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123 Cards in this Set

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Arteriosclerosis
Term applied to a number of pathological conditions in which there is a gradual thickening, hardening, and losss of elasticity of the walls of the arteries.
Atherosclerosis
A form of arteriosclerosis characterized by accumulation of plaque, blood, and blood products lining th wall of the artery, causing partial or complete blockage of an artery.
Bruit
A humming heard when auscultating a blood vessel that is caused by turbulent blood flow through the vessel.
Claudication
Severe pain in the calf muscle from inadequate blood supply.
Clubbing
A condition in which the ends of the fingers and toes appear bulbous and shiny, most often the result of lung disease.
Dysrhythmia
Abnormal, disordered, or disturbed cardiac rhythm.
Homans' sign
An assessment for venous thrombosis in which calf pain with dorsiflexion occurs if thrombosis is present.
Ischemia
Condition of inadequate blood supply.
Murmur
An abnormal sound heard on auscultation of the heart and adjacent large blood vessels.
Pericardial friction rub
Friction sound heard over the fourth left intercostal space near the sternum; a classic sign of pericarditis.
Poikilothermy
The absence of sufficient arterial blood flow, causing the extrimity to become the temperature of the enviroment.
Point of maximal impulse
The area of the chest where the greatest force can be felt with the palm of the hand when the heart contracts or beats. Usually at the fourth to fifth intercostal space in the midclavicular line.
Preload
End-diastolic stretch of cardiac muscle fibers; equals end-diastolic volume.
Pulse deficit
A condition in which the number of pulse beats counted at the radial artery is less than those counted in the same period of time at the apical heart rate.
Thrill
Abnormal vessel that has a bulging or narrowed wall; a vibration is felt.
Cardiovascular changes that occur in the older adult include the following:
Decrease in heart size - Thickening of left ventricular wall - Increased collagen in the cardiac muscle - Decreased elastin in the cardiac muscle - Stiffer and thicker cardiac valves - Fibrosis of the SA node - Decreased number of pacemaker cells - Calcification of blood vessels - Loss of arterial distensibility - More tortuous vessels - Decreased response to baroreceptors.
The cardiovascular age related changes previously mentioned increase the risk of developing the following:
Sinus bradycardia - Arterial fibrillation - Atherosclerotic heart disease - Elevated systolic blood pressure - Decreased cardiac output and cardiac reserve - Hypertension - Peripheral vascular disease - Postural hypotension - Vagal syncope.
Acute Cardiovascular Nursing Assessment - History = Symptom * Allergies
Significance * For medication administration, diagnostic dyes.
Acute Cardiovascular Nursing Assessment - History = Smoking history
Significance * Risk factor for cardiovascular disorders.
Acute Cardiovascular Nursing Assessment - History = Medications
Significance * Toxic levels; influencing symptoms.
Acute Cardiovascular Nursing Assessment - History = Symptom * Pain
Significance * Location - chest, calf; radiation - arms, jaw, neck; description - pressure, indigestion, tightness, burning, angina, myocardial infacrction, thrombus, embolism.
Acute Cardiovascular Nursing Assessment - History = Symptom * Dyspnea
Significance * Left-sided heart failure; pulmonary edema or embolism.
Acute Cardiovascular Nursing Assessment - History = Symptom * Fatigue
Significance * Decreased cardiac output.
Acute Cardiovascular Nursing Assessment - History = Symptom * Palpitations
Significance * Dysrhythmias
Acute Cardiovascular Nursing Assessment - History = Symptom * Dizziness
Significance * Dysrhythmias
Acute Cardiovascular Nursing Assessment - History = Symptom * Weight gain
Significance * Right-sided heart failure.
Acute Cardiovascular Nursing Assessment - Physical Assessment - Vital signs
Possible Abnormal Findings - Bradycardia, tachycardia, hypotension, hypertension, tachypnea, apnea, shock.
Acute Cardiovascular Nursing Assessment - Physical Assessment - Heart rhythm
Possible Abnormal Findings - Dysrhythmias.
Acute Cardiovascular Nursing Assessment - Physical Assessment - Edema
Possible Abnormal Findings - Right-sided heart failure.
Acute Cardiovascular Nursing Assessment - Physical Assessment - Jugular vein destention
Possible Abnormal Findings - Right-sided heart failure.
Acute Cardiovascular Nursing Assessment - Physical Assessment - Breath Sounds
Possible Abnormal Findings - Crackles, wheezes with left-sided heart failure.
Acute Cardiovascular Nursing Assessment - Physical Assessment -
Possible Abnormal Findings - Acute heart failure-dry cough, pink frothy sputum.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Where is pain? Does it radiate?
Rationale - Cardiac pain may radiate to shoulders, neck, jaw, arms or back. Vascualr disorders cause extremity pain.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - How does it feel? Discomfort, burning, aching, indigestion, squeezing, pressure, tightness, heaviness, numbness in chest area? Fullness, heaviness, sharpness, throbbing in legs?
