PRELIM: 2ND QUIZ

Question 1

The common causes of both top 1 and top 2 are

Answer 1

arterial blockage or arteriosclerosis, smoking

Question 2

This sudden increase in the mortality rate is the target of the DOH campaign: “ Healthy Lifestyle to the Max.”

Answer 2

HEART DISEASE

Question 3

Common illnesses which may require treatment in Intensive Care Unit

Answer 3

HEART DISEASE

VASCULAR DISEASE

RENAL DISEASE

Question 4

Most Common cause of cardiovascular disability and death.

Answer 4

Coronary Heart Disease

Question 5

A client with chest pain and shortness of breathing arrived in ER. You are about to perform a physical assessment on this patient. Data obtained in the nursing history of relevance to heart disease MUST include?

Answer 5

D. Drowning feeling at night

Question 6

Modifiable Risk Factors

Answer 6

Hyperlipidemia- enhances atherosclerosis
Diabetes Mellitus
Obesity- result to increase cardiac workload
Personality type or behavioral factors
Contraceptive pills

Question 7

This is information patients give concerning how they feel, what symptoms they are experiencing, their fears, and concerns.

Answer 7

Subjective Data

Question 8

Nurse Lea is assessing a client who is previously diagnosed with Myocardial Ischemia, it is most important to ask which of the following?

Answer 8

A. “ What medications are you currently taking?”

Question 9

is an ISCHEMIA
Lack of blood supply due to occlusion of coronary artery and its branches

Answer 9

MYOCARDIAL INFARCTION

Question 10

MYOCARDIAL INFARCTION Most case are due to

Answer 10

ATHEROSCLEROSIS (90%)
Other causes- spasm, embolism,trauma ( 5%)

Question 11

Decreased tissue perfusion and oxygenation may cause

Answer 11

anaerobic metabolism causes production of lactic acid

Question 12

Nurse assess PQRST
in chest pain

Answer 12

P-rovoke
Q- uality
R- egion/ R-adiation
S- everity
T- iming

Question 13

(dark red = most typical area,
light red = other possible areas).

Answer 13

Rough diagram of pain zones in myocardial infarction

Question 14

DM- differences in pain threshold, autonomic neuropathy and psychological factors
After heart transplantation.

Answer 14

Silent MI

Question 15

CARDIOVASCULAR ASSESSMENT

Answer 15

EBRILE IF:
Cardiovascular infection,
Heightened cardiac workload,
MI , Acute Pericarditis,
Ineffective Endocarditis

Question 16

IF.. Assessing BP for the 1st time, take measurements in both arms
ALERT: a difference of more than 10mmhg in both arms may indicate

Answer 16

THORACIC OUTLET SYNDROME

Question 17

difference between systolic and diastolic pressure normal: 40 mmHg

Answer 17

Pulse Pressure

Question 18

Rising pulse pressure is seen with

Answer 18

Increased stroke volume
Declined Peripheral vascular resistance

Question 19

Mitral or Aortic stenosis
Constricted peripheral vessels
Declined stroke volume

Answer 19

Diminishing pulse pressure is seen with

Question 20

ESPIRATION EVALUATION

Answer 20

Observe for EUPNEA
Note for
Tachypnea with low cardiac output
Dyspnea
Cheyne Stokes
Shallow Breathing

Question 21

ubjective feeling (inability to get enough air)

Answer 21

Dyspnea

Question 22

Dyspnea on exertion is due to increased

Answer 22

O2 myocardial demand.

Question 23

related to blood pooling in the pulmonary bed; suspect Pulmonary Edema

Answer 23

Orthopnea

Question 24

Any sudden or acute dyspnea may be a sign of

Answer 24

Pulmonary Embolism

Question 25

Myocrdial Infarction- sputum is none specific but any changes in

Answer 25

patient’s secretion may signifies infection

Question 26

Mucoid and foamy sputum can be a sign of

Answer 26

CHF

Question 27

Pink-tinged frothy appearance may signal

Answer 27

Pulmonary Edema

Question 28

Whitish,

Answer 28

viral infection

Question 29

Change in color other than the above mentioned may signify

Answer 29

Bacterial infection.

