Chapter 30: Assessment of the Cardiovascular System Ignatavicius:
Med ical-Surgical Nursing, 10th Edition
1.1. A nurse assesses a client who had a myocardial infarction and has a
blood pressure of 88/58 mm Hg. Which additional assessment finding
would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min: ANS: A
When a client experiences hypotension, baroreceptors in the aortic
arch sense a pressure decrease in the vessels. The parasympathetic
system responds by lessening the inhibitory effect on the sinoatrial
node. This results in an increase in heart rate and respiratory rate.
This tachycardia is an early response and is seen even when blood
pressure is not critically low. An increased heart rate and respiratory
rate will compensate for the low blood pressure and maintain oxygen
saturation and perfusion. The client may not be able to compensate
for long and decreased oxygenation and cool, clammy skin will occur
later.
2.2. A nurse assesses a client after administering a prescribed beta
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21
, Chapter 30: Assessment of the Cardiovascular System Ignatavicius:
Med ical-Surgical Nursing, 10th Edition
blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.: ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart
rate (HR). The beta blocker will decrease HR and blood pressure,
increasing ventricular filling time. It usually does not have effects on
beta2-adrenergic receptor sites. Cardiac output may drop because of
decreased HR, but slowing the rate may allow for better filling and
better cardiac output.
3.3. A nurse assesses clients on a medical-surgical unit. Which client
would the nurse identify as having the greatest risk for cardiovascular
disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.:
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21
, Chapter 30: Assessment of the Cardiovascular System Ignatavicius:
Med ical-Surgical Nursing, 10th Edition
ANS: C
Of the options, the client with diabetes has a two- to four-fold increase
in risk for death due to cardiovascular disease. Advancing age also
increases risk, but not as much. Asthma, colorectal cancer, and
bisphosphonate therapy do not increase the risk for cardiovascular
disease.
3/
21
Med ical-Surgical Nursing, 10th Edition
1.1. A nurse assesses a client who had a myocardial infarction and has a
blood pressure of 88/58 mm Hg. Which additional assessment finding
would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min: ANS: A
When a client experiences hypotension, baroreceptors in the aortic
arch sense a pressure decrease in the vessels. The parasympathetic
system responds by lessening the inhibitory effect on the sinoatrial
node. This results in an increase in heart rate and respiratory rate.
This tachycardia is an early response and is seen even when blood
pressure is not critically low. An increased heart rate and respiratory
rate will compensate for the low blood pressure and maintain oxygen
saturation and perfusion. The client may not be able to compensate
for long and decreased oxygenation and cool, clammy skin will occur
later.
2.2. A nurse assesses a client after administering a prescribed beta
1/
21
, Chapter 30: Assessment of the Cardiovascular System Ignatavicius:
Med ical-Surgical Nursing, 10th Edition
blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.: ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart
rate (HR). The beta blocker will decrease HR and blood pressure,
increasing ventricular filling time. It usually does not have effects on
beta2-adrenergic receptor sites. Cardiac output may drop because of
decreased HR, but slowing the rate may allow for better filling and
better cardiac output.
3.3. A nurse assesses clients on a medical-surgical unit. Which client
would the nurse identify as having the greatest risk for cardiovascular
disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.:
2/
21
, Chapter 30: Assessment of the Cardiovascular System Ignatavicius:
Med ical-Surgical Nursing, 10th Edition
ANS: C
Of the options, the client with diabetes has a two- to four-fold increase
in risk for death due to cardiovascular disease. Advancing age also
increases risk, but not as much. Asthma, colorectal cancer, and
bisphosphonate therapy do not increase the risk for cardiovascular
disease.
3/
21
