Ch.12-14 - Decreased Cardiac Output: Cardiovascular Alterations

Question 1

A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?

1. This fluctuation will occur until maximum preload has been reached.
2. The patient’s heart rate is increasing, which causes a drop in stroke volume.
3. The patient’s preload has reached a critical point and now stroke volume will decrease.
4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.

Answer 1

Correct Answer: 3

Rationale 1: There is a point of maximum preload, but the cardiac output does not fluctuate until it is reached.

Rationale 2: The information in this question does not support increase in the heart rate.

Rationale 3: Until a critical point is reached, as preload increases, so does stroke volume. An optimal preload leads to an optimal stroke volume. Once past this point, an increase in preload results in a decrease in stroke volume. If the heart receives too much preload, it cannot effectively pump out that volume and stroke volume decreases. Stroke volume decreases because too much volume causes excessive stretching of the myocardial fibers and the ventricles cannot effectively contract.

Rationale 4: There is no need to look for a different pathophysiological event as the event at present is sufficient to cause decrease in cardiac output.

Question 1

Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect?

1. S1 followed closely by S2
2. S1 followed closely by S2 followed closely by S3
3. S1 followed closely by a split S2
4. S4 followed by S1 followed by S2 followed by S3 followed by S4

Answer 1

Correct Answer: 4

Rationale 1: S1-S2 is the normal lub-dub sound of the heart and does not represent a summation gallop.

Rationale 2: Presence of a third heart sound is documented as a ventricular gallop.

Rationale 3: Splitting of S2 does occur, but this is not documented as a summation gallop.

Rationale 4: The S4 heart sound is heart during atrial contraction, so it sounds as if it occurs before S1.

Question 1

A patient with history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history?

1. Ventricular tachycardia
2. Third-degree heart block
3. Junctional rhythm
4. Atrial fibrillation

Answer 1

Correct Answer: 4

Rationale 1: Ventricular tachycardia is not associated with mitral valve stenosis.

Rationale 2: Third-degree heart block is not associated with mitral valve stenosis.

Rationale 3: Junctional rhythm is not associated with mitral valve stenosis.

Rationale 4: With mitral valve stenosis the left atrial pressure raises and leads to changes in the left atrial electrical refractory period, which may precipitate atrial fibrillation.

Question 1

A patient with diabetes is surprised to learn that he has been having angina when the only problem he has been experiencing is a “bit of fatigue and shortness of breath.” How should the nurse explain to this patient?

1. Shortness of breath is the first symptom of angina.
2. There is no classic symptom of angina.
3. Slight fatigue is usually the first symptom of angina.
4. Persons with diabetes may experience pain differently.

Answer 1

Correct Answer: 4

Rationale 1: Anginal symptomology varies among patients. Shortness of breath may not occur in some patients.

Rationale 2: Classic symptoms of angina include chest pain and shortness of breath.

Rationale 3: Fatigue may occur in some patients, but is not a classic symptom associated with angina.

Rationale 4: Not all patients with altered myocardial tissue perfusion have classic anginal chest pain symptoms. Diabetics are especially prone to having silent ischemia and usually present with shortness of breath and fatigue because of the microvascular changes associated with diabetes leading to neuropathies and decreased sensitivity to pain.

Question 1

A patient, admitted with chest pain, has a baseline cTnT level of 1.1 mcg/L. Which explanation would the nurse provide the patient for redrawing this level in 6 hours?

1. “Trends in this value will help us determine your diagnosis.”
2. “If this level goes down we know your pain medication is working.”
3. “Hopefully we will see this level rise as an indicator that your oxygen therapy has been effective.”
4. “If this level does not increase, we will need to increase the rate of your intravenous fluid replacement.”

Answer 1

Correct Answer: 1

Rationale 1: Cardiac markers are obtained on admission when a patient complains of chest pain. Cardiac markers are redrawn approximately every 6 hours to evaluate for trends in elevation or decline that signals continued or resolving myocardial damage. Serial levels help determine the extent of myocardial damage.

Rationale 2: Response to pain medication is not determined by cTnT level.

Rationale 3: The effectiveness of oxygen therapy is not determined by cTnT level.

Rationale 4: Adequacy of intravenous fluid replacement is not gauged by changes in cTnT level.

Question 2

A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin?

1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours
2. What precipitated the pain, what it feels like, and where it is located
3. Changes in dietary habits, smoking history, and presence of cough
4. What home remedies were tried, activity level, and fluid intake changes

Answer 2

Correct Answer: 2

Rationale 1: Deficits in movement, timing of the pain, and dietary changes in the last 24 hours are not associated with either cardiac or pulmonary pain.

Rationale 2: Precipitating factors, quality, and location will help the health care team discriminate between pain of cardiac origin and pain of respiratory origin.

Rationale 3: This is important information to obtain, but would not help differentiate between pain of cardiac origin and pain of respiratory origin.

Rationale 4: This is important information, but will not help to differentiate between pain of cardiac origin and pain of respiratory origin.

Question 2

The nurse is caring for a patient having a transesophageal echocardiogram (TEE). What is an appropriate nursing intervention for the care of this patient?

1. Dim the lights in the room.
2. Monitor for bradycardia and hypotension.
3. Assess pedal pulses bilaterally.
4. Apply pressure to the puncture site.

Answer 2

Correct Answer: 2

Rationale 1: There is no specific reason to dim the room lights.

Rationale 2: The TEE is done under conscious sedation. During and immediately after the procedure, the nurse assesses for bradycardia and hypotension because of possible stimulation of the patient’s vagus nerve.

Rationale 3: There is no specific indication that assessing pedal pulses is necessary during this procedure.

Rationale 4: There is no puncture site in a TEE.

Question 2

The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider? Select all that apply

1. Development of an S3 heart sound
2. Sustained systolic hypertension
3. Development of bilateral crackles
4. Decrease in PAWP
5. Decrease in cardiac index

Answer 2

Correct Answer: 1,3,5

Rationale 1: Development of third or fourth heart sounds may indicate development of left ventricular failure.

Rationale 2: Sustained systolic hypotension would indicate development of left ventricular failure.

Rationale 3: Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing.

Rationale 4: Left ventricular failure would be manifested by elevation of PAWP.

