Chapter 33 Assessment of the Cardiovascular System PDF

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Adult health practice sheet on the cardiovascular system. Potential test questions...

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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Chapter33:AssessmentoftheCardiovascularSystem MULTIPLECHOICE 1.Anurseassessesaclientwhohadamyocardialinfarctionandishypotensive.Whichadditionalassessment findingshouldthenurseexpect? a.Heartrateof120beats/min b.Cool,clammyskin c.Oxygensaturationof90% d.Respiratoryrateof8breaths/min ANS:A Whenaclientexperienceshypotension,baroreceptorsintheaorticarchsenseapressuredecreaseinthe vessels.Theparasympatheticsystemrespondsbylesseningtheinhibitoryeffectonthesinoatrialnode.This resultsinanincreaseinheartrateandrespiratoryrate.Thistachycardiaisanearlyresponseandisseeneven whenbloodpressureisnotcriticallylow.Anincreasedheartrateandrespiratoryratewillcompensateforthe lowbloodpressureandmaintainoxygensaturationsandperfusion.Theclientmaynotbeabletocompensate forlong,anddecreasedoxygenationandcool,clammyskinwilloccurlater. DIF:Applying/ApplicationREF:652 KEY:Coronaryperfusion|hemodynamics MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 2.Anurseassessesaclientafteradministeringaprescribedbetablocker.Whichassessmentshouldthenurse expecttofind? a.Bloodpressureincreasedfrom98/42mmHgto132/60mmHg b.Respiratoryratedecreasedfrom25breaths/minto14breaths/min c.Oxygensaturationincreasedfrom88%to96% NURSINGTB.COM d.Pulsedecreasedfrom100beats/minto80beats/min ANS:D Betablockersblockthestimulationofbeta1-adrenergicreceptors.Theyblockthesympathetic(fight-or-flight) responseanddecreasetheheartrate(HR).ThebetablockerwilldecreaseHRandbloodpressure,increasing ventricularfillingtime.Itusuallydoesnothaveeffectsonbeta2-adrenergicreceptorsites.Cardiacoutputwill dropbecauseofdecreasedHR. DIF:Applying/ApplicationREF:644 KEY:Betablocker|medication MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 3.Anurseassessesclientsonamedical-surgicalunit.Whichclientshouldthenurseidentifyashavingthe greatestriskforcardiovasculardisease? a.An86-year-oldmanwithahistoryofasthma b.A32-year-oldAsian-Americanmanwithcolorectalcancer c.A45-year-oldAmericanIndianwomanwithdiabetesmellitus d.A53-year-oldpostmenopausalwomanwhoisonhormonetherapy ANS:C TheincidenceofcoronaryarterydiseaseandhypertensionishigherinAmericanIndiansthaninwhitesor AsianAmericans.Diabetesmellitusincreasestheriskforhypertensionandcoronaryarterydiseaseinpeopleof anyraceorethnicity.Asthma,colorectalcancer,andhormonetherapydonotincreaseriskforcardiovascular disease. DIF:Understanding/ComprehensionREF:646 KEY:Healthscreening MSC:IntegratedProcess:NursingProcess:Assessment

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 4.Anurseassessesanolderadultclientwhohasmultiplechronicdiseases.Theclientsheartrateis48 beats/min.Whichactionshouldthenursetakefirst? a.Documentthefindinginthechart. b.Initiateexternalpacing. c.Assesstheclientsmedications. d.Administer1mgofatropine. ANS:C Pacemakercellsintheconductionsystemdecreaseinnumberasapersonages,resultinginbradycardia.The nurseshouldcheckthemedicationreconciliationformedicationsthatmightcausesuchadropinheartrate, thenshouldinformthehealthcareprovider.Documentationisimportant,butitisnotthepriorityaction.The heartrateisnotlowenoughforatropineoranexternalpacemakertobeneeded. DIF:Applying/ApplicationREF:647 KEY:Medication|healthscreening MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 5.Anemergencyroomnurseobtainsthehealthhistoryofaclient.Whichstatementbytheclientshouldalert thenursetotheoccurrenceofheartfailure? a.IgetshortofbreathwhenIclimbstairs. b.Iseehalosfloatingaroundmyhead. c.Ihavetroublerememberingthings. d.Ihavelostweightoverthepastmonth. ANS:A Dyspneaonexertionisanearlymanifestationofheartfailureandisassociatedwithanactivitysuchasstair NURSINGTB.COM climbing.Theotherfindingsarenotspecifictoearlyoccurrenceofheartfailure. DIF:Applying/ApplicationREF:649 KEY:Healthscreening|heartfailure MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:HealthPromotionandMaintenance 6.Anurseobtainsthehealthhistoryofaclientwhoisnewlyadmittedtothemedicalunit.Whichstatementby theclientshouldalertthenursetothepresenceofedema? a.Iwakeuptogotothebathroomatnight. b.Myshoesfittighterbytheendoftheday. c.Iseemtobefeelingmoreanxiouslately. d.Idrinkatleasteightglassesofwateraday. ANS:B Weightgaincanresultfromfluidaccumulationintheinterstitialspaces.Thisisknownasedema.Thenurse shouldnotewhethertheclientfeelsthathisorhershoesorringsaretight,andshouldobserve,whenpresent, anindentationaroundthelegwherethesocksend.Theotheranswersdonotdescribeedema. DIF:Applying/ApplicationREF:649 KEY:Heartfailure|vascularperfusion MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 7.Anurseassessesanolderadultclientwhoisexperiencingamyocardialinfarction.Whichclinical manifestationshouldthenurseexpect? a.Excruciatingpainoninspiration b.Leftlateralchestwallpain c.Disorientationandconfusion d.Numbnessandtinglingofthearm