Question 30

Awareness of rapid or irregular heartbeat Autonomic Nervous System and Adrenal Glands response (stress)

Answer 30

Palpitations

Question 31

Transient loss of consciousness Due to decreased cerebral tissue perfusion

Answer 31

Syncope

Question 32

no pitting edema

Answer 32

0

Question 33

mild pitting edema, 2mm depression that disappears rapidly

Answer 33

+1

Question 34

moderate pitting edema, 4mm depression that disappears 10-15 sec

Answer 34

+2

Question 35

moderately severe pitting edema, 6mm depression that may last for more than 1 minute

Answer 35

+3

Question 36

severe pitting edema, 8 mm depression that may last for more than 2 minutes

Answer 36

+4

Question 37

Types of edema CHF or Renal Failure

Answer 37

Bilateral edema

Question 38

Types of edema caused by Vascular or Lymphatic obstruction

Answer 38

Unilateral edema

Question 39

Types of edema caused by inflammatory

Answer 39

Non pitting edema

Question 40

Types of edema caused by HP and COP derangement

Answer 40

Pitting edema

Question 41

Abnormal Findings Skin Color-

Answer 41

Cyanosis, pallor, jaundice, ugular vein distention Skin Temperature- cool, moist or clammy

Question 42

most often noted in heart and lung diseases that cause a lower than normal amount of oxygen in the blood

Answer 42

Clubbing

Question 43

Pathophysiology CLUBBING OF FINGERS

Answer 43

Blood vessel dilation in distal circulation ↓ Hypertrophy of the nail beds ↓ CLUBBING OF FINGERS

Question 44

used to monitor dehydration and the amount of blood flow to tissue.

Answer 44

CAPILLARY REFILL

Question 45

defined as the time taken for color to return to an

Answer 45

external capillary bed after pressure is applied to cause blanching.

Question 46

n newborn infants, capillary refill time can be measured by pressing on the _____________ for five seconds with a finger or thumb.

Answer 46

Sternum

Question 47

INSPECTION OF CHEST- exposed the anterior chest wall NURSE assess for the presence of the following findings

Answer 47

Pulsations Symmetry of movement Retractions Heave- strong outward thrust of the chest wall

Question 48

CHEST IRREGULARITIES THAT INHIBITS CHEST EXPANSION

Answer 48

Barrel Chest Pectus Excavatum- depressed sternum Pectus Carinatum– protruding sternum

Question 49

Affected patients tend to have lung volumes that are mildly decreased but within the normal range and they are often associated with

Answer 49

mild air-trapping.

Question 50

The deformity may be classified as either "chicken breast" (chondrogladiolar) or "Pouter pigeon breast"

Answer 50

PECTUS CARINATUM

Question 51

Cardiovascular Normal Findings

Answer 51

Normal Heart rate – 60-100 Rhythm – regular or irregular HEART SOUNDS- S1 AND S2- normal heart sounds S3- “ Protodiastolic Gallop” or “Ventricular Gallop” lab-dub-ta S4-” Presystolic gallop” Ta-lab-dub- or “ atrial gallop” which is pathologic.

Question 52

A sound heard over an artery or vascular channel, reflecting turbulence of flow. Most commonly, a bruit is caused by abnormal narrowing of an artery.

Answer 52

BRUIT

Question 53

A vibration caused by the movement of fluid felt by the NURSE on palpation.

Answer 53

THRILL

Question 54

Created by turbulence in a fluid column passing through an incompetent valve, or from a vessel of smaller caliber to a larger vessel

Answer 54

THRILL

Question 55

Nurse Mabel assessed bruit over the ABDOMINAL AORTA, aware that this is life threatening signals AORTIC ANEURYSM. What is the nursing action at this point?

Answer 55

Avoid deep palpation to prevent aneurysm to rupture

Question 56

During assessment palpated carotid bruit may signal

Answer 56

( TIA or CVA).

Question 57

KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE NO SIGNS OF PULMONARY OR VENOUS CONGESTION

Answer 57

EXPECTED HOSPITAL MORTALITY 0-5% CLASS 1

Question 58

KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE MODERATE HF OR PRESENCE OF BIBASAL RALES

Answer 58

EXPECTED HOSPITAL MORTALITY 10-20% CLASS 2

Question 59

KILLIP CLASSIFICATION OF AMI WITH EXPECTED MORTALITY RATE SEVERE HF, RALES ≥ 50% of THE LUNG FIELD

Answer 59

EXPECTED HOSPITAL MORTALITY 35-45 % CLASS 3

Question 60

SHOCK WITH SYSTOLIC BP ≤ 90MMHG

Answer 60

EXPECTED HOSPITAL MORTALITY 85-95% CLASS IV

Question 60

indicating ischemia in ECG

Answer 60

T wave inversion

Question 61

injury and the acuteness of MI

Answer 61

S-T segment elevation

Question 62

Abnormal Q wave

Answer 62

indicaating tissue death

Question 63

Myocardial infarct in ECG

Answer 63

ST elevation

Question 64

In order for a patient to be diagnosed with a myocardial infarction, they must have at least two of the following three criteria

Answer 64

Clinical history of chest discomfort consistent with ischemia, such as crushing chest pain An elevation of cardiac markers in blood (Troponin-I, CK-MB, Myoglobin) Characteristic changes on electrocardiographic tracings taken serially

Question 65

cardiac markers: CK-MB at what hours

Answer 65

0-20 hours

Question 66

Cardiac markers: Myoglobin

Answer 66

first mins