Rationale 5: Low cardiac index can indicate development of left ventricular failure.

Question 3

A patient admitted with a cardiac arrhythmia is scheduled to have an electrophysiology study (EPS). The nurse would reinforce which teaching about this test?

1. This test will be helpful in determining if you need a pacemaker.
2. This test will help us determine how your heart responds to stress.
3. We can learn about the strength of your heart valves with this test.
4. This test will reveal the health of your heart’s blood supply system.

Answer 3

Correct Answer: 1

Rationale 1: The electrophysiology study is an invasive procedure that evaluates the cardiac conduction system and helps classify cardiac arrhythmias. The findings from this study help to determine if the patient would benefit from further interventions such as a pacemaker, implantable cardiodefibrillator, and radiofrequency ablation or medication therapy.

Rationale 2: Exercise electrocardiograms evaluate heart muscle and its blood supply during physical stress.

Rationale 3: Echocardiograms are used to visualize blood, cardiac valves, the myocardium, and the pericardium.

Rationale 4: Cardiac catheterization is performed to determine the presence and extent of coronary artery disease, evaluate left ventricular function, and to evaluate valvular or myocardial disorders.

Question 4

Which assessment finding would indicate to the nurse that the patient has an altered blood supply to the right coronary artery affecting the posterior wall of the myocardium?

1. cTnT of 0.0 mcg/L
2. CK-MB of 4%
3. ST segment depression in V1 and V2
4. Peaked T waves in aVF

Answer 4

Correct Answer: 3

Rationale 1: A troponin level (cTnT) of 0.00 mcg/L is a normal result.

Rationale 2: A CK-MB level of 4% is within normal limits.

Rationale 3: ST segment depression in V1 and V2 is seen when there is an altered blood supply to the right coronary artery that supplies the posterior wall of the heart.

Rationale 4: Ischemia of the inferior wall is reflected in leads II, III and aVF.

Question 5

A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed? Select all that apply

1. Assure that there is an accurate current weight on the medical record.
2. Compare fluid input and output for the last 12 hours.
3. Measure the patient’s height.
4. Figure the patient’s age in years and months.
5. Obtain the patient’s current heart rate.

Answer 5

Correct Answer: 1,3,5

Rationale 1: Weight is a component of cardiac index.

Rationale 2: There is no need to compare fluid intake and output in order to calculate cardiac index.

Rationale 3: Height is used to calculate cardiac index.

Rationale 4: Age is not a consideration when calculating cardiac index.

Rationale 5: Heart rate is a component of cardiac index.

Question 5

A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?

1. The amount of blood the heart pumps every minute
2. The strength of the heartbeat
3. The amount of resistance the heart beats against
4. The amount of blood in the heart before it beats

Answer 5

Correct Answer: 2

Rationale 1: The amount of blood the heart pumps every minute is the cardiac output. Ejection fraction is related to cardiac output, but describing cardiac output does not fully explain ejection fraction.

Rationale 2: Contractility is defined as the force of myocardial contraction and reflects the ability of the heart muscle to work independently of preload and afterload; the ability to function as a pump. Ejection fraction is a measure of the percent of blood ejected with each stroke volume and is used as an index of myocardial function.

Rationale 3: Afterload is the amount of resistance the heart must beat against. Increasing afterload will affect both ejection fraction and cardiac output.

Rationale 4: Preload represents the volume of blood in the ventricle at the end of diastole. A low preload can result in low cardiac output and may also affect ejection fraction.

Question 6

A nurse has completed instruction regarding the DASH eating plan for a patient with hypertension. Which patient statements would indicate additional education is required? Select all that apply

1. “I will take walks several times a week.”
2. “I can drink a glass of wine weekly.”
3. “I will avoid dairy products.”
4. “I will avoid changing my intake of green leafy vegetables until my medication is stabilized.”
5. “I will limit my intake of sodium and potassium.”

Answer 6

Correct Answer: 3,4,5

Rationale 1: Physical activity is included in the DASH eating plan.

Rationale 2: The patient following a DASH diet should moderate alcohol consumption. One glass of wine weekly is considered moderate intake.

Rationale 3: The DASH diet encourages intake of calcium. Dairy products are a good source of this mineral.

Rationale 4: The patient taking anticoagulants should eat a stable amount of green leafy vegetables due to vitamin K content. This is not necessary for the patient on the DASH diet for control of hypertension.

Rationale 5: Intake of sodium should be restricted, but intake of potassium is encouraged.

Question 6

A patient has been diagnosed with an abdominal aortic aneurysm (AAA) that is not large enough to be treated surgically. What is the most important teaching for the nurse to provide this patient on discharge?

1. Information about smoking cessation
2. Information on how to monitor radial pulses
3. Need for frequent blood pressure measurements in both arms
4. Need to eat a very low-fat diet

Answer 6

Correct Answer: 1

Rationale 1: There is a strong association between ongoing smoking and more rapid expansion and rupture of aortic aneurysm. Smoking cessation is essential.

Rationale 2: Radial pulses are not monitored in AAA. It is important to monitor pedal pulses.

Rationale 3: The nurse would teach the patient to measure blood pressure in both arms if a thoracic aneurysm was present.

Rationale 4: The patient should eat a healthy diet, but dietary control is not as important as another teaching topic.

Question 6

At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding?

1. The patient’s heart moves too slowly.
2. The patient’s heart wall moves very quickly to impulses.
3. The patient’s heart wall moves opposite from normal.
4. A portion of the patient’s heart does not move at all.

Answer 6

Correct Answer: 3

Rationale 1: Hypokinesis is when there is a decrease in movement of the heart muscle.

Rationale 2: Dyskinesis is not associated with rapid response to stimuli.

Rationale 3: Dyskinesis means that the patient’s heart wall moves in the opposite direction from what is normal.

Rationale 4: If a portion of the heart wall does not move at all it is called akinesis.

Question 6

During the first 24 hours after a patient has received thrombolytic therapy. What is a priority nursing intervention?

1. Monitor level of consciousness.
2. Administer pain medications.
3. Monitor for decreased output.
4. Monitor for pulmonary emboli.

