clients may even need assistance turning in bed until they adapt. 22. A client is scheduled for a below-the-knee amputation for treatment of chronic infected arterial ulcers and leg pain. The client seems calm, and even happy. The nurse should respond to this client based on understanding that the client c. may prefer an amputation to living with chronic pain. Assessment of the client’s attitude towards amputation is a vital preoperative assessment. While all options are certainly possible, some clients who suffer from chronic ischemia might prefer an amputation to living with pain and disability. This is an important quality of life value and should be assessed in order to plan holistic postoperative care. 23. The nurse working in the emergency department (ED) receives a telephone call from an individual who states a co-worker’s finger was amputated and asks what should be done. The nurse would tell the caller to immediately d. wrap the finger in a clean cloth and place it in a plastic bag, then on ice. The limb should be wrapped in a cloth and placed in a plastic bag and then on ice. The limb or digit should not come in contact with ice or water to prevent direct tissue damage. 24. When a client who has been taking warfarin (Coumadin) for 2 years tells the nurse of plans for oral surgery, the nurse would caution the client to d. stop taking Coumadin for 3 or 4 days before surgery. Warfarin has a long half-life of 3 to 4 days. Before surgery the client should cease taking Coumadin for that period. 25. The nurse reading the admission note for a client who has an arterial leg ulcer would anticipate that the ulcer will be characterized a. as being surrounded by atrophic tissue. Arterial leg ulcers are very painful, which distinguishes them from venous stasis ulcers. Arterial ulcers also have a sharp edge and a pale base and often are surrounded by atrophic tissue. lOMoARcPSD| 26. A client scheduled for a repair of an abdominal aortic aneurysm reports increased abdominal pain accompanied by new onset of intense back and flank pain. The priority action by the nurse would be to b. notify the physician immediately. Ruptured abdominal aortic aneurysm presents with a triad of manifestations, including abdominal pain combined with intense back and flank pain and possible scrotal pain, a pulsating abdominal mass or a rigid abdomen from the hemorrhage, and shock. Surgery is the only intervention for clients with a ruptured abdominal aortic aneurysm. 27. A client is scheduled for discharge to home after repair of an abdominal aortic aneurysm. As an acceptable activity during the first 6 to 12 weeks after surgery, the nurse would suggest c. walking. Activities that involve lifting heavy objects, usually more than 15 to 20 pounds, are not permitted for 6 to 12 weeks postoperatively. Activities that involve pushing, pulling, or straining may also be restricted. Driving may be restricted because of postoperative weakness and decreased response time. Walking is acceptable. Clients can resume sexual activity within 4-6 weeks; however, the risk of impotence should be discussed preoperatively with male clients. 28. A client who is overweight and smokes is newly diagnosed with thromboangiitis obliterans. The nurse’s teaching plan would focus on the highest priority of d. smoking cessation. The need for smoking cessation must be clearly and unequivocally conveyed to the client and family. 29. The nurse caring for a client with a traumatic arm amputation knows that care will be significantly different from other clients with amputations because d. there was no time beforehand to grieve the loss of the limb. In a planned amputation, the client has some time before the operation to grieve the upcoming loss of limb and to begin to incorporate this into a new self-identity. With traumatic amputations, the client has no warning and no time to grieve or to adjust beforehand. 30. When a client scheduled for insertion of a vena cava filter begins to sweat and becomes diaphoretic, the nurse would recognize these clinical manifestations as d. pulmonary embolism. These are cardinal manifestations of a pulmonary embolism, which requires immediate intervention. 31. In teaching the preoperative ambulatory surgery client scheduled for vein ligation and stripping, the nurse would include that immediately after surgery, the client will lOMoARcPSD| b. have legs wrapped with Ace bandages from heel to groin. Elastic compression bandages are applied from foot to groin. The legs should not be dependent. There will be some pain, which can be managed. 