22 minute read
Chapter 13: Cardiovascular Alterations
from TEST BANK for Introduction to Critical Care Nursing 7th Edition by Sole, Kelein, Mosley.
by StudyGuide
Sole: Introduction to Critical Care Nursing, 7th Edition
Multiple Choice
1. The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)?
a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels
ANS: A
ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 313 | Nursing Care Plan
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting
2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to find?
ANS: C
NURSINGTB.COM
In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and distended neck veins are related to right-sided heart failure.
DIF: Cognitive Level: Analyze/Analysis REF: p. 326 | Box 13-13
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia
3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process?
ANS: C
Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 328 | Table 13-13
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery
4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question?
ANS: A
The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.
DIF: Cognitive Level: Analyze/Analysis
NURSINGTB.COM
REF: p. 312
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery
5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following?
ANS: C
In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy. Complete occlusion is associated with a myocardial infarction. A fatty streak is present in all vessels affected by coronary artery disease. Vasospasm leads to Prinzmetal’s angina.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 295
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. ACE inhibitors and diuretics b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta blockers d. Statins, bile acid, and nicotinic acid
6. A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated?
ANS: C
Conservative intervention for the patient experiencing angina includes nitrates, beta blockers, and oxygen.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 306
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study
7. A patient is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers?
ANS: C
Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers. The ECG provides information related to the heart’s electrical activity. A cardiac catheterization directly visualizes coronary arteries. Electrophysiology studies are done to evaluate dysrhythmias.
DIF: Cognitive Level: Understand/Comprehension
NURSINGTB.COM
REF: p. 336
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins
8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient?
ANS: D
The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs such as bile acid resins and nicotinic acid. Nitroglycerin is used for chest pain.
DIF: Cognitive Level: Understand/Comprehension REF: p. 301
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Gallop rhythm b. New murmur c. S1 heart sound d. S3 heart sound
9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture?
ANS: B
The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 294
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).
10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process?
ANS: C
Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches. Coronary artery spasms and transient oxygen imbalance are not related to a myocardial infarction. Ischemia, if not reversed, will eventually lead to tissue necrosis.
NURSINGTB.COM
DIF: Cognitive Level: Analyze/Analysis
REF: p. 311
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Hypokalemia b. Non–Q wave MI c. Silent myocardial infarction d. Unstable angina
11. A 72-year-old woman is brought to the ED by her family. The family states that she’s “just not herself.” Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis?
ANS: C
Some individuals may have ischemic episodes without knowing it, thereby having a “silent” infarction. These can occur with no presenting signs or symptoms; however, the patient’s troponin levels and ECG are consistent with an MI. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients. The patient does not fit the criteria for hypokalemia, a non
Q wave MI, or unstable angina.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 311
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. The patient is not a candidate for thrombolysis. b. The patient’s history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non–Q wave MI. d. Thrombolysis should be started immediately.
12. A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient’s 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient?
ANS: A
To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours. Therefore, this patient is not a candidate for this therapy.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 314
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Coronary artery bypass graft surgery
13. The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient?
NURSINGTB.COM b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization
ANS: A
Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%). The stent or PTCA are not appropriate because the patient is a candidate for CABG. The transmyocardial revascularization is reserved for patients who do not have other treatment options.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 317
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement
14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient?
ANS: C
Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway. A cardioverter-defibrillator is used on patients with potentially lethal rhythms such as ventricular fibrillation. A pacemaker is not used for this condition.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 320 | p. 322
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
15. The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the back and down both arms, as well as numbness in the left arm. While taking the patient’s vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.
ANS: C
These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 339
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
NURSINGTB.COM
MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min
16. A patient is admitted to the emergency department with clinical indications of an acute myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient?
ANS: A
Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Because interventional cardiology is unavailable, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.
DIF: Cognitive Level: Apply/Application
REF: p. 314
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
17. A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. c. asthma. d. peripheral vascular disease.
ANS: A
A history of the patient’s use of sildenafil citrate or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies. The other conditions would not be a contraindication for nitroglycerin.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 295
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test
18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink?
ANS: B
In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is unable to eat until the gag reflex returns. The other tests do not alter the gag reflex.
DIF: Cognitive Level: Apply/Application
REF: p. 299
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option
19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient’s quality of life?
ANS: B
LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.
DIF: Cognitive Level: Analyze/Analysis REF: p. 331 | Box 13-14
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
20. The provider prescribes a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. dopamine. b. dobutamine. c. adenosine. d. atropine.
ANS: C
If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed. Dopamine and atropine are not used.
DIF: Cognitive Level: Analyze/Analysis REF: p. 299
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. It is an autosomal dominant inherited disorder of connective tissue. b. It is caused by a random genetic mutation and is not familial.
21. A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to teach the patient about this condition?
NURSINGTB.COM c. There are no drugs that help control the cardiac symptoms of the disease. d. Contact sports are permitted if precautions against concussion are taken.
ANS: A
Marfan syndrome is an autosomal dominant inherited disorder of connective tissue with a definite familial pattern. Beta blockers and ACE inhibitors are commonly used to treat the condition. Contact sports and weight lifting are generally prohibited.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 338 Genetics Box
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX Client Needs Category: Physiological Integrity a. “It will be worth it to have a healthy spouse, won’t it?” b. “The low-cholesterol diet is one from which everyone can benefit.” c. “As long as you change at least a few things in the diet, it will be okay.” d. “You can go on the diet with him, and then let the children eat whatever they want.”
22. The patient’s spouse is feeling overwhelmed about cooking different dinners for the patient and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best?