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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ANS:C Inolderadults,disorientationorconfusionmaybethemajormanifestationofmyocardialinfarctioncausedby poorcardiacoutput.Painmanifestationsandnumbnessandtinglingofthearmcouldalsoberelatedtothe myocardialinfarction.However,thenurseshouldbemoreconcernedaboutthenewonsetofdisorientationor confusioncausedbydecreasedperfusion. DIF:Applying/ApplicationREF:651 KEY:Coronaryperfusion|olderadult MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 8.Anurseassessesaclient2hoursafteracardiacangiographyviatheleftfemoralartery.Thenursenotesthat theleftpedalpulseisweak.Whichactionshouldthenursetake? a.Elevatethelegandapplyasandbagtotheentrancesite. b.Increasetheflowrateofintravenousfluids. c.Assessthecolorandtemperatureoftheleftleg. d.Documentthefindingasleftpedalpulseof+1/4. ANS:C Lossofapulsedistaltoanangiographyentrysiteisserious,indicatingapossiblearterialobstruction.The pulsemaybefaintbecauseofedema.Theleftpulseshouldbecomparedwiththeright,andpulsesshouldbe comparedwithpreviousassessments,especiallybeforetheprocedure.Assessingcolor(pale,cyanosis)and temperature(cool,cold)willidentifyadecreaseincirculation.Onceallperipheralandvascularassessment dataareacquired,theprimaryhealthcareprovidershouldbenotified.Simplydocumentingthefindingsis inappropriate.Thelegshouldbepositionedbelowtheleveloftheheartordanglingtoincreasebloodflowto thedistalportionoftheleg.Increasingintravenousfluidswillnotaddresstheclientsproblem. DIF:Applying/ApplicationREF:658 NURSINGTB.COM KEY:Assessment/diagnosticexamination|vascularperfusion MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 9.Anurseassessesaclientwhoisrecoveringafteraleft-sidedcardiaccatheterization.Whichassessment findingrequiresimmediateintervention? a.Urinaryoutputlessthanintake b.Bruisingattheinsertionsite c.Slurredspeechandconfusion d.Discomfortintheleftleg ANS:C Aleft-sidedcardiaccatheterizationspecificallyincreasestheriskforacerebralvascularaccident.Achangein neurologicstatusneedstobeactedonimmediately.Discomfortandbruisingareexpectedatthesite.Ifintake decreases,aclientcanbecomedehydratedbecauseofdyeexcretion.Thesecondinterventionwouldbeto increasetheclientsfluidstatus.Neurologicchangeswouldtakepriority. DIF:Applying/ApplicationREF:658 KEY:Assessment/diagnosticexamination|vascularperfusion MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 10.Anurseassessesaclientwhoisscheduledforacardiaccatheterization.Whichassessmentshouldthenurse completepriortothisprocedure? a.Clientslevelofanxiety b.Abilitytoturnselfinbed c.Cardiacrhythmandheartrate d.Allergiestoiodine-basedagents ANS:D