32. The nurse would inform a client with a venous ulcer that the client’s ulcer will be treated with the traditional protocol of d. pressure dressing left in place for 5 to 7 days. No topical treatment for venous ulcer is adequate without a compression dressing capable of sustaining pressure for at least 1 week. 33. For a hospitalized client who experienced a sudden arterial occlusion yesterday, the nurse would review the chart for a history of a. atrial fibrillation. Emboli, the most common cause of sudden ischemia, usually are of cardiac origin during periods of atrial fibrillation. 34. When a client with arterial insufficiency complains of being awakened at night by pain in the legs, the nurse would recommend that the client sleep b. in a recliner with feet dependent. Placing the legs in a dependent position provides increased gravitational blood supply 35. A client’s blood pressure is mm Hg in the brachial artery and mm Hg in the tibialis artery. After computing the A/B index, the nurse would record that the client’s index indicates a. a normal ratio. The ankle systolic pressure (A) is divided by the brachial pressure (B): . The normal A/B value is more than 1; the value is 0.5 in severe disease. 1. Important health promotion measures a nurse could teach a client in order to avoid another episode of DVT include (Select all that apply) a. avoiding prolonged sitting. c. maintaining an ideal body weight. lOMoARcPSD| d. remaining hydrated. Virchow’s triad describes the pathophysiologic conditions that have to exist in order to have a DVT. The components are venous stasis (caused by immobilization, prolonged travel, pregnancy, lack of use of the calf muscle pump, and heart disease, among others), hypercoagulability (caused by dehydration, blood dyscrasias, and oral contraceptives, among other things), and vascular injury (caused by fractures, trauma, dislocations, and chemical irritation, among other things). Two of the three factors must be present to form a DVT. 2. A client who is receiving IV heparin has a PTT reported by the lab as 101. Appropriate actions by the nurse include (Select all that apply) b. instituting safety precautions. c. notifying the physician. e. turning off the heparin IV. Bleeding can occur in the client receiving anticoagulant therapy. Heparin infusions are monitored with the PTT. Therapeutic levels are generally greater than 60, but at 1.5-2.5 times the baseline (normal is around 25-35). A PTT of 101 is a critical result and the nurse should (1) stop the heparin infusion, (2) notify the physician, and (3) place the client on bleeding precautions. A small injury to the client can cause bleeding. The client can also have spontaneous bleeding. The nurse should observe the client for bleeding, as evidenced by frank hemorrhage, changes in mental status, pink-tinged or frank blood in the urine, dark or tarry stools, and bleeding after brushing the teeth. 3. A nurse suspects a client has an acute arterial occlusion. Early assessment findings that would confirm her suspicion include (Select all that apply) a. pain. b. pallor. e. pulselessness. Early signs are pain, pallor, and pulselessness. Paresthesias indicate advanced damage. Paralysis indicates irreversible damage. 1. The nurse establishing teaching priorities for a community health program would rank cardiovascular disease as a cause of death as a. first. lOMoARcPSD| Cardiovascular disease is the leading cause of illness and death in the United States, affecting more than one in five people. 2. The nurse would explain that angina pain usually differs from the pain of a myocardial infarction (MI) in that angina pain c. lasts less than 15 minutes. The pain of angina is usually short-lived, lasting less than 15 minutes; does not radiate; can be relieved by rest, with or without vasodilators; and is not associated with palpitations. Stable angina is relieved with rest or nitrates. Both types of pain may radiate. Both types of pain may occur with palpitations, and in women, palpitations may occur instead of chest pain. 3. The nurse assessing an American Indian client would assess for other cardiovascular risk factors because the prevalence of heart disease in this group is c. the second highest of all ethnic groups in America. The ethnic group with the highest prevalence of CVD is native Hawaiians, followed by American Indians, whites, and blacks. 4. A client’s record contains a notation that the client is orthopneic. Which question by the nurse would obtain the most useful information? c. “How many pillows do you need to sleep on?” Orthopnea is difficulty in breathing except when sitting erect or when standing. When the person lies down there is an increase in pulmonary venous and capillary pressure in the lungs, leading to cough and dyspnea. Orthopnea generally indicates a serious cardiac problem, and quantifying the distress helps the nurse gauge the degree the client is compromised. People with orthopnea try various things to be able to sleep including sleeping in recliners and increasing the number of pillows used. 5. The nurse would explain to a client who reports being frequently short of breath that the most common form of dyspnea associated with cardiac disorders is a. exertional dyspnea. The most frequently reported dyspnea in clients with cardiovascular disorders is that associated with exertion. 