ANS: B
Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease. It will be easier if the family members all eat the same type of meal, so the nurse should suggest this option. Asking whether it’s worth the trouble is not giving the spouse any information with which to make decisions. A diet low in cholesterol requires changing more than just a few things.
DIF: Cognitive Level: Understand/Comprehension REF: p. 301
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery
23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery?
ANS: D
Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention. Lesions in the other locations are candidates for this procedure.
DIF: Cognitive Level: Understand/Comprehension REF: p. 317
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease. TOP: Nursing Process Step: Assessment
NURSINGTB.COM
MSC: NCLEX Client Needs Category: Physiological Integrity a. “I had a heart attack because I work too hard, and it puts too much strain on my heart.” b. “The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on.” c. “If I change my diet and exercise more, I should get over this and be healthy.” d. “What kind of pills can you give me to get me over this and back to my lifestyle?”
24. Which comment by the patient indicates a good understanding of a diagnosis of coronary heart disease?
ANS: B
Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion. Stress and strain can increase the heart’s oxygen demands but do not typically cause coronary artery disease. Coronary artery disease is a chronic illness. The patient asking for pills and a return to a previous lifestyle does not understand how risk factors lead to coronary artery disease.
DIF: Cognitive Level: Evaluate/Evaluation REF: p. 295
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Second-degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions
25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse’s responsibilities is to monitor the patient for which common postoperative dysrhythmia?
ANS: B
Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 320
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
26. An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.
ANS: B
Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure. Notifying the provider of a weight gain and assessing a pulse are important self-care activities but will not prevent a recurrence of heart failure. Nitroglycerin is used for coronary artery disease.
NURSINGTB.COM
DIF: Cognitive Level: Apply/Application
REF: p. 327 | Table 13-12
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance a. “This will help prevent chest pain until the intervention is complete.” b. “This medication dries oral and respiratory secretions during the procedure.” c. “This is a mild sedative and amnesic agent, so you’ll be very relaxed.” d. “This drug helps prevent blood clotting and is often used for this procedure.”
27. A patient is having an emergent coronary intervention, and the nurse is starting an infusion of abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best?
ANS: D
Abciximab is a glycoprotein IIb/IIIc inhibitor and antiplatelet agent. It is used to prevent clotting in acute coronary syndromes and coronary intervention patients. The other statements are inaccurate.
DIF: Cognitive Level: Understand/Comprehension REF: p. 308
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX Client Needs Category: Physiological Integrity a. “The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel.” b. “The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.” c. “This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open.” d. “The stent will remove any clots that are in the vessel and protect the heart muscle from damage.”
28. A patient is having a stent and asks why it is necessary after having an angioplasty. Which response by the nurse is best?
ANS: B
Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 316
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX: Client Needs Category: Physiological Integrity a. “I have an incredible headache!” b. “There is blood on my toothbrush!” c. “Look at the bruises on my arms!” d. “My arm is bleeding where my IV is!”
29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse?
NURSINGTB.COM
ANS: A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. The worst complication is intracranial bleeding. Any neurological signs and symptoms must be taken seriously, and all fibrinolytic and/or heparin therapies must be discontinued until this is ruled out.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 313 | Nursing Care Plan
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
Multiple Response
1. A patient with a 10-year history of heart failure presents to the emergency department reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.)
a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device e. Biventricular pacemaker
ANS: A, B, C
This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.
DIF: Cognitive Level: Apply/Application REF: p. 327 | Table 13-12
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells
2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply.)
ANS: A, B, D
The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct. Transfusion is not required except in the setting of severe anemia, which may limit oxygen delivery to the heart. Dopamine infusion is usually used to treat hypotension but causes tachycardia which would be deleterious for the patient having an AMI because it increases the heart’s workload and demand for oxygen.
NURSINGTB.COM
DIF: Cognitive Level: Analyze/Analysis
REF: pp. 314-315
OBJ: Develop a research-related care plan for the acutely ill cardiovascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.
3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.)
ANS: A, C, D, E
Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a “silent” infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 311
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Angina b. Nonischemic c. Non–Q wave d. Q wave e. Frequent PVCs
4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.)
ANS: C, D
AMI can be classified as Q wave or non–Q wave.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 313 Nursing Care Plan
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture e. Chest pain
5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.)
ANS: A, B, C, D
NURSINGTB.COM
Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI. Chest pain is a possible symptom of AMI.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 312
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. “Pain can occur anywhere in the chest, neck, arms, or back. Don’t hesitate to call the emergency medical services if you think it’s a heart attack.” b. “For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone.” c. “The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack.” d. “You need to make sure it’s a heart attack before you call the emergency response personnel.” e. “Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911.”
6. The patient tells the nurse, “I didn’t think I was having a heart attack because the pain was in my neck and back.” The nurse explains: (Select all that apply.)
ANS: A, B, C
Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word “several” is vague.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 311 | p. 312
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Integrated Process: Teaching-Learning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Jugular venous distension b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses e. Hepatomegaly
7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)
ANS: A, B, E
Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure. Crackles are indicative of left ventricular failure. Weak peripheral pulse are not a manifestation of right ventricular failure. Crackles are indicative of left sided failure.
DIF: Cognitive Level: Remember/Knowledge
REF: Box 13-13
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NURSINGTB.COM a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in place. e. Maintain NPO status for 12 hours.
8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.)
ANS: B, C
The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration, unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity. NPO status does not need to be maintained after the patient is fully alert.
DIF: Cognitive Level: Apply/Application
REF: p. 300
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
