Chapter 48 (Test 1) Flashcards
The nurse is aware that which layer is the muscle layer of the heart, which is responsible for the heart’s contraction?
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.
ANS: D
The nurse clarifies that which is the area of the heart that normally initiates electrical impulses?
a. left ventricle.
b. atrioventricular (A V) node.
c. sinoatrial (SA) node.
d. bundle of His.
ANS: C
The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having which disorder? :
a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications.
ANS: B
The nurse identifies the “lub” sound of the “lub/dub” of the cardiac cycle as the sound of which event?
a. AV valves closing.
b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles.
ANS: A
A patient is admitted from the emergency department. The emergency department health care provider notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient has which class of heart failure?
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.
ANS: B
The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be in which stage?
a. stage A.
b. stage B.
c. stage C.
d. stage D.
ANS: A
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
a. “I can ambulate in the hallway with this gadget on.”
b. “I always take off the telemetry device when I shower.”
c. “My EKG is being watched by one of the nurses in CCU on the home unit.”
d. “I am able to sleep just fine with this device on.”
ANS: B
The nurse assesses pitting edema that can be depressed approximately 4 mm and refills in 15 seconds. The nurse would document this assessment as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema.
ANS: B
What do dark or “cold” spots on a thallium scan indicate?
a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion
ANS: D
The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of which situation?
a. normal heart action.
b. mild heart failure.
c. moderate heart failure.
d. severe heart failure.
ANS: C
The nurse takes into consideration that age-related changes can affect the peripheral circulation because of which factor?
a. sclerosed blood vessels.
b. hypotension.
c. inactivity.
d. poor nutrition.
ANS: A
The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this as whicharrhythmia?
a. sinus bradycardia.
b. atrial fibrillation.
c. sinus tachycardia.
d. ventricular tachycardia.
ANS: C
After an influenza-like illness, the patient reports chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of whichdisorder?
a. congestive heart failure.
b. heart block.
c. aortic stenosis.
d. infective endocarditis.
ANS: D
The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into which complication?
a. atrial fibrillation and possible emboli.
b. sinus tachycardia and syncope.
c. ventricular tachycardia and death.
d. sinus bradycardia and fatigue.
ANS: C
The nurse reminds the patient who is taking warfarin for the treatment of peripheral artery disease not to eat excessive green and yellow vegetables for which reason?
a. Potassium in the vegetables can cause additional bleeding
b. Green and yellow vegetables cause loose bowel movements
c. Vitamin K in the vegetables counteracts the anticoagulant effect
d. Potassium in the vegetables can cause hyperkalemia to develop
ANS: C
A patient with unstable angina should be provided with instructions to avoid which activity?
a. Walking outside
b. Eating red meat
c. Swimming in warm pool
d. Shoveling snow
ANS: D
The older adult patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse should reinforce whichinstruction?
a. “Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is
relieved.”
b. “If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals,
call your health care provider and come to the hospital.”
c. “When nitroglycerin is not relieving the pain, lie down and rest.”
d. “Use oxygen at home to relieve pain when nitroglycerin is not successful.”
ANS: B
A patient questions “Why all the fuss about a little high blood pressure? My father had it and he lived to be 65 years old.” The nurse bases the answer, knowing that which complication can occur due to untreated blood pressure?
a. Chronic Obstructive Pulmonary Disease (COPD)
b. Frequent and severe infectious disease of the lungs
c. Increased risk of myocardial infarctions (MI) and stroke
d. Severe corneal abrasions, requiring corneal transplants
ANS: C
What is the major cause of cardiac valve disease in past years?
a. Rheumatic fever
b. Long history of malnutrition
c. Drug abuse
d. Obesity
ANS: A
The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurse reinforces which instruction?
a. Good job! Continue with your low fat diet.
b. These levels are borderline: you still aren’t eating properly.
c. The dietician will need to talk to you about lowering your cholesterol a lot more.
d. Your cholesterol level needs to be lowered a great deal to improve your survival
chances.
ANS: A
A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Which is a characteristic signs and symptoms of angina pectoris?
a. substernal pain that radiates down the left arm.
b. epigastric pain that radiates to the jaw.
c. indigestion, nausea, and eructation.
d. fatigue, shortness of breath, and dyspnea.
ANS: A
A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?
a. CK-MB
b. Elevated white count
c. Elevated sedimentation rate
d. Low level of sodium
ANS: A
The patient, age 26, is hospitalized with cardiomyopathy. While assisting with data collection from the patient, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor?
a. Cocaine use
b. Viral infection
c. Vitamin B1 deficiency
d. Pregnancy
ANS: A
The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.
d. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.
