Med/Surg Exam #1 questions with correct answers

A patient is seen at the clinic for a routine physical examination. After the patient is assessed for evidence of peripheral vascular disease, the nurse explains that which of the following tests is typically used to assist in the diagnosis? 1. Allen's Test 2. Ankle brachial pressure index. 3. Cardiac Stress Test. 4. Echocardiogram 2. Ankle brachial pressure index. Rationale: The ankle brachial index (ABI) is the blood pressure ratio between the lower legs and the arms. Blood pressure in the legs is normally higher than the arms, and abnormalities indicate narrowing of the arteries. Clinical findings that may suggest the presence of PVD includes a history of angina with activity, intermittent claudication, and abnormal (weak or absent) pedal pulses. The formula for ABI is the systolic blood pressure of the ankle (measured at the dorsalis pedis or posterior tibial arteries) divided by the systolic pressure in the arms. It is measured on both sides. A ratio of 1.0 indicates peripheral vascular disease. Incorrect: Allen's test is used to assess blood supply to the hand.Incorrect: Cardiac stress tests are used to measure the heart's ability to respond to stress. Incorrect: ECG evaluates the structure and function of the heart muscle, but does not tell if there is peripheral vascular disease present. A patient has been diagnosed with left-sided congestive heart failure, and is confused about the return of oxygenated blood from the lungs. To clarify the confusion, the nurse explains all chambers of the heart dealing with blood circulation. The nurse is correct when she tells the client: 1. A muscular space called the pericardial space separates the chambers of the right side from the left side. 2. Blood flows into the left ventricle which pumps it out against high resistance into the systemic circulation. 3. The blood moves to the left ventricle, which pumps blood into the lungs. 3. The heart consists of 5 chambers. 4. The left atrium receives oxygenated blood from the lungs. 5. The right atrium receives deoxygenated blood from the body tissues. 2. Blood flows into the left ventricle which pumps it out against high resistance into the systemic circulation. 3. The blood moves to the left ventricle, which pumps blood into the lungs. 4. The left atrium receives oxygenated blood from the lungs. 5. The right atrium receives deoxygenated blood from the body tissues. Rationale: Heart consists of 4 chambers: 2 atria and 2 ventricles. The right and left chambers are separated down the middle of the heart by a septum, like a wall. The right atrium receives deoxygenated from the body, and the blood then moves down into the right ventricle, which pumps it to the lungs with low resistance. The left atrium then receives oxygenated blood from the lungs, and that blood moves down into the left ventricle. The left ventricle, which is the most muscular chamber, pumps oxygen rich blood into the systemic circulation. A patient recovering from a MI has been in bed for 6 days. The patient now complains of calf pain. The nurse should first: 1. Administer pain medication as ordered. 2. Assess the calf for redness warmth and swelling. 3. Massage the calf to relieve the muscle cramp. Observe the patient walking. 2. Assess the calf for redness warmth and swelling. Rationale: Due to the time spend in bed and inactive, the patient is at high risk for the development of a DVT. Pain in the calf, redness or heat, and swelling in the affected extremity are signs of a DVT. Diagnostic tests that help diagnose a DVT include a D-dimer test to confirm the presence of fibrin degradation in products from a clot, venous ultrasound, venography to visualize the clot with contrast, or less commonly MRI or CT. The nurse is caring for a patient in the early stages of heart failure. The family is curious as to how the body adapts to heart failure. The nurse knows that during the early stages of heart failure, which specific compensatory mechanisms occur? 1. Decreased cardiac output inhibits the release of ADH by the pituitary gland. 2. Hypotension stimulates the baroreceptors to increase sympathetic activity. 3. Hypotension stimulates the baroreceptors to decrease sympathetic activity. 4. Impaired renal perfusion inhibits aldosterone release. 2. Hypotension stimulates the baroreceptors to increase sympathetic activity. Rationale: As arterial blood pressure falls, the baroreceptors of the carotid and aorta are stimulated. This causes a sympathetic release of catecholamines, resulting in vasoconstriction and an increased heart rate to compensate. The compensatory mechanism increases peripheral vascular resistance and also the work load of the heart. This can worsen heart failure if not treated. Incorrect: Decreased cardiac output will INCREASE ADH release, leading to fluid retention. Incorrect: Impaired renal perfusion will stimulate aldosterone release leading to addition fluid and sodium retention. The nurse is assessing a patient with atrial fibrillation and a rapid ventricular rate. The nurse would expect to see: 1. Distended juglar veins. 2. Dizziness and hypotension. 3. Hypertension and headache. 4. Lower extremity pain. 2. Dizziness and hypotension. Rationale: Atrial fibrillation is any arrhythmia in which the atria initiate rapid, ineffective contractions that are not synchronized with ventricular contractions. This patient has uncontrolled atrial fibrillation, which can result in a low cardiac output. Signs and symptoms of a low cardiac output include hypotension, dizziness, weakness, fatigue, shortness of breath, and syncope. The nurse is caring for a patient scheduled to undergo a mitral valve replacement. The nurse should monitor for which complication of mitral stenosis? 1. Left-sided heart failure. 