A 35-year-old male was knifed in the street fight, admitted through the ED, and is now in the ICU. An
assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm
H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing
these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the
following conditions?
Cardiac tamponade
A 48 y/o man presents to ED complaining of severe substernal CP radiating down left arm. He is admitted
to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment
activity is a priority on admission to the CCU?
a. begin ECG monitoring
b. obtain information about family hx of heart disease
c. ausculate lung fields
d. determine if pt smokes
A
,A 54y/o man has just been diagnosed with small cell lung cancer. The pt asks the nurse why the doctor is
not offering surgery as a treatment for his cancer. What fact about lung cancer tx should inform the nurses
response?
a. the cells in small cell cancer of the lung are not large enough to visualize in surgery
b. small cell lung cancer is self-limiting in many pt's and surgery should be delayed
c. pt's w/ small cell lung cancer are not normally stable enough to survive surgery
d. small cell cancer of the lung grows rapidly and metastasizes early and extensively
D
A 56-year-old male patient has been admitted to the cardiac unit with exacerbation of heart failure
symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart
failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which
of the following nursing intervention is most appropriate in this situation?
Admin stool softeners as ordered
,56 y/o male pt has been admitted to the cardiac unit w exacerbations of HF sx. The nurse has given him a
nursing dx of ↓CO r/t HF as evidenced by poor ejection fraction, weakness, edema, & ↓UO. Which of the
following nursing interventions is most appropriate in this situation?
a. administer stool softeners as ordered
b. administer IV fluid boluses to increase urine output
c. maintain pt in Trendelenburg position while in bed
d. increase activity by encouraging ambulation
C
AAA symptoms of rupture
warmth in abdomen or back
Palpable mass but do not palpate it
Decreasing BP
Increasing HR
, Abdominal Aortic Aneurysm (AAA)
A condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the
vessel, causing it to bulge.
• Abnormal fast heart rate of more than 100beats per minute:
.- Compensatory response to increased demandfor cardiac output or reduced stroke volume.
- Sympathetic activation
- Decreased parasympathetic activity
Greater than 100 but less than 120 BPM
Sinus Tachycardia
ACCUMULATION OF PERICARDIALFLUID WITHOUT CLINICAL
Cardiac tampanode
assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm
H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing
these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the
following conditions?
Cardiac tamponade
A 48 y/o man presents to ED complaining of severe substernal CP radiating down left arm. He is admitted
to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment
activity is a priority on admission to the CCU?
a. begin ECG monitoring
b. obtain information about family hx of heart disease
c. ausculate lung fields
d. determine if pt smokes
A
,A 54y/o man has just been diagnosed with small cell lung cancer. The pt asks the nurse why the doctor is
not offering surgery as a treatment for his cancer. What fact about lung cancer tx should inform the nurses
response?
a. the cells in small cell cancer of the lung are not large enough to visualize in surgery
b. small cell lung cancer is self-limiting in many pt's and surgery should be delayed
c. pt's w/ small cell lung cancer are not normally stable enough to survive surgery
d. small cell cancer of the lung grows rapidly and metastasizes early and extensively
D
A 56-year-old male patient has been admitted to the cardiac unit with exacerbation of heart failure
symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart
failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which
of the following nursing intervention is most appropriate in this situation?
Admin stool softeners as ordered
,56 y/o male pt has been admitted to the cardiac unit w exacerbations of HF sx. The nurse has given him a
nursing dx of ↓CO r/t HF as evidenced by poor ejection fraction, weakness, edema, & ↓UO. Which of the
following nursing interventions is most appropriate in this situation?
a. administer stool softeners as ordered
b. administer IV fluid boluses to increase urine output
c. maintain pt in Trendelenburg position while in bed
d. increase activity by encouraging ambulation
C
AAA symptoms of rupture
warmth in abdomen or back
Palpable mass but do not palpate it
Decreasing BP
Increasing HR
, Abdominal Aortic Aneurysm (AAA)
A condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the
vessel, causing it to bulge.
• Abnormal fast heart rate of more than 100beats per minute:
.- Compensatory response to increased demandfor cardiac output or reduced stroke volume.
- Sympathetic activation
- Decreased parasympathetic activity
Greater than 100 but less than 120 BPM
Sinus Tachycardia
ACCUMULATION OF PERICARDIALFLUID WITHOUT CLINICAL
Cardiac tampanode