Answer 6

Correct Answer: 1

Rationale 1: The first 24 hours after thrombolytic administration holds the highest risk for intracranial hemorrhage. The intervention that has the highest priority for the first 24 hours after thrombolytic therapy is assessing level of consciousness.

Rationale 2: The nurse should treat the patient’s pain, but this is not the highest priority intervention.

Rationale 3: Monitoring for decreased output is an important intervention, but is not the highest priority.

Rationale 4: The nurse should monitor for the development of pulmonary emboli, but this is not the highest priority intervention.

Question 7

It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility? Select all that apply

1. Cardiac glycosides
2. Loop diuretics
3. Sympathomimetic agents
4. Phosphodiesterase inhibitors
5. Ace-inhibitors

Answer 7

Correct Answer: 1,3,4

Rationale 1: Cardiac glycosides such as digoxin are positive inotropes and improve cardiac contractility.

Rationale 2: Diuretics are given to decrease the work load on the heart by decreasing fluid overload. They are not given to specifically improve cardiac contractility.

Rationale 3: Dopamine and dobutamine are sympathomimetic agents given to improve cardiac contractility.

Rationale 4: Phosphodiesterase inhibitors such as inamrinone and milrinone improve cardiac contractility.

Rationale 5: ACE inhibitors affect afterload and preload, but do not directly affect myocardial contractility.

Question 8

Testing reveals that a patient’s myocardial infarction damaged the papillary muscles of the mitral valve. The nurse plans care based on the knowledge that the patient is at high risk for which complication?

1. Extension of the myocardial damage
2. Catastrophic left heart failure
3. Pulmonary edema from right heart failure
4. Pulmonary embolism from clots in the left atrium

Answer 8

Correct Answer: 2

Rationale 1: All patients who have MI are at risk for extension of the damage. It is not specific to this patient.

Rationale 2: The mitral valve is between the left ventricle and the left atrium. If the mitral valve suddenly becomes incompetent because of papillary muscle failure, catastrophic left heart failure will occur.

Rationale 3: The mitral valve is on the left side of the heart.

Rationale 4: The blood that goes through the mitral valve has already returned from the lungs and is about to be pumped to the systemic circulation.

Question 9

A patient is scheduled for an exercise electrocardiogram. The nurse will ensure that which objects are in the room prior to the beginning of the test?

1. Oral fluids
2. A defibrillator
3. External pacemaker
4. Portable chest x-ray machine

Answer 9

Correct Answer: 2

Rationale 1: There is no reason that oral fluids are required for this test.

Rationale 2: Emergency medications and a defibrillator should be present in the room during an exercise electrocardiogram test. The patient may respond poorly to the stress placed on the heart during exercise and may require an emergency response with this equipment.

Rationale 3: There is no specific indication that it is necessary to have an external pacemaker present when this testing is taking place.

Rationale 4: There is no reason for a portable x-ray machine to be present in the room during this test.

Question 11

Which assessment techniques will the nurse use to evaluate the patient’s cardiac output? Select all that apply

1. Inspection of color changes in the periphery
2. Strength of pulses
3. Percussion of heart borders
4. Auscultation of heart sounds
5. Pulse pressure determination

Answer 11

Correct Answer: 1,2,4,5

Rationale 1: Color changes in the periphery can indicate decreased cardiac output.

Rationale 2: Strength of pulse is an indirect measure of cardiac output and contractility.

Rationale 3: Percussion is incorrect because it measures heart size very crudely but not output.

Rationale 4: Auscultation helps the nurse assess heart rate and rhythm which can alter cardiac output.

Rationale 5: Determination of pulse pressure is an indirect measure of stroke volume which is a component of cardiac output.

Question 12

A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction?

1. “It will be necessary for you to rest more and to limit exercise.”
2. “In some cases, this condition is treated with a surgical procedure to remove part of the ventricular septum.”
3. “You will need to take calcium channel blockers exactly as prescribed for the rest of your life.”
4. “A common treatment for your condition is the implantation of a cardioverter-defibrillator.”

Answer 12

Correct Answer: 4

Rationale 1: Exercise restriction is indicated in the management of the patient with restrictive cardiomyopathy.

Rationale 2: Surgery to remove a part of the ventricular septum is indicated in the care of the patient with hypertrophic cardiomyopathy.

Rationale 3: Calcium channel blockers are used in treatment of hypertrophic cardiomyopathy.

Rationale 4: The management of a patient diagnosed with dilated cardiomyopathy includes management of the heart failure and use of an implantable cardioversion defibrillator as needed. Additional management includes a heart transplant if indicated.

Question 13

A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient’s cardiac status? Select all that apply

1. Increase in cardiac output
2. Increase in blood pressure
3. Decrease in cardiac output
4. Decrease in blood pressure
5. No change in blood pressure or cardiac output

Answer 13

Correct Answer: 1,4

Rationale 1: Decreased afterload causes cardiac output to increase. This will occur initially in septic shock, but will change as sepsis continues.

Rationale 2: Since blood pressure is a product of cardiac output and afterload, a decrease in afterload causes a decrease in blood pressure.

Rationale 3: Initially the decrease in afterload will increase cardiac output.

Rationale 4: Decrease in afterload results in decrease in blood pressure.

Rationale 5: Changes in afterload will change both blood pressure and cardiac output.

Question 14

The nurse is instructing a patient who is scheduled for a cardiac catheterization. Which comment made by the patient would indicate the need for additional education?

1. “The nurse will check my feet very often after the procedure.”
2. “I will place a warm pack at the puncture site for pain relief.”
3. “I should let the nurse know if I need to cough after the procedure is done.”
4. “I will have someone available to drive me home following the procedure.”

Answer 14

Correct Answer: 2

Rationale 1: Pedal pulses are checked bilaterally after the procedure.

Rationale 2: The vasodilatory effect of a warm pack would cause vessel rupture and, therefore, is the choice that indicates a need for further education.

Rationale 3: In order to minimize stress on the insertion site, it should be manually compressed when the patient coughs.

Rationale 4: Many of these procedures are done as outpatient procedures, which would require someone to drive the patient home.

Question 15

A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain? Select all that apply

1. P
2. Q
3. R
4. S
5. T

Answer 15

Correct Answer: 1,3

Rationale 1: The PQRST mnemonic is a tool used to assess chest pain. P represents provoked pain or precipitating factors. The patient stated that the pain occurred when moving the trash can so P is one aspect that is used.