Rationale - Pain can be associated with angina or MI. The quality of pain varies. Venous pain is the fullness or heaviness. Sharpness or throbbing is arterial pain.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Aggravating/alleviating factors that increase/relieve the pain?
Rationale - Activity may cause or increase angina. Rest or medications may relieve angina. Leg activity pain, intermittent claudication, results from decreased perfusion that is aggravated by activity. Rest pain, from severe arterial occlusion, increses when lying. Dangling reduces the pain because blood flow is increased by gravity.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Timing of pain: onset, duration, frequency?
Rationale - Pain may be continuous, intermittent, acute or chronic. Arterial occlusion causes acute pain.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Severity of pain?
Rationale - Rate pain on a scale of 0 to 10.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Useful data for associated symptoms?
Rationale - Accompanying symptoms and their characteristics guide diagnosis and treatment.
Cardiovascular History Assessment - Pain: WHAT'S UP? Format - Question - Perception of patient about problem?
Rationale - Patient's insight to problem is helpful in planning care.
Cardiovascular History Assessment - Level of Consciousness (LOC)-Question - What is your name? What is the month? Year? Where are you now?
Rationale - A lack of oxygen caused by cardiac disease can decrease LOC.
Cardiovascular History Assessment - Dyspnea -Question - Are you short of breath? What increases your shortness of breath? What relieves your shortness of breath?
Rationale - Dyspnea can be present with heart failure that reduces cardiac output, on exertion in angina pectoris or from a pulmonary embolus resulting from thrombophlebitis, heart failure, or dysrhythmias.
Cardiovascular History Assessment - Palpitations -Question - Are you having palpitations or irregular heartbeat? Does your heart ever race, skip beats, or pound?
Rationale - Palpitations can occur from dysrhythmias resulting from ischemia, electrolyte imbalance, or stress. Dizziness can be assocated with dysrhythmias.
Cardiovascular History Assessment - Fatigue -Question - *Have you noticed any change in your energy level? * Are you able to perform activities that you would like to?
Rationale - *Fatigue occurs from reduced cardiac output resulting from heart failure. *Functional abilities can be limited from fatigue.
Cardiovascular History Assessment - Edema -Question - *Have you had any swelling in your feet, legs, or hands? *Have you gained weight?
Rationale - *Right-sided heart failure can cause fluid accumulation in the tissues. *Fluid retention causes weight gain.
Cardiovascular History Assessment - Paresthesia/Paralysis -Question - *Any numbness, tingling, or other abnormal sensations in extremities? *Can you move your extremity?
Rationale - *Numbness and tingling, pins and needles, and crawling sensations are pareshesia. *Paralysis is inability to move extremity. Reduced nerve conduction from decreased oxygen supply causes paresthesia and paralysis.
Six Ps characterize peripheral vascular disease:
*Pain *Poikilothermia *Pulselessness *Pallor *Paralysis *Paresthesia (decreased sensation)
Sentence to remember the hearts auscultation points. All People Eat Three Meats
Aortic, Pulmonic, Erb's point, Tricuspid, & Mitral. (Erb's point - the point on the neck 2 to 3 cm above the clavicle and in front of the transverse process of the 6th cervical vertebra.
The mitral and tricuspid valves prevent backflow of blood from which of the following?
a. Ventricles to atria when the ventricles contract.
b. Atria to ventricles when the ventricles relax.
c. Ventricles to atria when the atria contract.
d. Atria to ventricles when the atria contract.
a. Ventricles to atria when the ventricles contract.
Which of the following describes the purpose of the edocardium of the heart?
a. Cover the heart muscle and prevent friction.
b. Support the coronary blood vessels.
c. Line the chambers of the heart and prevent abnormal clotting.
d. Prevent backflow of the blood from atria to ventricles.
c. Line the chambers of the heart and prevent abnormal clotting.
The function of the coronary blood vessels is to do which of the following?
a. Prevent abnormal clotting within the heart.
b. Bring oxygenated blood to the myocardium.
c. Carry deoxygenated blood to the lungs.
d. Carry oxygenated blood to the lungs.
b. Bring oxygenated blood to the myocardium.
Which of the following is the location of the cardiac centers in the nervous system?
a. Cerebrum
b. Hypothalamus
c. Spinal cord
d. Medulla
d. Medulla
The functions of angiotensin II are to increase which of the following?
a. Vasodilation and ADH secretion.
b. Vasoconstriction and aldosterone secretion.
c. Heart rate and vasodilation.
d. Heart rate and ADH secretion.
b. Vasoconstriction and aldosterone secretion.
The increase of resting blood pressure with age may contribute to which of the following?
a. Dysrhythmias
b. Thrombus formation
c. Left-sided heart failure
d. Peripheral edema
c. Left-sided heart failure
Which one of the following is a modifiable cardiovascular risk factor that should be noted during patient data collection?
a. Age
b. Gender
c. Ethnic origin
d. Tobacco use
d. Tobacco use
If it takes longer than 3 seconds for the color to return when assessing capillary refill, it may indicate which of the following?
a. Decreased aterial flow to the extremity.
b. Increased aterial flow to the extremity.
c. Decreased venous flow from the extremity.
d. Increased venous flow from the extremity.
a. Decreased arterial flow to the extremity.
Which one of the following is an important safety intervention that should be used while assessing a patient for orthostatic hypotension?
a. Reality orientation
b. Gait or walking belt
c. Liquids at bedside
d. Standing patient quickly
b. Gait or walking belt
You are caring for a patient who is on bedrest. In which area will you assess for the presence of edema?
a. Arms
b. Ankles
c. Sternum
d. Sacrum
d. Sacrum
Which of the following should be included in patient teaching for coronary angiography with femoral catheter insertion site?
a. Dye injection causes hot, flushing sensation.
b. General anesthesia is administered.
c. Claustrophobia may be experienced.
d. Ambulation is possible immediately after procedure.
a. Dye injection causes hot, flushing sensation.
A high-fiber diet for cardiac patients is recommended to do which of the following?
a. Increase absorption of nutrients
b. Reduced cardiac workload
c. Reduce edema development
d. Reduce appetite
b. Reduced cardiac workload
Clubbing - early
****************
Clubbing - severe
160 degree
***********************
Greater than 180 degree
Identify a word that is obtained during a history that maches the given assessment statement. Allergies
Assessed before medication administration, test dyes.
Identify a word that is obtained during a history that maches the given assessment statement. Smoking
Modifiable risk factor for cardiovascular disorders.
Identify a word that is obtained during a history that maches the given assessment statement. Pain
Location: chest,calf; radiation: arms, jaw neck.
Identify a word that is obtained during a history that maches the given assessment statement. Weight gain
Sign resulting from right-sided heart failure.
Identify a word that is obtained during a history that maches the given assessment statement. Crackles
Lungs sounds with left-sided heart failure.
Identify a word that is obtained during a history that maches the given assessment statement. Dizziness
Symptom of dysrhythmias.
Identify a word that is obtained during a history that maches the given assessment statement. Fatigue
Effect of decreased cardiac output.
Identify a word that is obtained during a history that maches the given assessment statement. Pink-tinged sputum
Classic symptom of acute heart failure.
Each normal heartbeat is initiated by which of the following?
a. Sinoatrial node in the wall of the right atrium.
b. Bundle of His in the interventricular septum.
c. Cardiac center in the medulla.
d. Sympathetic nerves from the spinal cord.
a. Sinoatrial node in the wall of the right atrium.
During one cardiac cycle which of the following occurs?
a. Ventricles contract first, followed by the atria.
b. Atria contract first, followed by the ventricles.
c. Atria and ventricles contract simultaneously.
d. Ventricles contract twice for every contraction of the atria.
b. Atria contract first, followed by the ventricles.
Which of the following detects changes in the blood pressure?
a. Pressoreceptors in the medulla.
b. Blood vessels in the medulla.
c. Pressoreceptors in the carotid and aortic sinuses.
d. Coronary vessels in the myocardium.
c. Pressoreceptors in the carotid and aortic sinuses.
Epinepherine increases blood pressure because it does which of the following?
a. increases water resoption by the kidneys.
b. Causes vasodilation in the skin and viscera.
c. Decreases heart rate and force of contraction.
d. Increases heart rate and force of cardiac contraction.
d. Increases heart rate and force of cardiac contraction.
When blood pressure decreases, the kidneys help raise it by secreting which of the following?
a. Renin
b. Epinepherine
c. Aldosterone
d. Erythropoietin
a. Renin
Which of the following prevents the backflow of blood in veins?
a. Precapillary sphincters
b. Middle layer
c. Smooth muscle layer
d. Valves
d. Valves
A patient has had a bilateral mastectomy, so the nurse obtains blood pressurs readings from the patient's legs. Which of the following does the nurse inderstand is the usual difference between blood pressure readings in the leg and the arm?
a. 10 mm Hg higher
b. 10 mm Hg lower
c. 15 mm Hg higher
d. 15 mm Hg lower
a. 10mm Hg higher
The nurse obtains a lower blood pressure on a patient's left arm than the right arm. As a result, which of the following extremities should the nurse use for ongoing blood pressure measurement?
a. Left arm
b. Right arm
c. Right leg
d. Either arm
b. Right arm
The nurse is checking a patient's blood pressure for orthostatic hypotension. The nurse understands that normally when the patient stands, the blood pressure drops by which of the following amounts?
a. Up to 15 mm Hg
b. Up to 20 mm Hg
c. Up to 25 mm Hg
d. Up to 30 mm Hg
a. Up to 15 mm Hg
While the nurse checks the patient's blood pressure for orthostatic hypotension, the patient's heart rate increases. The nurse understands that normally when the patient stands, the heart rate does which of the following?
a. Drops up to 10 beats per minute.
b. Drops up to 20 beats per minute.
c. Increases up to 20 beats per minute.
d. Increases up to 30 beats per minute.
c. Increases up to 20 beats per minute.
The nurse is examining a patient's legs for data collection and notes that there is bilateral decreased hair distribution, thick, brittle nails, and shiny, taut, dry skin. The nurse understands that this can indicate which of the following?
a. Increased arterial blood flow.
b. Decreased arterial blood flow.
c. Increased venous blood flow.
d. Decreased venous blood flow.
b. Decreased arterial blood flow.
The nurse is explaining to a paient ha for his thallium strss test dipyridamole (Persantine), a coronary vasodilator, will be given. Which of the following purposes will the nurse explain as the reason that this medication is being given?
a. To decrease blood flow to cardiac cells.
b. To increase blood flow that occurs with exercise.
c. To prevent a clot from forming during the test.
d. To reduce systemic vascular resistance.
b. To increase blood flow that occurs with exercise.
For which of the following dysrhythmias will the nurse anticipate a patient's need for a permanent pacemaker?
a. Ventricular fibrillation
b. Asymptomatic bradycardia
c. Atrial fibrillation
d. Third degree heart block
d. Third degree heart block
Cardiovascular changes of normal aging.
1. Decreased elasticity of the heartand arteries; efficiency of heart and peripheral valves; maximum heart rate with exercise.
2. Increased peripheral resistance and formation of atherosclerotic plaques.
3. Takes longer to recover following exercise.
Nursing implications of cardiovascular changes of normal aging.
1. Assess cardiovascular (CV) functioning.
2. Nursing diagnosis
3. Nursing interventions:
* Provide for rest periods
* Teach the client about low salt, low fat, and high fiber diets and about having regular health checkups, including blood pressure checks.
* Monitor for orthostatic hypertension; suggest a slow position change from lying to sitting to standing.
The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
1. asystole
2. bigeminy
3. tachycardia
4. bradycardia
(3)Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest. There is no heart beat. Bigeminy means that the heart beats are coming in pairs. Bradycardia in an adult is defined at a heart rate of 60 beats or less per minute.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
1. Gall bladder disease
2. Liver disease
3. Myocardial infarction
4. Skeletal muscle injury
(3)AST is an enzyme released in response to tissue damage. The symptoms are suggestive of myocardial damage. AST rises 24 hours after a myocardial infarction. It will also rise when there is liver damage and skeletal muscle injury. This client has symptoms typical of myocardial infarction; however, gall bladder disease may present with pain in the right scapula (shoulder blade) region but would not have an elevated AST.
An adult has a coagulation time of 20 minutes. The nurse should observe the client for:
1. Blood clots
2. Ecchymotic areas
3. Jaundice
4. Infection
(2)The normal clotting time is 9-12 minutes. A prolonged clotting time would suggest a bleeding tendency; the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a clotting time of less than normal. Jaundice occurs with liver damage or rapid breakdown of red blood cells, such as is seen in sickle cell anemia. Infection occurs when there are too few white blood cells.
A prothrombin time test should be performed regularly on persons who are taking which medication?
1. Heparin
2. Warfarin
3. Phenobarbital
4. Digoxin
(2)A prothrombin time test is done to determine the effectiveness of warfarin. A partial thromoplastin time test is done for persons taking heparin. Phenobarbital and digoxin do not require regular clotting tests. Serum levels of these drugs may be done if the client is on long-term therapy.
Which prothrombin time value would be considered normal for a client who is receiving warfarin (coumadin)?
1. 12 seconds
2. 20 seconds
3. 60 seconds
4. 98 seconds
(2)When a client is receiving coumadin, the prothrombin time should be 1-1/2 to 2 times the normal value, which is 11-12.5 seconds. Twenty seconds is normal for someone who is not receiving coumadin. Sixty seconds is normal for a PTT would be acceptable for a client who is receiving heparin. It should be 1-1/2 to 2 times the normal range of 60 to 70 seconds.
The nurse is caring for a client who is receiving heparin. What drug should be readily available?
1. Vitamin K
2. Caffeine
3. Calcium gluconate
4. Protamine sulfate
(4)The antidote for heparin is protamine sulfate. Vitamin K is the antidote for coumadin. Calcium gluconate is the antidite for magnesium sulfate. Caffeine is a central nervous system stimulant and will increase alertness and heart rate.
An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The nurse responds that heparin is given parenterally because:
1. It is destroyed by gastric secretions.
2. It irritates the gastric mucosa.
3. It irritates the intestinal lining.
4. Therapeutic levels can be achieved more quickly.
(1)Heparin is a protein and is destroyed by gastric secretions. It is given either IV or subcutaneously for that reason.
An adult who is admitted for a cardiac catheterization asks the nurse if she will be asleep during the cardiac catheterization asks the nurse if she will be asleep during the cardiac cathetrization. What is the best initial response for the nurse to make?
1. "You will be given a general anesthesia."
2. "You will be sedated but not asleep."
3. "The Doctor will give you an anesthetic if you are having too much pain."
4. "Why do you want to be asleep?"
(2)Persons who are undergoing cardiac catheterization will receive a sedative but are not put to sleep. Their cooperation is needed during the procedure. Asking "why" makes the client defensive and is not appropriate for the client at this time. Give the client the information asked for.
During the admission interview, a client who is admitted for a cardiac catheterization says, "Every time I eat shrimp I get a rash." What action is essential for the nurse to take at this time?
1. Notify the physician.
2. Ask the client if sh gets a rash from any other foods.
3. Instruct dietary department not to give the client shrimp.
4. Teach the client the dangers of eating shrimp and other shell fish.
(1)Allergy to shellfish is indicative of an allergy to iodine. The dye used in cardiac catheterization is an iodine dye. Anaphylactic reactions can occu. because the exam is scheduled for the morning, the nurse should notify the physician immediately. The other actions might have relevance but are not essential (safety related) at this time.
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
1. Administer a radioisotope as ordered.
2. Give the client a cleansing enema.
3. Locate and mark peripheral pulses.
4. Encourage high fluid intake before the test.
(3)It is essential to monitor peripheral pulses after the procedure. They should be assessed before the procedure. They should be assessed before the procedure to determine location and baseline levels. An iodine dye is used during a cardiac catheterization, not a radioisotope. There is no need to give the client an enema. Fluids may be encouraged after the test. The client will be NPO for eight hours before the test.
A young adult with a history of rheumatic fever as a child is to have a cardiac catheterization. She asks the nurse why she must have a cardiac catheterization. The nurse's response is based on the understanding that cardiac catheterization can accomplish all of the following EXCEPT:
1. Assessing heart structures
2. Determining oxygen levels in the heart chambers
3. Evaluating cardiac output
4. Obtaining a biopsy specimen
(4)A biopsy specimen cannot be obtained during a cardiac catheterization. Heart structures can be assessed, oxygen levels in the heart chambers can be determined, and cardiac output can be meausred during a cardiac catheterization.
When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to:
1. Check peripheral pulses.
2. Maintain NPO.
3. Apply heat to the insertion site.
4. Start range of motion exercises immediately.
(1)Checking peripheral pulses is of highest priority. The complications most likely to occur are hemorrhage and obstruction of the vessel. he client is NPO before the procedure, not after. Cold may be applie to the insertion site to vasoconstrict. Heat vasodilates and is contraindicated because it might cause bleeding. The extremity used for the insertion site kept quiet immediately following a cardiac catheterization.
A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
1. "I had chest pain while I was walking in the snow on Thursday."
2. "We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant."
3. "I had chest pain yesterday while I was sitting in the living room watching television."
4. "I felt pain all the way down my left arm after I was playing with my grandson on Monday."
(3)This answer indicates pain at rest, which suggests a progression of the angina. The other answers all indicate pain with known causes of angina-exercise, cold environment, or eating.
The Nurse responds to the call light of a client who has a history of angina pectoris. He tells the nurse that he has just taken a nitroglycerin tablet sublingually for anginal pain. What action should the nurse take next?
1. If the pain does not subside within five minutes, place a second tablet under the tongue.
2. Position him in the Trendelenburg position.
3. Administer a prn narcotic for pain if he still has pain in 10 minutes.
4. Call his physician and alert the code team for possible intervention.
(1)Nitroglycerine can be given at five-minute intervals for up to three doses if the pain is not relieved. The Trendelenburg position (head lower than feet) increases cardiac work load and would make the client worse. PRN narcotics are not usually ordered for clients who have anginal pain. Nitroglycerine, a vasodilator, is usually the medication of choice. At some point, the physician will need to be called, but there is no need to alert the code team for possible intervention.
The nurse is teaching an adult who has angina about taking nitroglycerine. The nurse tells him he will know the nitroglycerine is effective when:
1. He experiences tingling under the tongue.
2. His pulse rate increases.
3. His pain subsides.
4. His activity tolerance increases.
(3)Pain relief is the expected outcome when taking nitroglycerine. Vasodilation of coronary vessels will increase the blood supply to the heart muscle, decreasing pain caused by ischemia. Tingling under the tongue and a headache indicate that the medication is potent. His pulse rate should decrease when pain is relieved. Increase in activity tolerance is nice but nitroglycerine is given to relieve anginal pain.
A client with angina will have to make lifestyle modifications. Which of the following statements by the client would indicate that he understands the necessary modifications in lifestyle to prevent angina attacks?
1. "I know that I will need to eat less, so I will only eat one meal a day."
2. "I will need to stay in bed all the time so I won't have pain."
3. "I'll stop what I'm doing whenever I have pain and take a pill."
4. "I will need to walk more slowly and rest frequently to avoid the angina."
(4)Walking more slowly and resting decreases energy expenditure and prevents an attack. Answer #3 treats an attack. By the time he has pain, he is experiencing angina. To prevent angina, he needs to walk slowly and rest frequently. He should eat small, frequent meals-not one large meal. He should exercise within his tolerance level. Staying in bed predisposes the client to the comlications of immobility, such as clots and pneumonia.