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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Beforetheprocedure,thenurseshouldascertainwhethertheclienthasanallergytoiodine-containing preparations,suchasseafoodorlocalanesthetics.Thecontrastmediumusedduringtheprocedureisiodine based.Thisallergycancausealife-threateningreaction,soitisahighpriority.Second,itisimportantforthe nursetoassessanxiety,mobility,andbaselinecardiacstatus. DIF:Remembering/KnowledgeREF:657 KEY:Assessment/diagnosticexamination|allergies|patientsafety MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 11.Anursecaresforaclientwhoisprescribedmagneticresonanceimaging(MRI)oftheheart.Theclients healthhistoryincludesapreviousmyocardialinfarctionandpacemakerimplantation.Whichactionshouldthe nursetake? a.ScheduleanelectrocardiogramjustbeforetheMRI. b.NotifythehealthcareproviderbeforeschedulingtheMRI. c.Callthephysicianandrequestalaboratorydrawforcardiacenzymes. d.InstructtheclienttoincreasefluidintakethedaybeforetheMRI. ANS:B ThemagneticfieldsoftheMRIcandeactivatethepacemaker.Thenurseshouldcallthehealthcareprovider andreportthattheclienthasapacemakersotheprovidercanorderotherdiagnostictests.Theclientdoesnot needanelectrocardiogram,cardiacenzymes,orincreasedfluids. DIF:Applying/ApplicationREF:661 KEY:Assessment/diagnosticexamination|patientsafety MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 12.Anurseassessesaclientwhoisrecoveringfromamyocardialinfarction.Theclientspulmonaryartery pressurereadingis25/12mmHg.Whichactionshouldthenursetakefirst? NURSINGTB.COM a.Comparetheresultswithpreviouspulmonaryarterypressurereadings. b.Increasetheintravenousfluidratebecausethesereadingsarelow. c.Immediatelynotifythehealthcareprovideroftheelevatedpressures. d.Documentthefindingintheclientschartastheonlyaction. ANS:A Normalpulmonaryarterypressuresrangefrom15to26mmHgforsystolicandfrom5to15mmHgfor diastolic.Althoughthisclientsreadingsarewithinnormallimits,thenurseneedstoassessanytrendsthatmay indicateaneedformedicaltreatmenttopreventcomplications.Thereisnoneedtoincreaseintravenousfluids ornotifytheprovider. DIF:Applying/ApplicationREF:652 KEY:Coronaryperfusion|assessment/diagnosticexamination|vascularperfusion MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 13.Anursecaresforaclientwhohasan80%blockageoftherightcoronaryartery(RCA)andisscheduledfor bypasssurgery.Whichinterventionshouldthenursebepreparedtoimplementwhilethisclientwaitsfor surgery? a.AdministrationofIVfurosemide(Lasix) b.Initiationofanexternalpacemaker c.Assistancewithendotrachealintubation d.Placementofcentralvenousaccess ANS:B TheRCAsuppliestherightatrium,therightventricle,theinferiorportionoftheleftventricle,andthe atrioventricular(AV)node.Italsosuppliesthesinoatrialnodein50%ofpeople.Iftheclienttotallyoccludes theRCA,theAVnodewouldnotfunctionandtheclientwouldgointoheartblock,soemergencypacing shouldbeavailablefortheclient.Furosemide,intubation,andcentralvenousaccesswillnotaddressthe

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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primarycomplicationofRCAocclusion,whichisAVnodemalfunction. DIF:Applying/ApplicationREF:642 KEY:Coronaryperfusion|assessment/diagnosticexamination|cardiacelectricalconduction MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 14.Anurseteachesaclientwithdiabetesmellitusandabodymassindexof42whoisathighriskforcoronary arterydisease.Whichstatementrelatedtonutritionshouldthenurseincludeinthisclientsteaching? a.Thebestwaytoloseweightisahigh-protein,low-carbohydratediet. b.Youshouldbalanceweightlosswithconsumingnecessarynutrients. c.Anutritionistwillprovideyouwithinformationaboutyournewdiet. d.Ifyouexercisemorefrequently,youwontneedtochangeyourdiet. ANS:B ClientsatriskforcardiovasculardiseasesshouldfollowtheAmericanHeartAssociationguidelinestocombat obesityandimprovecardiachealth.Thenurseshouldencouragetheclienttoeatvegetables,fruits,unrefined whole-grainproducts,andfat-freedairyproductswhilelosingweight.High-proteinfooditemsareoftenhigh infatandcalories.Althoughthenutritionistcanassistwithclienteducation,thenurseshouldincludenutrition educationandassisttheclienttomakehealthydecisions.Exercisingandeatingnutrient-richfoodsareboth importantcomponentsinreducingcardiovascularrisk. DIF:Applying/ApplicationREF:647 KEY:Nutrition|patienteducationMSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 15.Anursecaresforaclientwhohasadvancedcardiacdiseaseandstates,Iamhavingtroublesleepingat night.Howshouldthenurserespond? a.Iwillconsulttheprovidertoprescribeasleepstudytodeterminetheproblem. b.Youbecomehypoxicwhilesleeping;oxygentherapyvianasalcannulawillhelp. NURSINGTB.COM c.Acontinuouspositiveairwaypressure,orCPAP,breathingmaskwillhelpyoubreatheatnight. d.Usepillowstoelevateyourheadandchestwhileyouaresleeping. ANS:D Theclientisexperiencingorthopnea(shortnessofbreathwhilelyingflat).Thenurseshouldteachtheclientto elevatetheheadandchestwithpillowsorsleepinarecliner.Asleepstudyisnotnecessarytodiagnosethis client.OxygenandCPAPwillnothelpaclientwithorthopnea. DIF:Understanding/ComprehensionREF:649 KEY:Heartfailure|respiratorydistress/failure|patienteducation MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 16.Anursecaresforaclientwhoisrecoveringfromamyocardialinfarction.Theclientstates,Iwillneedto stopeatingsomuchchilitokeepthatindigestionpainfromreturning.Howshouldthenurserespond? a.Chiliishighinfatandcalories;itwouldbeagoodideatostopeatingit. b.Theproviderhasprescribedanantacidforyoutotakeeverymorning. c.Whatdoyouunderstandaboutwhathappenedtoyou? d.Whendidyoustartexperiencingthisindigestion? ANS:C Clientswhoexperiencemyocardialinfarctionoftenrespondwithdenial,whichisadefensemechanism.The nurseshouldasktheclientwhatheorshethinkshappened,orwhattheillnessmeanstohimorher.Theother responsesdonotaddresstheclientsmisconceptionaboutrecentpainandthecauseofthatpain. DIF:Applying/ApplicationREF:654 KEY:Coronaryperfusion|copingMSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PsychosocialIntegrity

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MEDICAL SURGICAL NURSING 9TH EDITION IGNATAVICIUS TEST BANK TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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17.Anursepreparesaclientforcoronaryarterybypassgraftsurgery.Theclientstates,IamafraidImightdie. Howshouldthenurserespond? a.Thisisaroutinesurgeryandtheriskofdeathisverylow. b.Wouldyouliketospeakwithachaplainpriortosurgery? c.Tellmemoreaboutyourconcernsaboutthesurgery. d.Whatsupportsystemsdoyouhavetoassistyou? ANS:C Thenurseshoulddiscusstheclientsfeelingsandconcernsrelatedtothesurgery.Thenurseshouldnotprovide falsehopeorpushtheclientsconcernsoffonthechaplain.Thenurseshouldaddresssupportsystemsafter addressingtheclientscurrentissue. DIF:Applying/ApplicationREF:661 KEY:Assessment/diagnosticexamination|coping|anxiety MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PsychosocialIntegrity 18.Anemergencydepartmentnursetriagesclientswhopresentwithchestdiscomfort.Whichclientshouldthe nurseplantoassessfirst? a.A42-year-oldfemalewhodescribesherpainasadullachewithnumbnessinherfingers b.A49-year-oldmalewhoreportsmoderatepainthatisworseoninspiration c.A53-year-oldfemalewhoreportssubsternalpainthatradiatestoherabdomen d.A58-year-oldmalewhodescribeshispainasintensestabbingthatspreadsacrosshischest ANS:D Allclientswhohavechestpainshouldbeassessedmorethoroughly.Todeterminewhichclientshouldbeseen first,thenursemustunderstandcommondifferencesinpaindescriptions.Intensestabbing,vise-likesubsternal painthatspreadsthroughtheclientschest,arms,jaw,back,orneckisindicativeofamyocardialinfarction. Thenurseshouldplantoseethisclientfirsttopreventcardiaccelldeath.Adullachewithnumbnessinthe NURSINGTB.COM fingersisconsistentwithanxiety.Painthatgetsworsewithinspirationisusuallyrelatedtoapleuropulmonary problem.Painthatspreadstotheabdomenisoftenassociatedwithanesophageal-gastricproblem,especially whenthispainisexperiencedbyamaleclient.Femaleclientsmayexperienceabdominaldiscomfortwitha myocardialevent.Althoughclientswithanxiety,pleuropulmonary,andesophageal-gastricproblemsshouldbe seen,theyarenotahigherprioritythanmyocardialinfarction. DIF:Applying/ApplicationREF:658 KEY:Assessment/diagnosticexamination MSC:IntegratedProcess:NursingProcess:Planning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 19.Anurseauscultatedhearttonesonanolderadultclient.Whichactionshouldthenursetakebasedonheart tonesheard? (Clickthemediabuttontoheartheaudioclip.) a.Administeradiuretic. b.Documentthefinding. c.DecreasetheIVflowrate. d.Evaluatetheclientsmedications. ANS:B ThesoundheardisanatrialgallopS4.Anatrialgallopmaybeheardinolderclientsbecauseofastiffened ventricle.Thenurseshoulddocumentthefinding,butnootherintervention...