6. The nurse performing an admission assessment of a 36-year-old client with cardiac valve disease would know the most relevant fact is that the client has a. a childhood history of rheumatic fever. A childhood history of rheumatic fever is associated with structural mitral valve disease. lOMoARcPSD| 7. The finding during a routine assessment that would most strongly suggest to the nurse the presence of serious heart or lung disease is c. duskiness of the buccal mucosa. The nurse should observe the skin and mucous membranes for abnormalities such as central or peripheral cyanosis. The presence of a bluish tinge or duskiness is indicative of central cyanosis. Central cyanosis implies serious heart or lung disease because impaired physiologic functioning is leading to decreased arterial oxygen saturation. Peripheral cyanosis, seen in lips, ear lobes, and nail beds, suggests peripheral vasoconstriction. 8. During the physical examination of a client, the nurse checks the client for neck vein distention. To perform this assessment properly, the client should be positioned c. lying supine with head of bed elevated 15-30 degrees. The distensibility of the neck veins reflects the pressure and volume changes within the right atrium in most people. Evaluate neck vein distention by having the client lay supine with the head of bed elevated 15-30 degrees (for most people), turn the client’s head slightly away from you, loosen or remove clothing that compresses the neck or upper thorax. Use oblique lighting and observe both sides of the neck. Measure the highest point of venous pulsation. 9. The nurse evaluating the head and neck of a client would assess the carotid arteries by b. auscultating the arteries with the diaphragm of the stethoscope. Carotid artery examination indicates the adequacy of stroke volume and the patency of the arteries. Using the fingertips, the nurse gently palpates the carotid arteries one side at a time. The nurse notes whether a bruit is present by listening to the carotid arteries with the diaphragm of the stethoscope. 10. The nurse palpating the precordium of a 73-year-old client for the point of maximal intensity (PMI) would place the hands c. at the fifth intercostal space, medial to the midclavicular line. Also called the point of maximal impulse, the PMI, or apical impulse, is usually seen at the apex. The PMI is associated with left ventricular contraction and should appear at the fifth intercostal space medial to the left midclavicular line. 11. The nurse auscultating heart sounds would recognize that the normal closure of the mitral and tricuspid valves creates the c. S1 heart sound. The first heart sound (S1) is linked to closure of the mitral and tricuspid valves. 12. The nurse is attempting to identify the timing of a murmur detected in a client. The additional activity necessary to make this assessment would be lOMoARcPSD| d. identification of S1 and S2. It is imperative to identify S1 and S2 heart sounds to determine the place and duration. The murmur is then described as occurring in early, mid, or late systole or diastole. 13. In doing a breath sound assessment on a client who has left ventricular failure, the nurse would anticipates the finding of b. crackles in the lung bases. Crackles frequently signal left ventricular failure and usually occur just after the onset of an S3 gallop. As pulmonary capillary pressure rises from the backward pressure of left ventricular failure, fluid shifts into the intra-alveolar spaces, and crackles can be auscultated. 14. The nurse would explain to a client that the isoenzyme most useful in the diagnosis of myocardial infarction is d. troponin The enzymes most often used to detect MI are myoglobin, creatine kinase, and troponin. Myoglobin is released rapidly, but its short half-life makes it less useful in clients who present several hours after an infarction. CK-MB is specific for cardiac muscle. Troponin is as sensitive as CK-MB but is more specific and is more useful in excluding myocardial infarction when CK-MB is falsely elevated. CK-MM is a measure of skeletal muscle enzymes. 15. A client who had a myocardial infarction has an elevated blood glucose level and is getting insulin. The client asks why this is occurring because the client does not have diabetes. The best answer by the nurse is c. “The stress of your heart attack makes blood sugar rise.” The stress of the illness and damage to the myocardium often raise blood glucose level. If the nurse does not know the answer to a question, he/she should be find out and tell the client. 