Unit6: Ch 27 (Porth's 5th Ed) - Disorders of Cardiac Function

Question 1

1. In which of the following patient situations would a physician be most justified in
   preliminarily ruling out pericarditis as a contributing pathology to the patient’s health
   problems?
   A) A 61-year-old man whose ECG was characterized by widespread T-wave
   inversions on admission but whose T waves have recently normalized
   B) A 77-year-old with diminished S3 and S4 heart tones, irregular heart rate, and a
   history of atrial fibrillation
   C) A 56-year-old obese man who is complaining of chest pain that is exacerbated by
   deep inspiration and is radiating to his neck and scapular ridge
   D) A 60-year-old woman whose admission blood work indicates elevated white cells,
   erythrocyte sedimentation rate, and C-reactive protein levels

Answer 1

Ans: B
Feedback:
S3 and S4 irregularities and irregular heart rate are not noted symptoms of pericarditis.
Widespread T-wave inversions that later normalize; chest pain radiating to the neck and
scapula that is worse on inspiration; and high white cells, erythrocyte sedimentation
rate, and C-reactive protein levels are all indicators of pericarditis.

Question 2

2. Following cardiac surgery, the nurse suspects the patient may be developing a cardiac
   tamponade. Which of the following clinical manifestations would support this
   diagnosis? Select all that apply.
   A) Muffled heart tones
   B) Narrowed pulse pressure
   C) Low BP—84/60
   D) Heart rate 78
   E) Bounding femoral pulse

Answer 2

Ans: A, B, C
Feedback:
Cardiac tamponade results in increased intracardiac pressure, progressive limitation of
ventricular diastolic filling, and decreased stroke volume and cardiac output. This
accumulation of fluid results in tachycardia, elevated CVP, jugular vein distention, fall
in systolic BP, narrowed pulse pressure, and signs of shock. Heart sounds may be
muffled. A pulse rate of 78 is normal (not tachycardic). With pulsus paradoxus, the
arterial pulse as palpated at the carotid or femoral artery becomes weakened (not
bulging) or absent with inspiration.

Question 3

3. Which of the following phenomena would be most likely to accompany increased
   myocardial oxygen demand (MVO2)?
   A) Inadequate ventricular end-diastolic pressure
   B) Use of calcium channel blocker medications
   C) Increased aortic pressure
   D) Ventricular atrophy

Answer 3

Ans: C
Feedback:
An increase in aortic pressure results in a rise in afterload, wall tension, and, ultimately,
MVO2. Increased, not inadequate, ventricular end-diastolic pressure would cause an
increase in MVO2, and medications such as calcium channel blockers would decrease
MVO2. Hypertrophy of ventricles would occur in response to prolonged wall
stress and consequent oxygen demand

Question 4

4. As part of the diagnostic workup for a male client with a complex history of
   cardiovascular disease, the care team has identified the need for a record of the electrical
   activity of his heart, insight into the metabolism of his myocardium, and physical
   measurements and imaging of his heart. Which of the following series of tests is most
   likely to provide the needed data for his diagnosis and care?
   A) Echocardiogram, PET scan, ECG
   B) Ambulatory ECG, cardiac MRI, echocardiogram
   C) Serum creatinine levels, chest auscultation, myocardial perfusion scintigraphy
   D) Cardiac catheterization, cardiac CT, exercise stress testing

Answer 4

Ans: A
Feedback:
An echocardiogram would provide an image of the client’s heart, while a PET scan
reveals metabolic activity and an ECG the electrical activity. Answer B would lack data
on the client’s myocardial metabolism; answer C would lack electrical and physical
measurement information; answer D would lack electrical measurement of his heart.

Question 5

5. Which of the following teaching points would be most appropriate for a group of older
   adults who are concerned about their cardiac health?
   A) “People with plaque in their arteries experience attacks of blood flow disruption at
   seemingly random times.”
   B) “The plaque that builds up in your heart vessels obstructs the normal flow of
   blood and can even break loose and lodge itself in a vessel.”
   C) “Infections of any sort are often a signal that plaque disruption is in danger of
   occurring.”
   D) “The impaired function of the lungs that accompanies pneumonia or chronic
   obstructive pulmonary disease is a precursor to plaque disruption.”

Answer 5

Ans: B
Feedback:
Stable plaque is associated with obstruction of blood flow, while unstable plaque may
dislodge and result in thrombus formation. Plaque disruption is noted to correlate with
sympathetic events and is not seemingly random; infections and respiratory problems
are not noted to be associated with obstruction of blood flow, however

Question 6

6. Four patients were admitted to the emergency department with severe chest pain. All
   were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were
   monitored by ECG. Which patient most likely experienced myocardial infarction?
   A) A 33-year-old male whose pain started at 7 AM during moderate exercise and was
   relieved by nitrates; ECG was normal; cardiac markers remained stable.
   B) A 67-year-old female whose pain started at 2AM while she was asleep and
   responded to nitrates; the ECG showed arrhythmias and ST-segment elevation;
   cardiac markers remained stable.
   C) An 80-year-old woman whose pain started at 6 AM shortly after awakening and
   was not relieved by nitrates or rest; the ECG showed ST-segment elevation with
   inverted T waves and abnormal Q waves; levels of cardiac markers subsequently
   rose.
   D) A 61-year-old man whose pain started at 9 AM during a short walk and responded
   to nitrates, but not to rest; ECG and cardiac markers remained stable, but anginal
   pattern worsened.

Answer 6

Ans: C
Feedback:
The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic
injury to the myocardium alters the ECG patterns, often elevating the ST segment and
inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released
in response to myocardial injury; rising levels indicate damage to the heart. The other
patients have angina of varying severity.

Question 7

7. Which of the following statements provides blood work results and rationale that would
   be most closely associated with acute coronary syndrome?
   A) Increased serum creatinine and troponin I as a result of enzyme release from
   damaged cells
   B) Increased serum potassium and decreased sodium as a result of myocardial cell
   lysis, release of normally intracellular potassium, and disruption of the
   sodium–potassium pump
   C) Elevated creatine kinase and troponin, both of which normally exist intracellularly
   rather than in circulation
   D) Low circulatory levels of myoglobin and creatine kinase as a result of the
   inflammatory response

Answer 7

Ans: C
Feedback:
Myocardial necrosis releases creatine kinase and troponins that normally exist
intracellularly. Serum creatinine and potassium are not core markers of heart damage,
and myoglobin and creatine kinase levels rise, not fall, with cardiac events.

Question 8

8. A number of clients have presented to the emergency department in the last 32 hours
   with complaints that are preliminarily indicative of myocardial infarction. Which of the
   following clients is least likely to have an ST-segment myocardial infarction (STEMI)?
   A) A 70-year-old woman who is complaining of shortness of breath and vague chest
   discomfort
   B) A 66-year-old man who presented with fatigue, nausea and vomiting, and
   cool, moist skin
   C) A 43-year-old man who woke up with substernal pain that is radiating to his neck
   and jaw
   D) A 71-year-old man who has moist skin, fever, and chest pain that is excruciating
   when he moves but relieved when at rest

Answer 8

Ans: D
Feedback:
STEMI pain is not normally relieved by rest, nor would fever be a common symptom.
Shortness of breath, vague chest discomfort, fatigue, GI symptoms, and radiating
substernal pain are all associated with STEMI

Question 9

9. Following a ST-segment myocardial infarction (STEMI), the nurse should be assessing
   the patient for which of the following complications? Select all that apply.
   A) Large amount of pink, frothy sputum and new onset of murmur
   B) Tachypnea with respiratory distress
   C) Frequent ventricular arrhythmia unrelieved with amiodarone drip
   D) Complaints of facial numbness and tingling
   E) Enhanced renal perfusion as seen as an increase in urine output

Answer 9

Ans: A, B, C, D
Feedback:
Following MI, many complications can occur: Answer choice A relates to pulmonary
edema or papillary muscle rupture; answer choice B refers that acute respiratory distress
could result from heart failure; answer choice C relates to life-threatening arrhythmias;
answer choice D relates to acute stroke.

Question 10

10. A 78-year-old man has been experiencing nocturnal chest pain over the last several
    months, and his family physician has diagnosed him with variant angina. Which of the
    following teaching points should the physician include in his explanation of the man’s
    new diagnosis?
    A) “I’ll be able to help track the course of your angina through regular blood work
    that we will schedule at a lab in the community.”
    B) “With some simple lifestyle modifications and taking your heparin regularly, we
    can realistically cure you of this.”
    C) “I’m going to start you on a low dose aspirin, and it will help greatly if you can lose
    weight and keep exercising.”
    D) “There are things you can do to reduce the chance that you will need a heart
    bypass, including limiting physical activity as much as possible.”

Answer 10

Ans: C
Feedback:
Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does
not normally necessitate blood work, heparin administration, or avoidance of activity.

Question 11

11. The initial medical management for a symptomatic patient with obstructive hypertrophic
    cardiomyopathy (HCM) would be administering a medication to block the effects of
    catecholamines. The nurse will anticipate administering which of the following
    medications?
    A) Lisinopril, an ACE inhibitor
    B) Lasix, a diuretic
    C) Propranolol, a -adrenergic blocker
    D) Lanoxin, an inotropic

Answer 11

Ans: C
Feedback:
-Adrenergic blockers are generally the initial choice for persons with symptomatic
HCM. Calcium channel blockers can also be used. ACE inhibitors, diuretics, or positive
inotropics are not the first-line medications.

Question 12

12. Which of the following ECG patterns would the nurse observe in a patient admitted for
    arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)? Select all that
    apply.
    A) Atrial flutter
    B) Ventricular tachycardia with left bundle branch block pattern
    C) T-wave inversion in the right precordial leads
    D) Sinus arrhythmia with a first-degree AV block
    E) Development of a “U” wave following a normal T wave

Answer 12

Ans: B, C
Feedback:
The electrical (ECG) changes associated with ARVC/D include ventricular tachycardia
with LBBB, T-wave inversion in the right precordial leads, and epsilon waves. Right
ventricular BBB may also be present. Atrial flutter and sinus arrhythmia with a
first-degree AV block are not characteristic of this form of cardiomyopathy.

Question 13

13. A 31-year-old African American female who is in her 30th week of pregnancy has been
    diagnosed with peripartum cardiomyopathy. Which of the following statements best
    captures an aspect of peripartum cardiomyopathy?
    A) Her diagnosis might be attributable to a disordered immune response, nutritional
    factors, or infectious processes.
    B) Treatment is possible in postpartum women, but antepartum women are
    dependent on spontaneous resolution of the problem.
    C) Mortality exceeds 50%, and very few surviving women regain normal heart
    function.
    D) Symptomatology mimics that of stable angina and is diagnosed and treated
    similarly.

Answer 13

Ans: A
Feedback:
Immune responses, diet, and infections are all potential etiologies of peripartum
cardiomyopathy. Treatment is complicated, but not impossible, in antepartum women
due to possible teratogenic drug effects. About half of women suffer long-term effects
on cardiac function, while signs and symptoms are similar to those of early heart failure.

Question 14

14. An IV drug abuser walks into the ED telling the nurse that, “he is sick.” He looks
    feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and
    fatigued. The assessment reveals a loud murmur. An echocardiogram was ordered that
    shows a large vegetation growing on his mitral valve. The patient is admitted to the
    ICU. The nurse will be assessing this patient for which possible life-threatening
    complications?
    A) Systemic emboli, especially to the brain
    B) Petechial hemorrhages under the skin and nail beds
    C) GI upset from the massive amount of antibiotics required to kill the bacteria
    D) Pancreas enlargement due to increased need for insulin secretion

Answer 14

Ans: A
Feedback:
Systemic emboli develop and break off the mitral valve and travel into the vascular
system. There is a high probability that the emboli could lodge in the brain, kidneys,
lower extremities, etc. Answer choice B refers that petechial hemorrhages are signs and
symptoms of IE. GI upset is common following antibiotic therapy but is not usually life
threatening. Stress can increase insulin needs but not associated with pancreas
enlargement.

Question 15

15. A 34-year-old man who is an intravenous drug user has presented to the emergency
    department with malaise, abdominal pain, and lethargy. The health care team wants to
    rule out endocarditis as a diagnosis. Staff of the department would most realistically
    anticipate which of the following sets of diagnostics?
    A) CT of the heart, chest x-ray, and ECG
    B) Echocardiogram, blood cultures, and temperature
    C) ECG, blood pressure, and stress test
    D) Cardiac catheterization, chest x-ray, electrolyte measurement, and white cell count

Answer 15

Ans: B
Feedback:
An echocardiogram would help visualize the heart, while blood cultures would confirm
the presence or absence of microorganisms in circulation, and temperature would gauge
the presence of infection. A chest x-ray, blood pressure measurement, and cardiac
catheterization would be less likely to indicate infective endocarditis.

Question 16

16. A 13-year-old boy has had a sore throat for at least a week and has been vomiting for 2
    days. His glands are swollen, and he moves stiffly because his joints hurt. His parents,
    who believe in “natural remedies,” have been treating him with various herbal
    preparations without success and are now seeking antibiotic treatment. Throat cultures
    show infection with group A streptococci. This child is at high risk for
    A) myocarditis.
    B) mitral valve stenosis.
    C) infective endocarditis.
    D) vasculitis.

Answer 16

Ans: B
Feedback:
Group A streptococcal infection can be adequately treated with antibiotics, but this
infection may have been present long enough to trigger an immune response—
rheumatic fever—that will damage his heart valves, ultimately causing mitralvalve
stenosis. Group A streptococcal infection is not known to predispose to myocarditis,
endocarditis, or vasculitis and aneurysm of coronary arteries.

Question 17

17. On a routine physical exam visit, the physician mentions that he hears a new murmur.
    The patient gets worried and asks, “What does this mean?” The physician responds,
    A) “It would be caused by stress. Let’s keep our eye on it and see if it goes away with
    your next visit.”
    B) “This could be caused by an infection. Have you been feeling well the past few
    weeks?”
    C) “One of your heart valves is not opening properly. We need to do an
    echocardiogram to see which valve is having problem.”
    D) “This may make you a little more fatigued than usual. Let me know if you start
    getting dizzy or light-headed.”

Answer 17

Ans: C
Feedback:
Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to
open normally. Blood flow through a normal valve can increase by five to seven times
the resting volume. Valvular disease is not caused by stress. The murmur can be caused
not only by infection but also by stenosis or regurgitation of a valve leaflet. The valve
problem is very severe if it is causing signs of decreased cardiac output.

Question 18

18. A client has been diagnosed with mitral valve stenosis following his recovery from
    rheumatic fever. Which of the following teaching points would be most accurate to
    convey to the client?
    A) “The normal tissue that makes up the valve between the right sides of your heart
    has stiffened.”
    B) “Your mitral valve isn’t opening up enough for blood to flow into the part of your
    heart that sends blood into circulation.”
    C) “Your heart’s mitral valve isn’t closing properly so blood is flowing backward in
    your heart and eventually into your lungs.”
    D) “The valve between your left ventricle and left atria is infected and isn’t allowing
    enough blood through.”

Answer 18

Ans: B
Feedback:
Mitral valve stenosis represents the incomplete opening of the mitral valve during
diastole with left atrial distention and impaired filling of the left ventricle. It does not
exist in the right side of the heart, and the problem is associated primarily with improper
ventricular filling and with pulmonary backflow only secondarily. Although it is often
caused by infection, it is not an infectious process of the valve per se.

Question 19

19. A 66-year-old client’s echocardiogram report reveals a hypertrophied left ventricle. The
    health care provider suspects the client has aortic stenosis. Which of the following
    clinical manifestations would be observed if this client has aortic stenosis? Select all
    that apply.
    A) Decrease in exercise tolerance
    B) Exertional dyspnea
    C) Palpitations
    D) Syncope
    E) Heartburn

Answer 19

Ans: A, B, D
Feedback:
Because of the slow onset of aortic valve stenosis, the heart is able to compensate by
hypertrophying and may still maintain a normal chamber volume and ejection fraction.
As the stenosis progresses, the patient will experience classic symptoms of angina,
syncope, heart failure, and decrease in exercise tolerance or exertional dyspnea.
Palpitations and heartburn are not usually noted with aortic stenosis.

Question 20

20. Which of the following situations related to transition from fetal to perinatal circulation
    would be most likely to necessitate medical intervention?
    A) Pressure in pulmonary circulation and the right side of the infant’s heart fall
    markedly.
    B) Alveolar oxygen tension increases causing reversal of pulmonary vasoconstriction
    of the fetal arteries.
    C) Systemic vascular resistance and left ventricular pressure are both increasing.
    D) Pulmonary vascular resistance, related to muscle regression in the pulmonary
    arteries, rises over the course of the infant’s first week.

Answer 20

Ans: D
Feedback:
One of the hallmarks of the transition from placental circulation is a rapid and then
steady decrease in pulmonary vascular resistance. Answers A, B, and C relate normal
physiological processes.

Question 21

21. A pediatric nurse is assessing a newborn diagnosed with persistent patency of the ductus
    arteriosus. Which of the following findings are associated with this heart defect? Select
    all that apply.
    A) Murmur heard at the second intercostal space, during both systole and diastole
    B) BP 84/30 classified as a wide pulse pressure
    C) Shortness of breath with activity such as kicking
    D) Stridor with inspiratory wheezes
    E) Bulging jugular neck veins

Answer 21

Ans: A, B
Feedback:
Persistent patency of the ductus arteriosus is defined as a duct that remains open for
greater than 3 months. A murmur is detected within days of birth. It is loudest at the
second left intercostal space and is continuous through systole and diastole. A wide
pulse pressure is common (BP 84/30). Most newborns have an elevated respiratory rate
with exertional activity. Stridor is usually associated with bronchial infections or
narrowing of the airways. Bulging jugular neck veins are associated with right-sided
heart failure.

Question 22

22. A nurse who works on a pediatric cardiology unit of a hospital is providing care for an
    infant with a diagnosis of tetralogy of Fallot. Which of the following pathophysiologic
    results should the nurse anticipate?
    A) There is a break in the normal wall between the right and left atria that results in
    compromised oxygenation.
    B) The aortic valve is stenotic, resulting in increased afterload.
    C) Blood outflow into the pulmonary circulation is restricted by pulmonic valve
    stenosis.
    D) The right ventricle is atrophic as a consequence of impaired myocardial blood
    supply.

Answer 22

Ans: C
Feedback:
Tetralogy of Fallot is marked by obstruction or narrowing of the pulmonary outflow
channel, including pulmonic valve stenosis, a decrease in the size of the pulmonary
trunk, or both. The characteristic septal defect is ventricular, not atrial. Aortic valve
stenosis and right ventricular atrophy are not associated with the diagnosis.

Question 23

23. A 66-year-old obese man with diagnoses of ischemic heart disease has been diagnosed
    with heart failure that his care team has characterized as attributable to systolic
    dysfunction. Which of the following assessment findings is inconsistent with his
    diagnosis?
    A) His resting blood pressure is normally in the range of 150/90, and an
    echocardiogram indicates his ejection fraction is 30%.
    B) His end-diastolic volume is higher than normal, and his resting heart rate is
    regular and 82 beats/minute.
    C) He is presently volume overloaded following several days of intravenous fluid
    replacement.
    D) Ventricular dilation and wall tension are significantly lower than normal.

Answer 23

Ans: D
Feedback:
Systolic dysfunction is associated with increased ventricular dilation and wall tension.
Hypertension, low ejection fraction, high preload, and volume overload are a ll
commonly associated with systolic dysfunction.

Question 24

24. A nurse will be providing care for a female patient who has a diagnosis of heart failure
    that has been characterized as being primarily right sided. Which of the following
    statements best describes the presentation that the nurse should anticipate? The client
    A) has a distended bladder, facial edema, and nighttime difficulty breathing.
    B) complains of dyspnea and has adventitious breath sounds on auscultation
    (listening).
    C) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance ,
    and occasional upper right quadrant pain.
    D) has cyanotic lips and extremities, low urine output, and low blood pressure

Answer 24

Ans: C
Feedback:
Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper
right quadrant pain. Abdominal distention can occur with right-sided failure when the
liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine
output, and low blood pressure are less associated with right-sided failure. Left- sided
failure is primarily associated with pulmonary signs and symptoms like dyspnea ,
pulmonary edema, frothy pink sputum, and respiratory congestion

Question 25

25. An 81-year-old male resident of a long-term care facility has a long-standing diagnosis
    of heart failure. Which of the following short-term and longer-term compensa tory
    mechanisms are least likely to decrease the symptoms of his heart failure?
    A) An increase in preload via the Frank-Starling mechanism
    B) Sympathetic stimulation and increased serum levels of epinephrine a nd
    norepinephrine
    C) Activation of the renin–angiotensin–aldosterone system and secretion of bra in
    natriuretic peptide (BNP)
    D) AV node pacemaking activity and vagal nerve suppression

Answer 25

Ans: D
Feedback:
Reassignment of cardiac pacemaking activities and suppression of the vagal nerve a re
not noted compensatory actions related to heart failure. Increased preload a nd
sympathetic stimulation, increased levels of epinephrine and norepinephrine, a nd
activation of the renin–angiotensin–aldosterone system and secretion of brain natriureti c
peptide (BNP) are all noted compensatory mechanisms.

Question 26

26. The nurse working in the ICU knows that chronic elevation of left ventricular
    end-diastolic pressure will result in the patient displaying which of the following clinica l
    manifestations?
    A) Chest pain and intermittent ventricular tachycardia
    B) Dyspnea and crackles in bilateral lung bases
    C) Petechia and spontaneous bleeding
    D) Muscle cramping and cyanosis in the feet

Answer 26

Ans: B
Feedback:
Although it may preserve the resting cardiac output, the resulting chronic elevation of
left ventricular end-diastolic pressure is transmitted to the atria and the pulmona ry
circulation, causing pulmonary congestion.

Question 27

27. A 77-year-old patient with a history of coronary artery disease and heart failure ha s
    arrived in the emergency room with a rapid heart rate and feeling of “impending doom.”
    Based on pathophysiologic principles, the nurse knows the rapid heart rate could
    A) decrease renal perfusion and result in the development of ascites.
    B) be a result of catecholamines released from SNS that could increase the
    myocardial oxygen demand.
    C) desensitize the -adrenergic receptors leading to increase in norepinephrine
    levels.
    D) prolong the electrical firing from the SA node resulting in the development of a
    heart block.

Answer 27

Ans: B
Feedback:
An increase in sympathetic activity by stimulation of the -adrenergic receptors of the
heart leads to tachycardia, vasoconstriction, and arrhythmias. Acutely, tachycardia
significantly increases the workload of the heart, thus increasing myocardial O2 demand
and leading to cardiac ischemia, myocyte damage, and decreased contractility.
Decreased renal perfusion would activate the RAA system, increasing heart rate and BP
further. Ventricular arrhythmias are primarily seen at this stage of HF.

Question 28

28. A nurse educator in a geriatric medicine unit of a hospital is teaching a group of ne w
    graduates specific assessment criteria related to heart failure. Which of the following
    assessment criteria should the nurses prioritize in their practice?
    A) Measurement of urine output and mental status assessment
    B) Pupil response and counting the patient’s apical heart rate
    C) Palpation of pedal (foot) pulses and pain assessment
    D) Activity tolerance and integumentary inspection

Answer 28

Ans: A
Feedback:
Both increased and decreased urine output can be markers of heart failure, as ca n
changes in mental status not attributable to other factors. While heart auscultation, peda l
pulses, and activity tolerance are relevant parameters, integumentary inspection, pupil
response, and pain assessment are less likely to be relevant assessment components

Question 29

29. Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the
    nurse walks into his room, he is sitting on the edge of the bed, gasping for air, a nd his
    lips are dusty blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse
    oximeter reading of 81%. He starts coughing up frothy pink sputum. The priority
    intervention is to
    A) have medical supply department bring up suction equipment.
    B) apply oxygen via nasal cannula at 3 lpm.
    C) page the respiratory therapist to come give him a breathing treatment.
    D) call for emergency assistance utilizing hospital protocol

Answer 29

Ans: D
Feedback:
Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The
person is seen sitting and gasping for air. The pulse is rapid, the skin is moist, a nd the
lips/nail beds are cyanotic. Dyspnea and air hunger are accompanied by productive
cough with frothy and often blood-tinged sputum (pink). The patient needs t he
emergency responder team (including ICU nurses, physicians, respiratory therapist, e tc.)
to intervene. Applying O2 by mask will not increase his oxygen level fast enough, a nd
he is probably mouth breathing (gasping for air). Suction equipment may be neede d, but
getting a physician to give orders for diuretics and inotropic medications is the priority .
Of course respiratory therapist will arrive with the emergency assistance team.

Question 30

30. A female older adult client has presented with a new onset of shortness of brea th, and
    her physician has ordered meaNsUurReSmIenNtGofT hBer.bCrOaiMn natriuretic peptide (BNP) level s
    along with other diagnostic tests. What is the most accurate rationale for the physician’ s
    choice of blood work?
    A) BNP is released as a compensatory mechanism during heart failure, and
    measuring it can help differentiate the client’s dyspnea from a respiratory
    pathology.
    B) BNP is an indirect indicator of the effectiveness of the renin–angiotensin–
    aldosterone (RAA) system in compensating for heart failure.
    C) BNP levels correlate with the client’s risk of developing cognitive deficit s
    secondary to heart failure and consequent brain hypoxia.
    D) BNP becomes elevated in cases of cardiac asthma, Cheyne-Stokes respirations,
    and acute pulmonary edema, and measurement can gauge the severity of
    pulmonary effects.

Answer 30

Ans: A
Feedback:
BNP is released to compensate for heart failure, and elevated levels help confirm the
diagnosis of heart failure as opposed to respiratory etiologies. It does not measure the
effectiveness of the RAA system, the risk of cognitive deficits, or the specific severity
of pulmonary symptoms of heart failure

Question 31

31. A nurse is administering morning medications to a number of patients on a medical unit .
    Which of the following medication regimens is most suggestive that the patie nt has a
    diagnosis of heart failure?
    A) Antihypertensive, diuretic, antiplatelet aggregator
    B) Diuretic, ACE inhibitor, beta-blocker
    C) Anticoagulant, antihypertensive, calcium supplement
    D) Beta-blocker, potassium supplement, anticoagulant

Answer 31

Ans: B
Feedback:
Diuretics, ACE inhibitors, and beta-blockers are all commonly used in the treatment of
heart failure. Antiplatelet aggregators, calcium and potassium supplements, a nd
anticoagulants are less likely to relate directly to a diagnosis of heart failure.

Question 32

32. Emergency medical technicians respond to a call to find an 80-year-old ma n who is
    showing signs and symptoms of severe shock. Which of the following phenomena is
    most likely taking place?
    A) The man’s - and -adrenergic receptors have been activated, resulting in
    vasoconstriction and increased heart rate.
    B) Hemolysis and blood pooling are taking place in the man’s peripheral circulation.
    C) Bronchoconstriction and hyperventilation are initiated as a compensatory
    mechanism.
    D) Intracellular potassium and extracellular sodium levels are rising as a result of
    sodium–potassium pump failure

Answer 32

Ans: A
Feedback:
- and -adrenergic receptor activation is a central response to all types of shock.
Hemolysis is not a noted accompaniment to shock. Bronchodilation, not
bronchoconstriction, often results from adrenergic stimulation, and sodium–potassium
pump failure results in increased extracellular potassium and intracellular sodium.

Question 33

33. Following coronary bypass graft (CABG) surgery for a massive myocardial infarction
    (MI) located on his left ventricle, the ICU nurses are assessing for clinica l
    manifestations of cardiogenic shock. Which of the following assessment findings would
    confirm that the client may be in the early stages of cardiogenic shock? Select all tha t
    apply.
    A) Decreasing mean arterial pressure (MAP)
    B) Low BP reading of 86/60
    C) Urine output of 15 mL last hour
    D) Low pulmonary capillary wedge pressure (PCWP)
    E) Periods of confusion

Answer 33

Ans: A, B, C, E
Feedback:
Signs and symptoms of cardiogenic shock include indications of hypoperfusion with
hypotension (BP 96/60), decrease in mean arterial pressure (MAP) due to poor stroke
volume, and a narrow pulse pressure. Urine output decreases because of lower renal
perfusion pressures. PCWP is usually elevated due to increased preload. Periods of
confusion or altered cognition/consciousness may occur because of low cardiac output

Question 34

34. A 22-year-old male is experiencing hypovolemic shock following a fight in which his
    carotid artery was cut with a broken bottle. What immediate treatments are likely t o
    most benefit the man?
    A) Resolution of compensatory pulmonary edema and heart arrhythmias
    B) Infusion of vasodilators to foster perfusion inotropes to improve heart
    contractility
    C) Infusion of normal saline or Ringer lactate to maintain the vascular space
    D) Administration of oxygen and epinephrine to promote perfusion

Answer 34

Ans: C
Feedback:
Maintenance of vascular volume is the primary goal in the treatment of hyp ovolemic
shock and can be achieved in the short term through intravenous administration of sali ne
or Ringer lactate. Resolution of pulmonary edema and heart arrhythmias an d infusion of
vasodilators are associated with treatment of cardiogenic shock, while oxygen a nd
epinephrine would address anaphylactic shock

Question 35

35. A 30-year-old woman presents at a hospital after fainting at a memorial service, and she
    is diagnosed as being in neurogenic shock. Which of the following signs and symptom s
    is she most likely to display?
    A) Faster than normal heart rate
    B) Pain
    C) Dry and warm skin
    D) Increased thirst

Answer 35

Ans: C
Feedback:
In contrast to hypovolemic shock, in which the heart rate is faster than normal a nd the
skin is cold and clammy, a person in neurogenic shock is likely to have a slower tha n
normal heart rate and dry, warm skin. Fainting due to emotional causes is a transie nt
form of neurogenic shock, while increased thirst is an early sign of hypovolemic shock

Question 36

36. All of the following interventions are ordered stat. for a patient stung by a bee who is
    experiencing severe respiratory distress and faintness. Which priority intervention will
    the nurse administer first?
    A) Epinephrine (Adrenalin)
    B) Normal saline infusion
    C) Dexamethasone (Decadron)
    D) Diphenhydramine (Benadryl)

Answer 36

Ans: A
Feedback:
Treatment includes immediate discontinuation of the inciting agent; close monitoring of
CV and respiratory function; and maintenance of respiratory gas exchange, cardia c
output, and tissue perfusion. Epinephrine is given in an anaphylactic reaction because it
constricts blood vessels and relaxes the smooth muscle in the bronchioles.

Question 37

37. A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushe d
    skin accompanying his sudden decline in level of consciousness. The patient also ha s
    arterial and venous dilatation and a decrease in systemic vascular resistance. What i s
    this client’s most likely diagnosis?
    A) Hypovolemic shock
    B) Septic shock
    C) Neurogenic shock
    D) Obstructive shock

Answer 37

Ans: B
Feedback:
Low blood pressure accompanied by warm, flushed skin and cognitive changes is
indicative of septic shock, as is vessel dilatation and decreased vascular resistance.

Question 38

38. A client has many residual health problems related to compromised circulati on
    following recovery from septic shock. The nurse knows that which of the following
    complications listed below are a result of being diagnosed with septic shock a nd
    therefore should be assessed frequently? Select all that apply.
    A) Profound dyspnea due to acute respiratory distress syndrome
    B) Atelectasis resulting in injury to endothelial lining of pulmonary vessels, wh ich
    allows fluid/plasma to build up in alveolar spaces
    C) Formation of plaque within vessels supplying blood to the heart causing musc le
    damage and chest pain
    D) Acute renal failure due to decreased/impaired renal perfusion as a result of low
    BP
    E) Flushed skin and pounding headache that coincides with each heart beat

Answer 38

Ans: A, B, D
Feedback:
ARDS, atelectasis, and acute renal failure are all noted consequences of shoc k that
might be, respectively, treated by dialysis, an ostomy, or platelet transfusion. P laque
formation to heart vessels is not directly related to any of the identified consequences o f
shock. Pounding headache that coincides with each heart beat may occur with migra ine
headaches.

Question 39

39. A 3-year-old child with right-sided heart failure has been admitted for worsening of his
    condition. Which of the following assessments would be considered one of the earliest
    signs of systemic venous congestion in this toddler?
    A) Breathlessness with activity
    B) Excessive crying
    C) Enlargement of the liver
    D) Increased urine output

Answer 39

Ans: C
Feedback:
With RV function impaired, systemic venous congestion develops. Hepatomegaly due
to liver congestion often is one of the first signs on systemic venous congesti on in
infants and children

Question 40

40. A pediatrician is teaching a group of medical students about some of the particularities
    of heart failure in children as compared with older adults. Which of the physician n’s
    following statements best captures an aspect of these differences?
    A) “You’ll find that in pediatric patients, pulmonary edema is more often interstitial
    rather than alveolar, so you often won’t hear crackles.”
    B) “Because of their higher relative blood volume, jugular venous distention is a
    better assessment technique for suspected heart failure in young patients.”
    C) “Signs and symptoms in children may sometimes mimic those of shock, with a
    low blood pressure and high heart rate.”
    D) “Fever is a sign of heart failure in children that you are unlikely to see in older
    adults.”

Answer 40

Ans: A
Feedback:
The pulmonary edema that accompanies heart failure is more often interstitial rather
than alveolar in children. Jugular venous distention is difficult to gauge in children, and
low blood pressure and fever are not noted signs of heart failure in children.