Rationale 2: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information regarding the quality of the pain (Q).

Rationale 3: The PQRST mnemonic is a tool used to assess chest pain. The patient provided information about the region and radiation (R) of the pain in his chest and down his arm.

Rationale 4: The PQRST mnemonic is a tool used to assess chest pain. The patient did not provide any information about the severity of the pain (S).

Rationale 5: The PQRST mnemonic is a tool used to assess chest pain. The patient did provide information about the timing of the pain by stating it occurred when the trash can was picked up and went away when it was put down.

Question 16

A patient is diagnosed with rupture of an aortic aneurysm and surgery is imminent. What interventions would the nurse anticipate prior to surgery? Select all that apply

1. Starting intravenous lines for fluid resuscitation
2. Administration of blood
3. Administration of IV narcotic for pain
4. Preparation for endotracheal intubation
5. Administration of anticoagulants to prevent clots in the prosthesis

Answer 16

Correct Answer: 1,2,3,4

Rationale 1: The patient with a ruptured aortic aneurysm will likely need fluid resuscitation until the rupture can be repaired.

Rationale 2: Blood replacement therapy is initiated when a patient has a ruptured aortic aneurysm.

Rationale 3: The patient will likely be in pain and will require IV narcotics.

Rationale 4: The patient who has had rupture of an aortic aneurysm may have cardiac or respiratory arrest, which will require endotracheal intubation.

Rationale 5: The administration of anticoagulants will be started after surgery.

Question 17

A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated?

1. Increase IV fluids.
2. Administer vasoconstricting drugs.
3. Provide care in a calm, reassuring manner.
4. Withhold oral fluids and nutrition.

Answer 17

Correct Answer: 3

Rationale 1: Increasing IV fluids is not indicated when the patient’s heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently.

Rationale 2: It is more likely that vasodilating drugs like nitroglycerin will be administered.

Rationale 3: Providing care in a calm and quiet manner helps to decrease the patient’s anxiety, thereby reducing oxygen consumption.

Rationale 4: There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

Question 19

A female patient presents to the emergency department with complaint of chest pain. Which findings would raise the nurse’s suspicion that the chest pain is of cardiac origin? Select all that apply

1. The patient has 2+ edema in her ankles.
2. The patient has bilateral xanthomas.
3. The chest pain is described as a “burning” in the center of the chest that is worse when supine.
4. The patient has an S3 heart sound.
5. The patient has a dull humming sound just below the xiphoid process.

Answer 19

Correct Answer: 1,2,4,5

Rationale 1: Peripheral edema may indicate peripheral vascular disease of left ventricular dysfunction. This finding increases concern that the patient’s chest pain may be cardiac.

Rationale 2: Xanthomas are cholesterol filled lesions commonly seen around the eyes and could indicate elevated lipids. Presence of these lesions would increase the likelihood that the patient’s chest pain is cardiac.

Rationale 3: Burning pain in the chest that is worse when supine is often related to esophageal reflux disease rather than of cardiac origin.

Rationale 4: Presence of an S3 heart sound is not normal in an adult and increases concern that the chest pain is cardiac in origin.

Rationale 5: A dull humming sound below the xiphoid process may be an abdominal bruit, which increases the concern for cardiovascular disease.

Question 20

A patient has presented for a scheduled exercise stress test. Which patient comments should the nurse communicate immediately to the health care provider performing the test? Select all that apply

1. “I did tell you that I am allergic to iodine didn’t I?”
2. “I’m pretty hungry since I didn’t eat breakfast.”
3. “I had a cup of tea this morning instead of coffee.”
4. “I took my propranolol early this morning when I first woke up.”
5. “I am determined to quit smoking. I haven’t had a cigarette for 2 days.”

Answer 20

Correct Answer: 3,4

Rationale 1: Radionuclide injections are not part of an exercise stress test.

Rationale 2: The patient should not eat for several hours prior to the test.

Rationale 3: The patient should not drink beverages containing caffeine for several hours prior to the test.

Rationale 4: Certain drugs, like beta blockers, should be held for 24 hours prior to the procedure. Propranolol is a beta blocker.

Rationale 5: The patient should not smoke for several hours prior to the test.

Question 21

A patient tells the nurse that he smokes two packs per day, works 10-hour work days most days of the week, eats out twice a day when working, and has no time to exercise. Which nursing diagnosis is appropriate for this patient?

1. Anxiety
2. Ineffective Coping
3. Altered Health Maintenance
4. Imbalanced Nutrition: More than Body Requirements

Answer 21

Correct Answer: 3

Rationale 1: The nurse has no information that would support the choice of Anxiety as a nursing diagnosis.

Rationale 2: The nurse has no information that would support Ineffective Coping as a nursing diagnosis.

Rationale 3: The patient has several modifiable risk factors for the development of coronary artery disease that include smoking and lack of exercise. These risk factors would suggest to the nurse that the nursing diagnoses of Altered Health Maintenance would be appropriate for the patient. The nurse would also ask additional assessment questions about diet and stress, which would support other NDX.

Rationale 4: It is difficult to eat out often and maintain a healthy diet, but there is currently not enough information to support a diagnosis regarding nutrition.

Question 22

A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis?

1. High-density lipoprotein
2. Total cholesterol level
3. Triglyceride level
4. Low-density lipoprotein

Answer 22

Correct Answer: 4

Rationale 1: High-density lipoprotein is a desirable component of the lipid profile.

Rationale 2: Total cholesterol level includes both “good” and “bad” cholesterol and is not as specific as another level when predicting risk for atherosclerosis.

Rationale 3: High triglycerides are implicated in the development of coronary disease, but are not as specific as another value.

Rationale 4: Once an artery has been inflamed by hypertension, smoking, viruses, high cholesterol, or high glucose, the body sends macrophages to the site of inflammation. The macrophages oxidize low-density lipoprotein. The engulfing of the low-density lipoproteins by the macrophages creates foam cells, which are the basic structure behind the fatty streaks of atherosclerosis.

Question 23

A patient who was admitted in hypertensive crisis in now normotensive. The nurse notes the patient’s output from the indwelling urinary catheter has been 15 mL over the last hour and was 20 mL the previous hour. What nursing intervention is necessary?