2. MI 3. Pulmonary Hypertension 4. Respiratory Alkalosis 3. Pulmonary Hypertension Rationale: Mitral stenosis impeded blood flow from the left atrium to the left ventricle of the heart. This creates increased pulmonary vascular resistance, causing pulmonary hypertension. Other complications of mitral stenosis include edema, right-sided heart failure, and reduced cardiac output. A nurse is assessing a patient who has longstanding hypertension. The nurse know that complications of hypertension are possibly arising when which of the following signs are noted? 1. Dyspnea during activity 2. Fatigability 3. Recurrent episodes of severe headache. 4. Trace proteins in the urinalysis. 4. Trace proteins in the urinalysis. Proteinuria and albuminuria are early indications of renal injury, a serious complication that can be caused by hypertension. High pressures damage the kidney's ability to filter toxins, and evidence of this damage is seen as proteins leak out of the urine. The other choices are not direct indicators of progressive disease or complications. Fatigability and headache are symptoms of hypertension but are not direct indicators of progressive disease or complications. These may be side effects of certain medications used to treat hypertension. Dyspnea during activity is NOT associated with hypertension. Dyspnea can be a sign of low cardiac output (congestive heart failure), pulmonary edema, severe anemia, or a respiratory problem (asthma, pneumonia, etc.). ;./ The nurse is evaluating a 52 year old male for risk factors for CAD. The patient is overweight, male, and smokes a pack a day. The nurse questions the patient about other risk factors including: 1) A history of atherosclerotic heart disease. 2) A history of diabetes. 3) A history of gout. 4) Elevated HDL levels. 2) A history of diabetes. Rationale: The major risk factors for CAD are diabetes, smoking, increased LDL levels, and hypertension. Elevated HDL levels are PROTECTIVE against CAD. Atherosclerotic heart disease is just another name for coronary heart disease. Gout is not associated with CAD. The nurse is knowledgeable about sinoatrial node dysrhythmias if she selects which of the following causes of sinus tachycardia? Select all that apply. 1. Emotional and physical stress 2. Fever 3. Heart Failure 4. Increased Intracranial pressure 5. Infection 6. MI 1. Emotional and physical stress 2. Fever 3. Heart Failure 5. Infection Rationale: Sinus tachycardia is defined as sinus rhythm with a rate greater than 100 beats per minute. Causes of ST include: fever, emotional & physical stress, heart failure, fluid volume loss, hyperthyroidism, hypercalcemia, caffeine, nicotine, exercise, and some medications. In the vast majority of cases, sinus tachycardia results from some underlying condition such as exercise, infection, or congestive heart failure, which alters the autonomic nervous system. Sinus bradycardia may result from the following: Valsalva's maneuver, drugs like digitalis, MI, hyperkalemia, hypothyroidism, severe hypoxia, and increased ICP. The nurse is auscultating the heart of a patient with congestive heart failure. The nurse hears an extra sound with a very low pitch, immediately after the 2nd heart sound S2. The nurse interprets this as: 1. A murmur due to an aortic regurgitation. 2. A split S1. 3. A split S2. 4. A third heart sound (S3). Rationale: S3 occurs immediately after S2. It has a very low pitch and has been described as a "gallop" or vibration. It can occur normally in people under 40 and in athletes. Later in life, it may indicate heart failure (ventricular dysfunction) and/or fluid overload. An ICU nurse is providing continuing health education to new nurses in the unit. Which statements made by the nurse are correct? 1. Dysrhythmias can decrease the heart's ability to pump effectively but cannot cause death. 2. Dysrhythmias result from disturbances in the automaticity, conduction, and re-entry of impulses. 3. If the SA node fails to fire, in a normal heart, the AV node should take over the pacemaker function. 4. Normal sinus rhythm is the usual heart rhythm is the usual heart rhythm, beginning in the AV node. 5. The most serious complication of a dysrhythmia is MI. 6. The SA node is the pacemaker of the heart. 1. Dysrhythmias result from disturbances in the automaticity, conduction, and re-entry of impulses. 2. If the SA node fails to fire, in a normal heart, the AV node should take over the pacemaker function. 5. The SA node is the pacemaker of the heart. Rationale: The SA node is the pacemaker of the heart because it possesses the highest level of automaticity.The SA node is regulated by the nervous system through the vagus nerve. If it fails to fire, the AV node should take over pacemaker function. Dysrhythmias can severely decrease the heart's ability to pump effectively even causing death. Dysrhythmias can occur when there are disturbances from the three mechanisms of the heart: automaticity, conduction, and re-entry of impulses. The most serious complication of dysrhythmias is not MI. The most serious complication of a dysrhythmia is sudden death. A client has been admitted to the unit for treatment of dehydration. During the initial meeting of the client and the nurse, which nursing action is most appropriate? 1. Evaluate the client's response to treatment thus far. 2. Establish the outcomes of hospitalization for the client. 3. Tell the client that the provider will explain what to expect in the hospital. 4. Determine the preliminary client needs upon discharge. 4. Determine the preliminary client needs upon discharge. Rationale: Discharge planning should begin on admission to the unit and should be an ongoing process. As a rule, clients are not ready to discuss discharge plan on the day of admission; however planning for appropriate follow-up and coordination of care frequently cannot be achieved on the morning of discharge. The client has just been admitted so there are no fully executed treatments to evaluate. It is the nurse's responsibility to orient the client to the hospital and its routine. All outcomes should be mutually established by the client and the nurse.