16. The nurse would explain to a client that an electrical representation of the cardiac cycle shows that a normal PR interval is between 0.12 second and d. 0.20 second. The normal PR interval is between 0.12 and 0.20 second, averaging 0.16 second. 17. A nurse understands that the basic premise of an ECG is that it shows a. altered electrical activity from pathologic changes. lOMoARcPSD| The ECG provides multidirectional examination of electrical events in the heart. Myocardial infarction causes tissue damage/death, which alters the electrical activity in predictable patterns. This altered electrical activity shows up on the ECG as abnormalities that help diagnose the occurrence and location of an infarction. 18. In evaluating a client’s ECG tracing, the nurse notes three small squares between the upstroke and downstroke of the QRS wave. The nurse would record the QRS interval as d. 0.12 second. Each small square on ECG tracing paper is 0.04 second, making the QRS interval in this client 0.12 second. 19. The nurse would explain to a client that the benefit of a Holter monitor over an ECG is that the Holter monitor b. is a continuous recording, often for 24 hours. The Holter monitor is a recording of a continuous ECG tracing. It is usually placed for 24 hours on an outpatient basis. Neither it nor an ECG require hospitalization. It is not less expensive nor does it provide a view of the coronary arteries. 20. The nurse would explain to a client that an exercise ECG is useful as one means of detecting b. coronary artery disease. An exercise ECG, referred to as a “stress test,” is helpful as an adjunctive diagnostic study for coronary artery disease, although it can produce false-positive findings in some clients, especially women. 21. In developing a standard teaching plan for the outpatient unit where stress testing is performed, the nurse would include information that the a. test may cause chest pain and may need to be stopped. The nurse should include a warning that this test may trigger chest pain and dyspnea. The test will be terminated early if the client shows (1) signs of cardiac intolerance, (2) ECG changes, (3) wall motion abnormalities or reversible perfusion defects seen on a concurrent echocardiogram. 22. To best facilitate a client’s understanding of an electrophysiologic study, the nurse would explain that this study will a. enable the physician to reproduce dysrhythmias and evaluate antidysrhythmic drugs. The purpose of the electrophysiologic study is to reproduce any dysrhythmia so that its origin may be isolated. Antidysrhythmic drugs may be administered during the study to evaluate their effect. lOMoARcPSD| 23. The critical piece of information related to the client’s myocardium that is obtained through a PET scan is b. myocardial viability. A PET scan demonstrates cellular metabolism via tracing glucose uptake and use. A client with decreased perfusion but normal glucose uptake has viable, but hibernating, myocardium. This information is used to choose candidates for revascularization. 24. A nurse explains the purpose of echocardiography to a client as a. a picture of both the structures in the heart and their motion. The echocardiogram essentially provides a continuous picture of the beating heart. transesophageal echocardiogram: an image of the heart and great vessels from a posterior view. right heart catheterization: hemodynamic pressure monitoring and analysis of oxygenation. CT scan using the pulmonary embolus protocol: the use of extra contrast dye to visualize pulmonary arteries. 25. A client has an elevated level of C-reactive protein. The nurse explains the significance of this finding as a. an indication of an inflammatory process like atherosclerosis. Atherosclerosis is in part a chronic, low-grade inflammatory process. Elevation of the C-reactive protein occurs in inflammation and has been linked to future cardiovascular risks. 26. The nurse planning a secondary prevention program for risk reduction would focus on clients who a. already have a diagnosis of cardiovascular disease. Risk factor modification in clients who do not yet have cardiovascular disease is primary prevention. Risk factor modification in clients who do have cardiovascular disease is considered secondary prevention. 27. The nurse providing education at a community forum on obesity and heart disease informs the group that “obese” is described as a body mass index greater than d. 30 kg/m2. For adults, an overweight body mass index (BMI) is 25-29.9 kg/m2. Obesity is defined as a BMI of greater than 30 kg/m2. 