1. Assess the patient for development of stroke findings.
2. Discuss these findings with the primary care provider.
3. Increase the patient’s intravenous fluid rate.
4. Irrigate the patient’s indwelling urinary catheter.

Answer 23

Correct Answer: 2

Rationale 1: There is no indication that the patient has had a stroke.

Rationale 2: The nurse should alert the primary care provider about this low output as it may indicate poor organ perfusion. A patient in hypertensive crisis generally has chronic hypertension which increases the “normal” autoregulation range. Dropping the blood pressure to normal range may result in inadequate perfusion pressures.

Rationale 3: This intervention may be necessary, but is not the primary intervention indicated?

Rationale 4: There is no indication that irrigation of the urinary catheter is necessary or that it will improve output.

Question 26

A patient with heart failure tells the nurse that she is “allergic” to ACE inhibitors because they make her cough “all of the time.” What does this information suggest to the nurse?

1. The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy.
2. The patient’s asthma has been exacerbated by the use of an ACE inhibitors.
3. The patient experienced a side effect of the ACE inhibitor, which is a cough.
4. The patient’s cough is due to long-standing heart failure.

Answer 26

Correct Answer: 3

Rationale 1: Patients who cannot tolerate ACE inhibitors often are prescribed angiotensin receptor blockers since they do not cause the side effect of a cough.

Rationale 2: There is no evidence to suggest that this cough is related to asthma.

Rationale 3: Cough is a side effect of ACE inhibitors, not an allergy. Coughing is the result of the release of kinins that cause coughing with prolonged therapy.

Rationale 4: This cough is not likely to be due to heart failure.

Question 28

A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder?

1. “Your arteries have three layers that are all damaged by atherosclerosis.”
2. “Atherosclerosis damages the lining of your arteries.”
3. “Atherosclerosis is also called ‘hardening of the arteries’ because it damages the outside layer, making it hard for your artery to stretch.”
4. “The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.”

Answer 28

Correct Answer: 2

Rationale 1: Atherosclerosis does not damage all three layers of the arteries.

Rationale 2: Atherosclerosis is a chronic inflammatory disorder associated with injury to the intimal lining. It is a progressive disease characterized by formation of plaque in the intimal lining of medium and large arteries, including those in the aorta and its branches, the coronary arteries, and large vessels that supply the brain.

Rationale 3: Atherosclerosis does not damage the outer layer of the artery.

Rationale 4: Atherosclerosis does not damage the middle layer of the artery.

Question 29

The nurse has auscultated the patient’s heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment?

1. Pulse pressure of 38 mm Hg
2. Bounding, vigorous pulse
3. Split of S2
4. Apical pulse of 66

Answer 29

Correct Answer: 3

Rationale 1: The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range.

Rationale 2: A bounding vigorous pulse indicates increased myocardial contractility and would require additional assessment. This is not the priority need for reassessment.

Rationale 3: The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This may be a result of a structural defect, a mechanical defect, or an electrical defect. This is the priority need for additional assessment.

Rationale 4: The normal range of apical pulse is 60 to 80, so this is not a priority for additional assessment.

Question 31

A patient is admitted with chest pain of approximately 2 hours in duration. The CK level was 8 U/L. Which additional order should the nurse expect in order for assessment of this patient to be adequate?

1. Repeat CK level in 48 hours
2. CTnT level
3. CK-MB in the a.m.
4. LDL and HDL levels

Answer 31

Correct Answer: 2

Rationale 1: The CK level peaks in 12 to 24 hours, so repeating the level 50 hours after chest pain began is not indicated.

Rationale 2: The cardiac marker troponin-T has an onset of 2 to 4 hours and peaks in 24 to 36 hours. Since the patient has been experiencing chest pain for approximately 2 hours, this test should most likely be drawn to adequately assess the patient.

Rationale 3: CK-MB will still be elevated in the morning if the pain is cardiac in origin, however, the patient should be diagnosed and treated more rapidly that would occur with this order.

Rationale 4: LDL and HDL levels will reveal information about cholesterol levels, but not about heart damage.

Question 32

A patient is prescribed Carvedilol for hypertension. Which medication education should the nurse provide?

1. “Let me know if this medication causes you to have a headache.”
2. “This medication’s main side effect is dizziness, so be careful when you first sit up.”
3. “Some people get a mild skin rash for a few days after starting this therapy.”
4. “You should avoid eating foods high in vitamin K while on this medication.”

Answer 32

Correct Answer: 2

Rationale 1: Headache is not an expected side effect of carvedilol.

Rationale 2: Carvedilol is a beta-blocker medication used to treat heart failure and hypertension. The main side effect is dizziness.

Rationale 3: Skin rash is not an expected adverse effect of this medication.

Rationale 4: There is no reason to avoid foods high in vitamin K when taking Carvedilol.

Question 33

Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient’s cardiac function? Select all that apply

1. Heart rate will decrease.
2. Afterload will increase.
3. Stroke volume will decrease.
4. Stoke volume will increase.
5. Blood pressure will decrease.

Answer 33

Correct Answer: 3,4

Rationale 1: It is not possible to predict what change in heart rate will occur in the face of increased preload. Depending upon the pathophysiology causing the increased preload, the rate may increase, may decrease, or may stay the same.

Rationale 2: Afterload represents the force the heart must overcome to pump blood. It is not affected by preload.

Rationale 3: If the increase in preload is high enough that a critical point is reached stroke volume will decrease.

Rationale 4: The greater the volume of blood in the ventricle, the greater the amount of stretch that the fibers experience. To a point, this increase in stretch will result in an increase in stroke volume.

Rationale 5: It is not possible to determine if an increase in preload will cause a decrease in blood pressure. In most cases, increased preload will result in increased stroke volume which will result in increased blood pressure.

Question 33

Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis?

1. Edema of the lower extremities
2. A heart rate of 110 beats per minute
3. Altered deep tendon reflexes
4. Bounding peripheral pulse

Answer 33

Correct Answer: 2

Rationale 1: Development of edema is important but is not the most significant finding listed.