A client who has been treated for angina is discharged in stable condition. On a clinic cisit, he tells the nurse he has anginal pain when he has sexual intercourse with his wife. The best response for the nurse to make is:
1. "Do you have ambivalent feelings toward your wife?"
2. "Many persons with angina have less pain when their partner assumes the top position."
3. "Be sure that you attempt intercourse only when you are well rested and relaxed."
4. "You might try having a cocktail before sexual activity to help you relax."
(2)Reducing his physical activity reduces the cardiac workload. This response suggests a way he can engage in sexual activity with minimum strain on the heart. Ambivalent feelings toward his wife are inlikely to causes anginal pain. There is some truth t being well rested and relaxed, but telling him this is the only time he should have intercourse is not realistic. The nurse should not advise the client to have an alcoholic beverage before sexual activity.
A low-sodium, low-cholesterol weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
1. Baked chicken and mashed potatoes.
2. Stir-fried Chinese vegetables and rice.
3. Tuna fish salad with celery sticks.
4. Lean steak with carrots
(1)Chicken is lower in sodium than beef or seafood. Baking adds no sodium to the chicken. Barbecuing adds sodium and fat, and frying adds fat and usually sodium. Chinese food is usually high in sodium. Tuna fish is high in sodium; so is celery. Steak is high in sodium; so are carrots.
An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would be most likely be present?
1. Distended neck veins
2. Dyspnea
3. Hepatomegaly
4. Pitting edema
(2)Dyspnea occurs with left-sided heart failure. Distended neck veins, hepatomegaly and pitting edema are signs of right-sided heart failure.
Digoxin (Lanoxin) and Lasix (Furosemide) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
1. Potassium
2. Calcium
3. Aspirin
4. Coumadin
(1)Lasix is a potassium-depleting diuretic. Digoxin toxicity occurs more quickly in the presence of a low serum potassium. Potassium supplements are usually ordered when the client is on a potassium-depleting diuretic. There is no indication for supplemental calcium. Aspirin and coumadin are anticoagulants and not indicated because the client is taking lasix and digoxin.
When the nurse is about to administer digoxin to a client, the client says, "I think I need to see the eye doctor. Things seem to look kind of green today." The nurse takes his vital signs which are B.P. 150/94; P 60l R 28. What is the most appropriate initial action for the nurse to take?
1. Administer the medication and record the findings on his chart.
2. Withhold the digoxin and report to the charge nurse.
3. Request an appointment with the opthalmologist.
4. Reassure the client that he is a having a normal reaction to his medication.
(2)Disturbance is green and yellow vision is a sign of digoxin toxicity. A pulse of 60 is borderline for digoxin toxicity. A pulse of 60 is borderline for digoxin toxicity. When there is any possibility of digoxin toxicity, withhold the medication and report to the charge nurse. Once a person takes digoxin, it stays in the system for nearly a week. The LPN will of course record the findings, but withholding the medication is essential. The client needs to have serum digoxin levels done, not be seen by an opthalmologist. Visual disturbances are a sign of digoxin toxicity, but these are not normal.
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to:
1. Increase activity intolerance.
2. Relieve anxiety.
3. Protect from injury.
4. Help build a positive body image.
(3)Because the client has such poor blood supply to his legs, the nurse must be very careful to protect him from injury. Increasing activity tolerance might be desirable but is certainly not the primary nursing goal. Note that the question does not indicate that he has poor exercise tolerance. There is no data in the question to indicate that the client is anxious. He may need help building a positive body image because his legs are difigured, but this is certainly not a high priority.
An adult client who has peripheral vascular disease of the lower extremities was observed smoking in the waiting area. What is the most appropriate response for the nurse to make in regards to the client's smoking?
1. "Smoking is not allowed for patients with blood diseases."
2. "Smoking causes he blood vessels in your legs to constrict and reduces blood supply."
3. "Smoking increses your blood pressure and strains your heart."
4. "Smoking causes your body to be under greater stress."
(2)This is an accurate answer that relates his behavior to his illness. All of the other statements are true about smoking but do not relate to his current health problem.
An adult client with peripheral vascular disease tells the nurse he is afraid his left leg is not improving and may need to be amputated. How should the nurse respond?
1. "You and your wife should discuss your feelings before surgery."
2. "You sound concerned about your leg and possible surgery."
3. "It is better to have an amputation when the ulcers are not improving."
4. "You don't need to be afraid of surgery."
(2)This response opens communication and allows him to talk about his feelings. The other answers do not allow him to discuss his feelings with the nurse now.
An adult is diagnosed with hypertension. He is prescribed chlorothiazide (Diuril) 500 mg po. What nursing instruction is essential for him?
1. Drink at least two quarts of liquid daily.
2. Avoid hard cheeses.
3. Drink orange juice or eat a banana daily.
4. Do not take aspirin.
(3)Chlorothiazide (Diuril) is a potassium-depleting diuretic. Orange juice and bananas are good sources of potassium. It is not necessary to increase fluids to two quarts when the client is taking a diuretic. Hard cheeses should be avoided when the client is taking monamine oxidase inhibitors. MAOIs are antidepressants. People who take coumadin should not take aspirin.
A low-sodium diet has been ordered for an adult client. the nurse knows that the client understands his low-sodium diet when he client selects which menu?
1. Tossed salad carrot sticks, and steak.
2. Baked chicken, mashed potatoes, and green beans.
3. Hot dog, roll, and coleslaw.
4. Chicken noodle soup, applesauce and cottage cheese.
(2)Chicken is low in sodium, as are mashed potatoes and green beans. Carrot sticks, steak, hot dogs, soup and cottage cheese are all high in sodium.
A female client is admitted to the hospital with obesity and deep vein thrombophlebitis (DVT) of the right leg. She weighs 275 pounds. Which of the folling factors is least related to her diagnosis?
1. Shea has been taking oral estrogens for the last three years.
2. She smokes two packs of cigarettes daily.
3. Her right femur was fractures recently.
4. Sh is 30 years old.
(4)Age is the least related to the DVT. Oral estrogens, smoking, and a broken leg are all risks factors for DVT.
Which assessment finding would most likely indicate the client has thrombophlebitis in the leg?
1. Diminished pedal pulses.
2. Color changes in the extremities when elevated.
3. Red, shiny skin.
4. Pain when climbing stairs.
(3)Red, shiny skin suggests inflammation. Diminished pedal pulses, pain when climbing stairs, and color changes in the extremitites when elevated are indicative of arterial insufficiency, not a clot in the vein.
What should be included in the teaching plan for an adult who has hypertension?
1. Reduce dietary calcium.
2. Avoid aerobic exercise.
3. Reduce alcohol intake.
4. Limit fluid intake.
(3) High alcohol intake contributes to increases in blood pressure. Hypertensive clients are usually advised to limit alcohol intake to the equivalent of two glasses of wine or less per day. Dietary sodium should be limited in people with hypertension; however, dietary calcium is not a contributing factor in hypertension. Aerobic exercise is helpful incontrolling high blood pressure. It may also contribute to weight reduction, which can help decrease blood pressure. restriction of fluid intake is a medical order and is not appropriate advice for a nurse to give. Fluid restriction is avoided unless other measures or not successful.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitores for which of the follwing signs of toxicity?
1. Disorientation
2. Weight gain
3. Constipation
4. Dyspnea
(1)Disorientation and confusion are often the first signs of digitalis toxicity in the elderly. Weight gain and dyspnea are not signs of digoxin toxiciy. They might indicate exacerbation of congestive heart failure. Diarrhea, not constipation could occur if the client has restricted activity.
The LPN is assistinf the RN in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
1. Fluid volume deficit.
2. Impaired verbal communication.
3. Chronic pain.
4. Activity intolerance.
(4)Dyspnea and impaired oxygenation of tissues reduce the client's ability to tolerate exercise. Fluid volume excess, manifested by edema, is much more likely to occur with CHF than fluid volume deficit. Impaired verbal communication would describe dysphasia, which occurs with CVA, not CHF. Acute pain may occur with CHF when exacerbations occur. Chronic pain does not ususally occur with CHF.
The nurse is caring for a client who is being evaluated for arteriosclerosis obliternas. Which complaint is the client most likely to have?
1. Burning pain in the legs that wakens him/her at night.
2. Numbness of the feet and ankles with exercise.
3. Leg pain while walking that becomes severe enough to force him/her to stop.
4. Increasing wamth and redness of the legs.
(3)Severe leg pain while walking describes intermittent claudication, which is the most common symptom of arteriosclerosis obliterans. Pain at rest develops in the late stages of the disease. Pain is much more likely than numbness with exercise. Paresthesias (including numbness)do occur, but they are likely at rest. The legs and feet of the client with arteriosclerosis obliternas become cool and pale when elevated because there is not enough blood flow to the extremities.
An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
1. Application of an elastic stocking.
2. Ambulation three times a day.
3. Passive range of motion exercises to the legs.
4. Use of ice packs to control pain.
(1)Compression bandages or stockings help prevent edema and promote adequate venous blood flow and are a major element in the treatment of venous thromboembolism. Bed rest is appropriate in the acute stage of venous blood flow and are a major element in the treatment of venous thromboembolism. Bed rest is appropriate in the acute stage of venous thromboembolism. Ice causes vasoconstriction, which decreases blood flow to the extremities.
The nurse is observing the client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed:
1. Alternately dorisflexing and plantar flexing the feet while the legs are elevated.
2. Massaging the legs beginning at the feet and moving toward the heart.
3. Alternately walking short distances and resting with the legs elevated.
4. Elevating the legs, then dangling thm, then lying flat for three minutes.
(4)In Buerger-Allen exercises, the feet are elevated until they blanch, then dangleduntil they redden, then stretched out while the client is lying flat. This promotes arterial circulation to the feet. Dorsiflexing and plantar flexing the feet help to maintain range of motion bt are not Buerger-Allen exercises. The client with peripheral vascular disease should never massage the legs because of the high risk of dislodging a thrombus if one is present. Walking promotes venous circulation but is not a Buerger-Allen exercise.
What should be included in foot care for the client who has a peripheral vascular disorder?
1. Soaking the feet for 20 minutes before washing thm.
2. Walking barefoot only on carpeed floors.
3. Applying lotion between the toes to avoid cracking of the skin.
4. Avoiding exposure of the legs and feet to the sun.
(4)Sunburn would damage the already fragile skin, increasing the risk of ulceration and infection. Feet should not be soaked. Soaking leads to maceration, predisposing to skin breakdown or infection. The slient with a peripheral vascular disorder should never walk barefoot. Small sharp objects sich as pins may not be visible in carpet and could be stepped on. Lotion may be applied to dry areas of the legs and feet but must be avoided between the toes, where the excess moisture causes maceration. Ingredients in lotion provide a nutrient source for bacteria and fungi, increasing the infection risk if cracks in the skin occur.
An adult male is being evaluated for possible dysrythmia and is to be placed on a Holter monitor. What instructions should the nurse give to him to ensure that this test provides a comprehensive picture of his cardiac status?
1. Remove the elctrodes intermittently for hygiene measures.
2. Exercise frequently while the monitor is in place.
3. Keep a diary of all your activites while being monitored.
4. Refrain from activites that precipitate symptoms.
(3)The client should function according to his normal daily schedule unless direct to do otherwise by the physician. Keeping a diary or log of these daily activities is necessary so that is can be correlated with the continuos ECG monitor strip to determine whether the dysrythmia occurs during a certain activity or at a particular time of the day. The Holter monitor is usually worn for only 24 hours, so it is not necessary to change the leads. Activities that precipitate symptoms may be correlated with dysrhythmia that can be treated, preventing further symptoms from occuring. Therefore, it would be helpful if the patient were symptomatic while attached to the Holter monitor.
An older adult is scheduled for coronary arteriography during a cardiac catheterization. Which nursing intervention will be essential as she recovers from the diagnostic procedure on the hospital unit?
1. Encouraging frequent ambulation to prevent deep vein thrombosis.
2. Limiting fluid intake o prevent fluid overload.
3. Evaluating cardiac status via continuous ECG monitoring.
4. Assessing the arterial puncture site when taking vital signs.
(4)Following cardiac catheterizaion in which an arterial sie is used for access, the puncture or cutdown site should be assessed at least as often as vital signs are monitored. The client is at risk for development of bleeding, hemorrhage, hematoma formation, and arterial insufficiency of the affected extremity. When the arterial access site is used, the client is on strict bed rest for at least several hours. Fluids are encouraged after catheterization to increase urinary output and flush out the dye used during the procedure. Clients are not routinely placed on a cardiac monitor after cardiac catheterization.
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid "something bad is about to happen." How shoud the nurse position the client?
1. High-Fowler's
2. Trendelenurg
3. Supine
4. Prone
(1)The client's symptoms suggest pulmonary edema. Any client with sever dyspnea, orthopnea, and bubbling respirations needs to be in an upright position. High-Fowler's decreases venous return to the heart by allowing blood to pool in the extremities. Decreasing venous return lowers the output of the right ventricle and decreases lung congestion. High-Fowler's also allows the abdominal organs to fall away from the diaphragm, easing breathing. The trendelenburg position would not promote venous pooling in the extremities and would increase venous return and pulmonary congestion. The supine position also would contribute to increased pulmonary congestion. The prone position, lying on th eabdomen, does not decrease venous return-which is what this client desperately needs.
An adult male has a high level of high-density lipoproteins (HDL) in proportion to low-density lipoproteins (LDL) level. How does this realate to the risk of developing coronary artery disease (CAD)?
1. His risk for CAD is low.
2. There is no direst correlation.
3. His reisk may increase with exercise.
4. His risk will increase with age.
(1)While elevated LDL levels in proportion to HDL levels are positively correlated with CAD, elevated HDL levels in propartion to LDL levels may decrease the risk of developing CAD. Age is not a predictor of HDL and LDL levels.
A 72-year-old man had a otal hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan's sign. Which of hte following will be included in the initial care of this man?
1. Warm packs to the left leg.
2. Vigorous massage of the left leg.
3. Placing the left leg in a dependent position.
4. Performing range of motion exercises to the left leg.
(1)Warm, moist heat applied to the extremity reduces the discomfort associated with thrombophlebitis. Vigorous massage of the leg is contraindicated in any client beacuase it may cause a thrombus to become disloged and possible cause a pulmonary embolus. The leg should be eleveated to prevent venous stasis. Leg exercises are used to prevent thrombophlebitis,the leg is not exercised to prevent the thromus from becoming an embolus.