28. A client is taking the herbal supplements bilberry and evening primrose. The nurse would specifically question the client about manifestations of lOMoARcPSD| a. angina. Bilberry and evening primrose are among several anti-anginal herbal supplements. 1. Important information the nurse should collect when a client complains of chest pain includes (Select all that apply) a. aggravating and relieving factors. b. associated manifestations. c. characteristics. d. duration. e. location. All components are important to assess when the client complains of chest pain. 2. Women with heart disease often present with which symptom? (Select all that apply.) b. Dyspnea c. Fatigue d. Nausea e. Palpitations Women can experience chest pain, but most often present with complaints of dyspnea, nausea and vomiting, fatigue, neck or jaw pain, back pain, dizziness, or palpitations. This is a contributing factor to women’s higher death rate from heart disease. 1. The physician has expressed concern about the development of rheumatic fever in a client with a throat infection. The nurse would explain to the client that the organism causing the infection is b. beta-hemolytic streptococcus. lOMoARcPSD| Infections caused by beta-hemolytic streptococci are precursors to rheumatic fever. 2. The nurse teaching a class on long-term effects of rheumatic fever would stress that the most common problem following bouts of rheumatic fever is d. valvular disorders. Valvular disorders are the most frequent complication after episodes of rheumatic fever. 3. When performing cardiac auscultation on a client with mitral valve prolapse, the nurse would anticipate hearing a c. midsystolic click. In a client with mitral valve prolapse, physical examination may reveal a regurgitant murmur, or a midsystolic click on auscultation. 4. The nurse would explain to a client that the catabolism related to the hypermetabolic state caused by the client’s rheumatic fever can be avoided by eating a a. high-carbohydrate, high-protein diet. An enriched diet high in carbohydrates and protein will answer the body’s nutritional needs in the client with a hypermetabolic state induced by inflammatory processes and temperature elevation. 5. The nurse would recognize that splinter hemorrhages in the nails, painful swollen nodules on the fingertips, and splenomegaly indicate a. infective endocarditis. Clinical manifestations of embolization caused by infective endocarditis include splinter hemorrhages, Osler’s nodes, finger clubbing, Janeway’s lesions, ocular signs, and splenomegaly. 6. To help relieve the discomfort of a client with pericarditis who is experiencing pain, the nurse would position the client d. sitting upright. The most characteristic subjective clinical manifestation of pericarditis is chest pain. Sitting up often relieves the pain. 7. In the discharge teaching plan of a client with chronic myocarditis, the nurse would include the suggestion that lOMoARcPSD| b. family members should learn cardiopulmonary resuscitation (CPR). The client should be taught about self-monitoring pertinent to heart rhythm, rate, and palpitations, and family members should be encouraged to take CPR training in case of an emergency. 8. The nurse caring for a client with acute infective endocarditis would frequently assess for a. cardiac murmurs. The nurse should auscultate every 8 hours for heart murmurs and assess for rapid pulse rate, easy fatigability, dyspnea, restlessness, manifestations of heart failure, and embolic manifestations in the client with infective endocarditis. 9. The change in vital signs that would most strongly suggest cardiac tamponade to the nurse is c. narrowing pulse pressure. Although muffled heart sounds indicate accumulation of fluid around the heart, narrowing pulse pressure signals cardiac tamponade. 10. When a client is hospitalized with dilated cardiomyopathy, the nurse would examine the client’s record for the characteristic history of a. long-term alcohol abuse. Risk of cardiomyopathy increases in clients who chronically ingest excessive amounts of alcohol (toxins). Other common causes are viral myocarditis, infections, metabolic problems, pregnancy, neuromuscular disorder, connective tissue disorders, and genetic predisposition. Some forms are idiopathic. 11. The nurse auscultating heart sounds notes that a client has an opening snap and a low- pitched, rumbling murmur over the apex. This assessment would indicate b. mitral stenosis. The murmur characteristic of mitral stenosis is low pitched and rumbling and is preceded by an opening snap caused by the built-up pressure. It is heard best over the apex. The murmur of aortic stenosis is systolic and may be associated with a diminished second heart sound and early ejection click. The murmur of pulmonic prolapse is a crescendo-decrescendo, high-pitched diastolic blowing sound. Tricuspid regurgitation produces a holosystolic murmur heard best along the left sternal border. 