Rationale 2: If a patient with mitral valve stenosis experiences a sudden increase in heart rate, the diastolic filling time is shortened, which results in a substantial decrease in cardiac output. A heart rate of 110 beats per minute would be the most significant finding when assessing this patient.

Rationale 3: Alteration of deep tendon reflexes could indicate electrolyte imbalances, which is a serious development. However, a different complication is more significant.

Rationale 4: A bounding peripheral pulse indicates increased contractility, which should not be a problem for this patient.

Question 34

The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis? Select all that apply.

1. The patient is diabetic.
2. The patient tends to become anemic.
3. The patient’s mother and sister had myocardial infarctions before age 50.
4. The patient has high levels of low-density lipoproteins.
5. The patient is a 50-year-old male.

Answer 34

Correct Answer: 1,3,4,5

Rationale 1: Diabetes mellitus increases coronary artery/atherosclerotic disease risk by two-to fourfold. Diabetes can be controlled but is not curable.

Rationale 2: Anemia is not a risk factor for coronary artery disease.

Rationale 3: Family history of myocardial infarction increases risk for disease development.

Rationale 4: LDL, or “bad” cholesterol, increases risk for development of coronary artery disease.

Rationale 5: Being male is a nonmodifiable risk factor for development of coronary artery disease.

Question 35

The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis? Select all that apply

1. The patient reports having rheumatic heart disease as a child.
2. The patient has asthma.
3. The patient had a routine screening colonoscopy 1 month ago.
4. The patient is maintained on hemodialysis.
5. The patient has developed osteoarthritis over the last 2 years.

Answer 35

Correct Answer: 1,3,4

Rationale 1: Infective endocarditis is caused initially by damage to the endothelium of the heart valve, such as that with congenital diseases, one of which is rheumatic heart disease.

Rationale 2: Asthma in itself is not a risk factor for development of infective endocarditis.

Rationale 3: Dental or gastrointestinal procedures may provide the portal for bacteria to enter the blood and colonize the heart.

Rationale 4: Patients who require hemodialysis are at risk for development of infective endocarditis due to the frequent venous access required for treatments.

Rationale 5: Development of osteoarthritis is not associated with infective endocarditis.

Question 36

Cardiac catheterization reveals that a patient has an isolated lesion in the right coronary artery that occludes 90% of the vessels’ lumen. The nurse plans care for this patient based on the knowledge that total occlusion of the artery will result in damage to which portion of the heart?

1. Right ventricle
2. Anterior aspect of the left ventricle
3. The septum
4. The lateral wall of the left ventricle

Answer 36

Correct Answer: 1

Rationale 1: The right coronary artery supplies the right ventricle.

Rationale 2: The left anterior descending artery supplies the anterior aspect of the left ventricle.

Rationale 3: The left anterior descending artery supplies the septum.

Rationale 4: The left circumflex artery supplies the lateral wall of the left ventricle.

Question 36

A patient’s is admitted with complaint of chest pain. The electrocardiogram reveals ST segment elevation. What is the nurse’s priority intervention?

1. Give the patient 162 mg of aspirin.
2. Draw blood for serum cardiac markers.
3. Place the patient on a cardiac monitor.
4. Call for a portable chest x-ray.

Answer 36

Correct Answer: 1

Rationale 1: As soon as the ECG is done the patient should receive aspirin.

Rationale 2: Blood should be drawn for serum cardiac markers, but this is not the priority action.

Rationale 3: The patient should be placed on a cardiac monitor, but this is not the priority intervention.

Rationale 4: A portable chest x-ray will be taken, but this is not the priority intervention.

Question 38

A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient’s care would consider which physiology when explaining this disorder to the patient’s family?

1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema.
2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema.
3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema.
4. The arteries of the pulmonary circuit are single layer.

Answer 38

Correct Answer: 2

Rationale 1: The pulmonary circuit is normally a low-pressure system.

Rationale 2: There are no valves in the pulmonary veins so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema.

Rationale 3: The blood that enters the pulmonary circuit oxygen-poor.

Rationale 4: The capillaries in the lungs are single layer, but the arteries have three layers.

Question 40

The nurse is assessing a patient whose body mass index is 28 kg/m2. Which nursing diagnosis is appropriate for this patient?

1. Imbalanced Nutrition: More than Body Requirements
2. Altered Health Maintenance
3. Imbalanced Nutrition: Less than Body Requirements.
4. Risk for Exercise Intolerance

Answer 40

Correct Answer: 1

Rationale 1: The American Heart Association goal for BMI is less than 25. Since this patient’s BMI is above 25, the diagnosis of Imbalanced Nutrition: More than Body Requirements is appropriate.

Rationale 2: There is a more specific nursing diagnosis to address this patient’s BMI.

Rationale 3: This patient’s BMI does not support this diagnosis and the American Heart Association goals for a healthy heart.

Rationale 4: There is no evidence that this patient cannot tolerate exercise.

Question 41

When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask?

1. “Do you have a family history of coronary artery disease?”
2. “Do any of your family members have valvular problems?”
3. “Have you ever been diagnosed with rheumatic fever?”
4. “Have you ever been diagnosed with high blood pressure?”

Answer 41

Correct Answer: 3

Rationale 1: Family history of coronary artery disease is not the most significant finding for this patient.

Rationale 2: History of valvular problems is significant, but not as significant as another finding.

Rationale 3: A primary etiology of aortic valve stenosis is rheumatic fever.

Rationale 4: History of high blood pressure is always significant, but is not the most significant finding for this patient.

Question 43

A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete?

1. Obtain an electrocardiogram.
2. Measure the patient’s cardiac output.
3. Assess the patient’s neurological status.
4. Assess respiratory status.

Answer 43

Correct Answer: 4

Rationale 1: This patient will have need for an electrocardiogram if one has not already been done, but this is not the highest priority.

Rationale 2: Cardiac output measurement is important, but is not the highest priority intervention.

Rationale 3: Assessment of the neurological system is very important but is not the highest priority.

Rationale 4: In an acute situation, such as a myocardial infarction with papillary muscle damage, the left atrium and left ventricle cannot acutely compensate, which leads to backup pressure in the pulmonary vasculature, and acute pulmonary edema occurs. The nurse would detect this change on respiratory assessment.