ANS: C
The nurse caring for a patient recovering from a myocardial infarction (MI) administers stool softeners for which reason?
a. Prevent enema dependence in the hospitalized patient
b. Prevent fecal impactions which can lead to bowel obstruction
c. Stool softeners reduce the need for laxatives once the patient is discharged
d. Reduce the necessity to strain at the stool to lessen the effect of Valsalva’s maneuver
ANS: D
The nurse reminds the patient that the American Heart Association recommends a lipid study how frequently? .
a. Every 2 years
b. Every 2 to 3 years
c. At least every 4 years
d. Every 4 to 6 years
ANS: D
During a health interview by the home health nurse, which patient report suggests left-sided heart failure?
a. “I have to sleep in my recliner and I have this hacking cough.”
b. “I have no appetite and I have lost 3 lb in the last week.”
c. “I have to urinate every 2 hours, even during the night.”
d. “I go barefoot most of the time because my feet are so hot.”
ANS: A
The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask?
a. “Do you have a toothache?”
b. “Have you contacted your health care provider about your dental appointment?”
c. “Is your dentist board certified?”
d. “Do you think you should wait that long for your tooth extraction?”
ANS: B
A 70 year female patient arrives to the emergency department, reporting nausea, vomiting, fatigue and abdominal discomfort. The health care provider requests myocardial infarction (MI) protocols to begin. For which reason is this protocol beginning?
a. The provider is concerned a lawsuit could occur due to missed diagnosis.
b. Women tend to have less classic symptoms of a myocardial infarction.
c. Women are more likely to die from breast or cervical cancer than an MI.
d. The troponin I level is not as accurate for females as it is in male patients.
ANS: B
What is the difference between primary and secondary hypertension?
a. Secondary hypertension is caused by another disorder like renal disease.
b. Secondary hypertension is related to hereditary factors.
c. Secondary hypertension cannot be treated effectively.
d. Secondary hypertension is no real threat to health.
ANS: A
The nurse is treating a patient who had a pacemaker inserted 8 years ago for the correction of atrial fibrillation. Which diagnostic test may no longer be available to the patient because of this older model implanted device?
a. MRI
b. CT scan
c. Thallium scan
d. PET
ANS: A
Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
a. Cool dry lower limb
b. Darker, thick and toughened skin on medial surface of the leg
c. Lack of hair and shiny appearance of the lower leg
d. Lack of a pedal pulse
ANS: B
What is the patient goal of the walking exercise program designed for the rehabilitation of a patient who had a myocardial infarction (MI) 3 weeks ago?
a. Walk 2 miles in less than 60 minutes after 12 weeks.
b. Jog mile in less than 30 minutes after 12 weeks.
c. “Fast walk” 1 mile in less than 20 minutes after 12 weeks.
d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks.
ANS: A
The plan of care for a patient recovering from hip surgery mentions prevention of deep vein thrombosis (DVT). Which aspect of the plan of care addresses this concern?
a. Massaging the calves of the leg twice daily
b. Explaining the need for fluid restriction after surgery
c. Assisting the patient to change positions frequently
d. Encouraging the patient to take the anti-embolism stockings off at night for better
sleep.
ANS: C
Which intervention is appropriate for a patient who is experiencing an acute attack of Raynaud’s disease?
a. Vigorously rub both the hands in ice or snow.
b. Place the hands in ice water to observe for pallor.
c. Apply hot water over both the hands to rapidly warm the hands.
d. Place mittens on the hands and encourage the patient to move fingers.
ANS: D
The nurse reinforcing a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for which change?
a. reduction of alcohol intake.
b. avoiding cold remedies.
c. cessation of smoking.
d. weight reduction.
ANS: C
Which statement would lead the nurse to offer more instruction about taking warfarin?
a. “I eat a banana every morning with breakfast.”
b. “I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.”
c. “I try to eat a well-balanced, low-fat diet.”
d. “I don’t drink alcohol or caffeine.”
ANS: B
The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause whichdisorder?
a. hypotension.
b. thrombophlebitis.
c. pulmonary emboli.
d. heart failure.
ANS: D
The nurse making the schedule for the daily dose of furosemide would schedule the administration for which of the following times?
a. Late in the afternoon
b. At bedtime
c. With any meal
d. In the morning
ANS: D
What is the third step in the impulse pattern of conduction through the heart?
a. Atrial wall
b. Atrial-ventricular (AV) node
c. Purkinje fibers
d. Sinoatrial (SA) node
e. Bundle branches
f. Bundle of His
ANS: B
What is the second step in the path of blood through the coronary circulation?
a. Right atrium
b. Pulmonary artery
c. Tricuspid valve
d. Right ventricle
e. Superior and inferior vena cava
f. Pulmonary vein
g. Left atrium
h. Mitral valve
ANS: A
