CARDIO

116問 • 1年前

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Vickie, a call center agent, is admitted to the emergency department with a high blood pressure. The client reports a headache and states that she is seeing double. The nurse is about to measure Vicky's blood pressure (BP). The bell of the stethoscope is most commonly placed over which artery to obtain the BP?

Brachial

Vickie, a call center agent, is admitted to the emergency department with a high blood pressure. The client reports a headache and states that she is seeing double. Which action will the nurse in emergency department take in order to obtain an accurate baseline blood pressure (BP) for a new patient?

Have the patient sit with the feet flat on the floor.

Vickie, a call center agent, is admitted to the emergency department with a high blood pressure. The client reports a headache and states that she is seeing double. Vickie tells that nurse that she has no previous history of hypertension or other health problems. After reconfirming her BP, it is appropriate for the nurse to tell the patient that

more diagnostic testing may be needed to determine the cause of the hypertension.

Vickie, a call center agent, is admitted to the emergency department with a high blood pressure. The client reports a headache and states that she is seeing double. Which part of the eye is examined to see arterial changes caused by hypertension?

Retina

Vickie, a call center agent, is admitted to the emergency department with a high blood pressure. The client reports a headache and states that she is seeing double. Which information should the nurse include when teaching a patient with newly diagnosed hypertension?

Hypertension is usually asymptomatic until significant organ damage accurs.

The nurse just received the change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

43-year-old with a BP of 190/102 & chest pain

The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

Serum creatinine of 2.6 mg/dL

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage I hypertension in making needed dietary changes?

Have the patient record dietary intake for 3 days.

The unit is very busy and short staffed. What could be delegated to the nursing aide?

Obtain orthostatic blood pressure (BP) readings for older patients.

Which manifestation is an indication that a patient is having a hypertensive emergency?

A sudden rise In BP accompanied by neurologic impairment

Fredo, 56-year-old client presents with reports of a persistent, chronic cough unrelieved by sinus and cold medications or antacids. On assessment, the nurse notes that the client's blood pressure is 164/98 mm Hg, pulse 96 beats/min, and respirations 22/min. CT scan results indicate a 5-m enlargement of the ascending aorta. A patient has a 5-cm abdominal aortic aneurysm (AAA) that was discovered during a CT scan. When obtaining a nursing history from the patient, it will be most important to ask about all of the following symptoms, EXCEPT:

changes in bowel habits.

Fredo, 56-year-old client presents with reports of a persistent, chronic cough unrelieved by sinus and cold medications or antacids. On assessment, the nurse notes that the client's blood pressure is 164/98 mm Hg, pulse 96 beats/min, and respirations 22/min. CT scan results indicate a 5-m enlargement of the ascending aorta. Which sound is distinctly heard on auscultation over the abdominal region of a patient with AAA?

Bruit

Fredo, 56-year-old client presents with reports of a persistent, chronic cough unrelieved by sinus and cold medications or antacids. On assessment, the nurse notes that the client's blood pressure is 164/98 mm Hg, pulse 96 beats/min, and respirations 22/min. CT scan results indicate a 5-m enlargement of the ascending aorta. Upon seeing the CT scan results, Fredo's aneurysm is uniform in shape and shows a circumferential dilation of the artery. This type of aneurysm is classified by the nurse as:

Fusiform aneurysm

Fredo, 56-year-old client presents with reports of a persistent, chronic cough unrelieved by sinus and cold medications or antacids. On assessment, the nurse notes that the client's blood pressure is 164/98 mm Hg, pulse 96 beats/min, and respirations 22/min. CT scan results indicate a 5-m enlargement of the ascending aorta. Which symptom usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?

Lower back pain

Fredo, 56-year-old client presents with reports of a persistent, chronic cough unrelieved by sinus and cold medications or antacids. On assessment, the nurse notes that the client's blood pressure is 164/98 mm Hg, pulse 96 beats/min, and respirations 22/min. CT scan results indicate a 5-m enlargement of the ascending aorta. A patient with a small AAA is not a good surgical candidate. What should the nurse teach the patient is one of the best ways to prevent expansion of the lesion?

Control hypertension with prescribed therapy.

A nurse is performing an assessment with a client who is suspected to have a peripheral arterial disease (PAD). The patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should

palpate the dorsalis pedis and posterior tibial pulses.

A nurse is performing an assessment with a client who is suspected to have a peripheral arterial disease (PAD). The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find

prolonged capillary refill in all the toes.

A nurse is performing an assessment with a client who is suspected to have a peripheral arterial disease (PAD). For a client with severe PAD, the nurse should expect that the client may sleep most comfortably in which of the following positions?

Affected limb hanging from bed

A nurse is performing an assessment with a client who is suspected to have a peripheral arterial disease (PAD). When teaching the patient with PAD about modifying risk factors associated with the condition, what should the nurse emphasize?

Modifications will reduce the risk of other atherosclerotic conditions such as stroke.

A nurse is performing an assessment with a client who is suspected to have a peripheral arterial disease (PAD). In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says,

"I will use a heating pad on my feet at night to increase the circulation and warmth in my feet."

measure, record, and compare right and left calf and thigh circumferences.

Liro, a 65-year-old client with a diagnosis of deep vein thrombosis (DVT) and thrombophlebitis of the left lower extremity is admitted to a medical-surgical unit. Reported symptoms include left calf pain and tenderness with a sudden onset of swelling in the affected extremity. The provider has ordered thigh-high compression stockings to prevent chronic venous insufficiency. The nurse should Instruct the client to

apply the stockings in the morning upon awakening.

Liro, a 65-year-old client with a diagnosis of deep vein thrombosis (DVT) and thrombophlebitis of the left lower extremity is admitted to a medical-surgical unit. Reported symptoms include left calf pain and tenderness with a sudden onset of swelling in the affected extremity. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient's feet is to

put one pillow under thighs and two pillows under legs.

Liro, a 65-year-old client with a diagnosis of deep vein thrombosis (DVT) and thrombophlebitis of the left lower extremity is admitted to a medical-surgical unit. Reported symptoms include left calf pain and tenderness with a sudden onset of swelling in the affected extremity. What is the most important measure in the treatment of venous stasis ulcers?

Elastic compression stockings

Liro, a 65-year-old client with a diagnosis of deep vein thrombosis (DVT) and thrombophlebitis of the left lower extremity is admitted to a medical-surgical unit. Reported symptoms include left calf pain and tenderness with a sudden onset of swelling in the affected extremity. The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to:

sit with legs elevated.

Nurse Sharon is working in a Coronary Care Unit providing care to patients with angina and myocardial infarction (MI). Upon reading the chart of one of her patients, Nurse Sharon read a history of acute coronary syndrome. This means that Nurse Sharon's patient:

went through an abrupt interruption of oxygen supply to the heart muscle.

Nurse Sharon is working in a Coronary Care Unit providing care to patients with angina and myocardial infarction (MI). Which of the following is NOT a risk factor for MI?

Female gender

Nurse Sharon is working in a Coronary Care Unit providing care to patients with angina and myocardial infarction (MI). The nurse is reading the laboratory tests of the patient and confirms cardiac damage has transpired upon seeing an increased level of:

Troponin I

Nurse Sharon is working in a Coronary Care Unit providing care to patients with angina and myocardial infarction (MI). What is the primary reason for administering morphine to a client with a myocardial infarction?

To decrease the oxygen demand on the client's heart

Nurse Sharon is working in a Coronary Care Unit providing care to patients with angina and myocardial infarction (MI). Nurse Sharon finds a female client who had MI slumped on the side rails of the bed and unresponsive to shaking or shouting. Which should be Nurse Sharon's next action?

Call for help and note the time.

A patient is admitted to the Coronary Care unit for signs and symptoms of angina. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?

The patient states that the pain is resolved after rest.

A patient is admitted to the Coronary Care unit for signs and symptoms of angina. There are different types of angina. What is another term used for variant angina?

Prinzmetal angina

A patient is admitted to the Coronary Care unit for signs and symptoms of angina. When a patient reports chest pain, why must unstable angina be Identified and rapidly treated?

Spasm of a major coronary artery may cause total occlusion of the vessel with progression to MI.

A patient is admitted to the Coronary Care unit for signs and symptoms of angina. When instructing the patient with angina about taking sublingual nitroglycerin tablets, what should the nurse teach the patient?

To lie or sit and place one tablet under the tongue when chest pain occurs

A patient is admitted to the Coronary Care unit for signs and symptoms of angina. A chent with angina reports not being able to make all of the lifestyle changes recommended. Which of the following changes should the nurse suggest the client work on first?

Smoking cessation

He reports he has had no relief of the pain with rest or position change.

Eduardo, a 52-year-old politician is admitted to the emergency department with severe chest pain right after delivering a public speech. Upon evaluation of his chest pain, Eduardo has no abnormal serum cardiac markers 4 hours after the onset of pain. What noninvasive diagnostic test can be used to differentiate angina from other types of chest pain?

Exercise stress test

Eduardo, a 52-year-old politician is admitted to the emergency department with severe chest pain right after delivering a public speech. Upon evaluation of his chest pain, Eduardo has no abnormal serum cardiac markers 4 hours after the onset of pain. During the assessment, the nurse identifies crackles in the lungs and an S3) heart sound. Which complication of MI should the nurse suspect and further investigate?

Heart failure

Eduardo, a 52-year-old politician is admitted to the emergency department with severe chest pain right after delivering a public speech. Upon evaluation of his chest pain, Eduardo has no abnormal serum cardiac markers 4 hours after the onset of pain. After a myocardial infarction (MI), serum glucose levels and free fatty acid production both increase. What type of physiologic changes are these?

Metabolic

Eduardo, a 52-year-old politician is admitted to the emergency department with severe chest pain right after delivering a public speech. Upon evaluation of his chest pain, Eduardo has no abnormal serum cardiac markers 4 hours after the onset of pain. A patient who survived MI is exhibiting anxiety while being taught about possible lifestyle changes. The nurse evaluates that the anxiety is relieved when the patient states

"I'm going to take this recovery one step at a time."

Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. Prior to diagnosis of heart failure, a nurse is auscultating the chest of a patient for heart sounds. To auscultate for S3 or 54 gallops in the mitral area, the nurse listens with the

bell of the stethoscope with the patient sitting and leaning forward.

Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?

Observe for JVD with the head at 30 degrees.

Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. Which initial physical assessment finding would the nurse expect to be present in a patient with acute left sided heart failure?

Bubbling crackles and tachycardia

Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion The nurse enters the room of the client diagnosed with congestive heart fallure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

Assist the client to a sitting position.

Heart failure is the inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion The nurse determines that treatment of heart failure has been successful when the patient experiences

clear lung sounds and decreased MR.

The nurse is giving health education to a number of patients with heart failure in the medical surgical unit. She focuses her teachings on lifestyle modifications. Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?

The nurse obtains a bedside commode before administering furosemide.

The nurse is giving health education to a number of patients with heart failure in the medical surgical unit. She focuses her teachings on lifestyle modifications. Which Intervention will best assist the client with acute pulmonary edera in reducing anxiety and dyspnea?

Place the client in high Fowler's position with the legs down.

The nurse is giving health education to a number of patients with heart failure in the medical surgical unit. She focuses her teachings on lifestyle modifications. The nurse caring for a client with heart failure discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching?

"I should avoid grilling hamburgers."

The nurse is giving health education to a number of patients with heart failure in the medical surgical unit. She focuses her teachings on lifestyle modifications. A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective?

The client's weight decreases by 2.5 kg.

The nurse is giving health education to a number of patients with heart failure in the medical surgical unit. She focuses her teachings on lifestyle modifications. The nurse is providing discharge teaching to the client with heart fallure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching?

"I will call the provider if I have a cough lasting 3 or more days."

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-tead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

Reduce pain and myocardial oxygen demand.

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?

Blood pressure is 88/46.

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first:

Assess for changes in vital signs.

An older adult has chest pain and shortness of breath. The health care provider prescribes nitroglycerin tablets. What should the nurse instruct the client to do?

Put the tablet under the tongue until it is absorbed.

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should recelve the highest priority?

Confusion, urine output 15 mL over the last 2 hours, orthopnea.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:

Take the client's blood pressure.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:

Heart rate irregular with S3.

A 60-year-old comes Into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first:

Administer the morphine.

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to:

Prevent thrombophlebitis and blood clot formation.

Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?

Small, easily digested meals.

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission which of the following should the nurse assess first?

Blood pressure.

In which of the following positions should the nurse place a client with heart fallure who has orthopnea?

Sitting upright (high Fowler's position) with legs resting on the mattress.

The major goal of nursing care for a client with heart fallure and pulmonary edema is to:

Increase cardiac output.

The nurse should teach the client that signs of digoxin toxicity include which of the following?

Visual disturbances such as seeing yellow spots.

Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?

Tomato juice.

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Assess respiratory status.

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of doing which of the following?

Obtaining daily weights at the same time each day.

The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs?

Baked chicken, an apple, and a slice of white bread.

Which intervention would be most likely to assist the client with hypertension in maintaining an exercise program?

Tailoring a program to the client's needs and abilities.

The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?

Establish the client's daily smoking pattern.

A client is admitted to the hospital for evaluation of recurrent episodes of ventricular tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse Include in a teaching plan for this client?

"During the procedure, the doctor will insert a special wire to increase the heart rate and produce the irregular beats that caused your signs and symptoms."

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when palpation of the radial pulse reveals:

An irregular rhythm with pulse rate greater than 100.

When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following?

Stasis of blood in the atria.

A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD). The spouse expresses anxiety about what would happen if the device discharges during physical contact. The nurse should tell the spouse:

A warning device sounds before countershock, so there is time to move away.

An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours , after insertion of a permanent pacemaker is to:

Maintain cardiac conduction stability.

A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:

Pupils are reacting to light.

A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?

The number of premature ventricular contractions is decreasing.

During cardiopulmonary resuscitation (CPR), the xiphold process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compressions over the xiphoid process?

Liver.

When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:

2 inches (7.5 cm)

If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:

Reposition the airway.

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?

Ankle-brachial Index of 0.65.

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?

Pedal pulses.

A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

"I am able to walk further without leg pain."

The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:

Decreased blood flow.

The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:

Decreased blood flow.

When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:

Increased venous pressure.

The nurse Is unable to palpate the client's left pedal pulses. Which of the fottowing actions should the nurse take next?

Use a Doppler ultrasound device.

Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease?

High levels of low-density lipid (LDL) cholesterol.

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

Coldness of the left foot and ankle.

Which of the following clients is at greatest risk for Buerger's disease?

A 29-year-old male with a 14-year history of cigarette smoking.

The primary goal for the client with Buerger's disease is to prevent:

Thrombus formation.

A client with Buerger's disease smokes two packs of cigarettes a day. When helping a client change smoking behavior, it is important to know the client's:

Perception of the negative behavior.

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?

Bupropion.

The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing:

Inflammation and fibrosis of arteries, veins, and nerves.

When instructing a client who has been newly diagnosed with vasospastic disorder (Raynaud's phenomenon) about management of care, the nurse should discuss which of the following topics?

Follow-up monitoring for development of connective tissue disease.

Which of the following clients is at greatest risk for vasospastic disorder (Raynaud's phenomenon)?

Young women.

The client with vasospastic disorder (Raynaud's phenomenon) has coldness and numbness in the fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?

Pallor.

During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change from pink to white in the fingers. The nurse should first assess:

Radial pulse.

The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:

Wear gloves when handling ice or frozen foods.

100

The nurse is taking care of patients with hiatal hernia. The following questions apply. A client is admitted with a hiatal hernia. The nurse should assess the client for which symptom?

Esophageal reflux

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Kyla Angelique Son · 19問 · 1年前

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