Question 45

It is suspected that a patient who was severely injured in an automobile accident may have had a myocardial infarction prior to the crash. Which laboratory test result drawn while the patient was in the emergency department would the nurse evaluate as supporting that theory?

1. Increased serum potassium
2. Increased creatine kinase level
3. Increased BNP level
4. Increased troponin level

Answer 45

Correct Answer: 4

Rationale 1: Potassium level changes may indicate damage to muscle tissue, but is not specific to heart muscle.

Rationale 2: Creatine kinase levels do not rise until 4 to 12 hours after onset of myocardial necrosis. Unless a CK-MB level was drawn, the CK level is not specific to cardiac muscle.

Rationale 3: BNP level is assessed for the presence of heart failure.

Rationale 4: Troponin is a protein found in cardiac muscle and can appear in the blood as early as 1 to 3 hours after symptoms of MI. Troponin has a higher sensitivity and specificity of identifying myocardial damage than does creatine kinase.

Question 47

A patient is admitted for a severe headache and is found to have a blood pressure of 185/115 mm Hg. The nurse would prepare to management administration of which drug most likely to be prescribed?

1. Clonodine
2. Oral furosemide
3. Nitroprusside
4. Captopril

Answer 47

Correct Answer: 3

Rationale 1: Clonodine would be used for hypertensive urgency. This situation represents hypertensive emergency.

Rationale 2: IV furosemide would be used for this patient who is experiencing hypertensive emergency. Oral furosemide is given for hypertensive urgency.

Rationale 3: Nitroprusside is an IV medication that can be titrated and is used for hypertensive emergency.

Rationale 4: Captopril is an oral agent used for hypertensive urgency. This patient is experiencing hypertensive emergency.

Question 49

The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included?

1. This is one of the few medications that will not need to be monitored with periodic blood tests.
2. Contact your physician if you develop muscle pain.
3. It will take about 6 months before this medication will improve your low density lipoprotein level.
4. This medication helps your liver break down LDL.

Answer 49

Correct Answer: 2

Rationale 1: Liver function tests should be monitored when taking this medication at weeks 6 and 12 and periodically thereafter, especially when the dose is changed.

Rationale 2: Lipitor is a medication that works on the low-density lipoprotein receptors in the liver. Major side effects include muscle pain. The patient should be instructed to contact the physician if muscle pain occurs.

Rationale 3: This medication will lower lipid levels within 2 to 4 weeks.

Rationale 4: Lipitor is a medication that increases the low-density lipoprotein receptors in the liver. The LDL from the blood is brought into liver cells where it is further broken down.

Question 50

The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary?

1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy.
2. The patient tells the nurse of his plans to visit Rome next year.
3. The patient orders a pasta salad with broiled salmon for lunch.
4. The patient makes plans to stay with his daughter in her three story condominium for a few weeks after discharge.

Answer 50

Correct Answer: 4

Rationale 1: The patient with a mechanical valve replacement must learn to monitor blood pressure and heart rate.

Rationale 2: There is no reason the patient cannot travel.

Rationale 3: There is no reason a patient with a valve replacement should avoid pasta salad or salmon.

Rationale 4: The patient with valve replacement should avoid exertion, so staying in a condominium that has three stories may not be the best choice.

Question 51

A patient admitted in hypertensive crisis is being cared for by a newly licensed nurse and his preceptor. The preceptor would consider which information when explaining the potential etiology of this crisis? Select all that apply

1. How well has the patient’s hypertension been controlled in the past?
2. How old is the patient?
3. Has the patient been following the prescribed therapy?
4. What therapy was the patient prescribed?
5. How long has the patient been hypertensive?

Answer 51

Correct Answer: 1,3,4

Rationale 1: A history of poorly controlled hypertension is often associated with the development of hypertensive crisis.

Rationale 2: Patient age is not a determining factor in risk for development of hypertensive crisis.

Rationale 3: Inadequate adherence to prescribed therapy for hypertension is related to development of hypertensive crisis.

Rationale 4: Inadequate treatment of existing hypertension may result in hypertensive crisis.

Rationale 5: The length of time a patient has had hypertension is not a significant factor. Many people with long-standing hypertension manage it well and never experience a crisis.

Question 52

A patient is admitted with a decrease in cardiac output. Which assessment findings would the nurse attribute to that condition?

1. Increased output of very clear urine
2. Changes in skin color
3. Localized edema in the calf
4. Skin that is warm and damp

Answer 52

Correct Answer: 2

Rationale 1: A decrease in cardiac output generally results in a decrease in urine output.

Rationale 2: Changes in skin color can be a sign of hemodynamic compromise and a decrease in cardiac output.

Rationale 3: Localized edema in the calf is indicative of obstruction of venous blood flow from a clot in a leg vein.

Rationale 4: Cool skin is a finding associated with decreased cardiac output.

Question 53

A patient was sent to a rural emergency department after screening by the occupational health nurse revealed a blood pressure of 185/115 mm Hg. The patient reports feeling “fine” and denies associated symptoms. The nurse would anticipate which interventions for this patient? Select all that apply

1. Administration of oral antihypertensive medications
2. Admission to the hospital for monitoring
3. Teaching the patient how to monitor blood pressure at home
4. IV administration of antihypertensive medications
5. Transfer to an intensive care unit in a larger hospital

Answer 53

Correct Answer: 1,3

Rationale 1: This blood pressure level and the lack of associated symptoms meet the definition of hypertensive urgency. Hypertensive urgency is treated with oral antihypertensive medications.

Rationale 2: Because no symptoms are present, the patient can be managed in an outpatient setting.

Rationale 3: The patient has no symptoms, so home management, including monitoring blood pressure, is indicated.

Rationale 4: This blood pressure level and the lack of associated symptoms meet the criteria for hypertensive urgency. IV medications are given for hypertensive emergency.

Rationale 5: There is no reason to admit this patient to an intensive care unit.

Question 54

A patient tells the nurse that he has been experiencing a “pain in the chest” for the last 3 hours. What does this information suggest to the nurse?

1. The pain is of non-cardiac origin.
2. The patient is in the midst of an acute myocardial infarction.
3. The patient is going to have a myocardial infarction within hours.
4. The patient is having continuous angina.