12. A client with mitral stenosis tells the nurse that she will not seek treatment for this disorder because she “doesn’t really feel that bad.” The nurse’s best response would be that untreated mitral stenosis can result in a. creation of small emboli. lOMoARcPSD| Untreated mitral stenosis can progress from mild disability to severe disability in about 3 years. Ineffective atrial contractions allow some stagnation of blood in the left atrium and encourage the formation of mural thrombi. These thrombi easily break away and travel as small emboli in the arterial system, causing tissue infarction. Untreated, a client can progress from asymptomatic to having a severe disability in less than 10 years. 13. In caring for a client considering mechanical mitral valve replacement, the essential determination for the nurse (and physician) to make would be whether the client can or will a. comply with the lifelong requirement for anticoagulant therapy. Clients with mechanical valves require continuous anticoagulation therapy for the remainder of their lives. A client who cannot tolerate or cooperate with this regimen might be considered for a tissue valve. 14. For a client who has undergone a tissue valve replacement, the most appropriate anticipatory guidance provided by the nurse would be b. follow-up is important, since most tissue valves eventually need replacement. The mechanical valves are very durable but require anticoagulant therapy; the tissue valves may not require anticoagulant therapy but are less durable. Almost every client with a tissue valve will require replacement. 15. In counseling a client who is considering a heart transplant, the nurse would know the client has an accurate perception of this treatment option when the client says c. “The survival rate for patients having a heart transplant is about 80%.” Cardiac transplantation is now a standard and effective treatment for clients with end-stage cardiac disease. Currently, 84% of heart transplant patients survive 1 year, and 77% survive 3 years. Selection criteria include age less than 65 years. 16. The nurse would stress in a discharge teaching plan for a client recovering from endocarditis that to avoid further complication, the client should d. notify the physician when invasive dental procedures are planned. Clients recovering from endocarditis should take special precaution by contacting the physician for extra antibiotic coverage when invasive dental procedures are scheduled. 17. For a client waiting for a heart transplant who has been fitted with a left ventricular assist device (LVAD), the nurse would explain that the purpose of this device is to b. extract blood from the left ventricle and propel it into the systemic circulation. lOMoARcPSD| The LVAD helps support the dangerously impaired heart while the client is waiting for a donor heart by extracting blood from the left ventricle and propelling it into the systemic circulation. 18. A client has dilated cardiomyopathy and is angry and irritable to all the nursing staff. When planning care for this client, which nursing diagnoses would be the priority to address this problem? b. Hopelessness Clients with dilated cardiomyopathy require strong psychological support. The chronic and progressive nature of this illness deplete coping resources, leaving many clients feeling helpless, hopeless, and frustrated. As the disease progresses, they may have feelings of inadequacy and poor self-esteem. They may become angry, irritable, withdrawn, or overly dependent. 19. To encourage a client recovering from endocarditis, the nurse would stress that new guidelines for home care are less restrictive than in the past and the client no longer needs to a. observe complete bed rest. The client recovering from endocarditis is no longer restricted to bed rest unless there is evidence of fever or heart damage. Antibiotic therapy, limited activity, and precautions against emboli are still part of the recovery protocol. 20. Examining the electrocardiogram strips of a client with mitral stenosis, the nurse would recognize the characteristic dysrhythmia of a. atrial fibrillation. Atrial fibrillation is a dysrhythmia that frequently develops as a result of mitral stenosis. 21. When the client with rheumatic fever becomes irritable and impatient with the restrictions of the disease, the home health nurse would remind the client that manifestations of rheumatic fever usually abate in about a. 3 months. The manifestations of rheumatic fever usually abate within 3 months of onset. 1. The nurse would assess that the individual most at risk for death from coronary heart disease (CHD) is a d. 62-year-old African American woman.