Answer 54

Correct Answer: 1

Rationale 1: Chest pain that lasts several seconds or constant pain over a period of hours is not typical pain associated with altered myocardial tissue perfusion. This information should suggest to the nurse that the pain is of non-cardiac origin.

Rationale 2: Pain associated with myocardial infarction will generally not last for 3 hours without deterioration of the patient’s condition.

Rationale 3: Anginal pain can herald myocardial infarction, but generally does not last for several hours.

Rationale 4: Angina is not continuous.

Question 55

The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions?

1. “I am going to start walking my dog for 30 or 40 minutes every day.”
2. “I will substitute vegetables for some of the fruit I have been eating.”
3. “I will increase weight bearing activities.”
4. “I will avoid becoming dependent upon laxatives.”

Answer 55

Correct Answer: 1

Rationale 1: Unless contraindicated, patients should exercise at least 30 minutes a day, 5 to 6 days a week.

Rationale 2: The goal is 4.5 or more cups of fruits or vegetables daily. There is no reason to substitute one for the other.

Rationale 3: Increasing weight bearing activities will help increase muscle mass and bone strength and may or may not help with reducing the risk of developing coronary artery disease, so this is not the best answer.

Rationale 4: Avoiding laxatives will not reduce the patient’s risk of developing coronary artery disease.

Question 56

A patient is diagnosed with Prinzmetal’s angina. Which assessment findings would the nurse attribute to this diagnosis? Select all that apply

1. The patient experiences lightheadedness that occurs at rest.
2. The patient has chest pain that lasts several hours.
3. The patient can predict the level of activity that will cause the pain.
4. The patient is awakened from sleep by chest pain.
5. The patient has chest pain that is not related to physical activity.

Answer 56

Correct Answer: 4,5

Rationale 1: Lightheadedness with rest is not characteristic of angina.

Rationale 2: Chest pain that lasts several hours is not characteristic of angina.

Rationale 3: Stable angina is chest pain that occurs with a predictable amount of exertion.

Rationale 4: Prinzmetal’s angina, or variant angina, is not common, and is a form of unstable angina. It is chest pain that occurs at rest and often occurs at night.

Rationale 5: Prinzmetal’s angina is chest pain that is not related to physical activity.

Question 57

It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region?

1. The patient has severe pain.
2. The patient becomes rapidly hypotensive.
3. Syncope occurs
4. The blood pressure reading is different from arm to arm.

Answer 57

Correct Answer: 4

Rationale 1: Pain can be severe in dissections in any portion of the aorta.

Rationale 2: Hypotension can occur if an aneurysm in any area of the aorta progresses from dissection to rupture.

Rationale 3: Syncope can occur with dissection or rupture in an aneurysm in any portion of the aorta.

Rationale 4: Blood pressure differences greater than 15 mm Hg from arm to arm suggests that the aneurysm is thoracic.

Question 58

A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis?

1. “I often have headaches early in the morning.”
2. “I have some numbness in my feet.”
3. “I wake up a lot at night.”
4. “I find I bruise more easily now.”

Answer 58

Correct Answer: 3

Rationale 1: Morning headaches are not associated with heart failure.

Rationale 2: Sensation loss is not associated with heart failure.

Rationale 3: Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep.

Rationale 4: Bleeding tendencies are not associated with heart failure.

Question 59

A patient with acute coronary syndrome has received thrombolytic therapy. The nurse would monitor and report which findings that indicate this therapy was successful? Select all that apply

1. Respiratory rate of 18 per minute
2. Resolution of ST segment elevation
3. Resolution of chest pain
4. Occurrence of premature ventricular complexes
5. Occurrence of a headache

Answer 59

Correct Answer: 2,3,4

Rationale 1: Respiratory rate of 18 per minute is a normal respiratory rate and is not an indicator of the therapeutic effectiveness of thrombolytic therapy.

Rationale 2: Resolution of ST segment elevation would indicate that ischemia is reduced and that the therapy is successful.

Rationale 3: When the cardiac tissues are reperfused, pain abates.

Rationale 4: Thrombolysis and reperfusion of the effected myocardium may be indicated by the occurrence of reperfusion arrhythmias, such as premature ventricular complexes or ventricular tachycardia.

Rationale 5: Presence of a headache does not indicate reperfusion and may indicate an adverse effect is occurring.

Question 60

A patient’s blood pressure is measured as 138/88 mm Hg in the right arm. The nurse will anticipate which action as a result of this finding?

1. Initiation of therapy with a thiazide diuretic
2. Repeating the measurement in the left arm
3. Diagnosis of prehypertension will be made
4. Instructing the patient to follow the DASH diet

Answer 60

Correct Answer: 2

Rationale 1: Thiazide diuretics are used for stage 1 hypertension. This patient has not met criteria for this diagnosis.

Rationale 2: Before staging of hypertension can occur the patient’s blood pressure is taken in both arms and on three separate occasions.

Rationale 3: The patient must be further assessed before prehypertension is diagnosed.

Rationale 4: Additional assessment is required before prescribing a diet for this patient.

Question 61

A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education?

1. The patient’s functional status prior to illness
2. Family history of disease, diet history, and prior medical history
3. Demographic data including age, sex, race, and weight of patient
4. Cardiovascular risk factors, such as history of smoking and stress level

Answer 61

Correct Answer: 1

Rationale 1: Knowledge of the patient’s functional status prior to illness assists the nurse in setting goals that are realistic for the patient. The nurse must know the patient’s pre-illness capabilities.

Rationale 2: Family history, diet history, and prior medical history are important assessment components but do not directly indicate the patient’s capabilities.

Rationale 3: Demographic data is not as important as other assessment components for use in determining realistic goals.

Rationale 4: Cardiovascular risk factors, smoking history, and stress level may indicate areas in which education is needed but does not specifically address goals of therapy.

Question 62

A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse?

1. “I still sleep better in a recliner.”
2. “I do pretty well as long as I don’t try to do too much at one time.”
3. “My heart rate runs around 60 to 64 most of the time.”
4. “I’ve gained 4 pounds since yesterday.”

Answer 62

Correct Answer: 4

Rationale 1: Since this patient says “I still” there is no indication of change in status.

Rationale 2: Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy.

Rationale 3: A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication.

Rationale 4: A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated.