The nurse is aware that the muscle layer of the heart, which is
responsible for the heart's contraction, is the:
a.
endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.
ANS: D
The myocardium is the specialized muscle layer that
allows the heart to contract.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page
1533
OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation
The nurse clarifies that the master pacemaker of the heart is
the:
a. left ventricle.
b. atrioventricular (AV)
node.
c. sinoatrial (SA) node.
d. bundle of His.
ANS: C
The SA node is the master pacemaker of the heart.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1533 OBJ: 10
TOP: Acute myocardial infarction
KEY: Nursing Process Step: Planning
The nurse is aware that the symptoms of an impending myocardial
infarction (MI) differ in women because acute chest pain is not
present. Women are frequently misdiagnosed as having:
a.
hepatitis A.
b. indigestion.
c. urinary infection.
d.
menopausal complications.
ANS: B
Indigestion, gallbladder attack, anxiety attack, and
depression are frequent misdiagnoses for women having an MI.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1559 OBJ: 16
TOP: MIs in women
KEY: Nursing Process Step: Planning
The nurse identifies the "LUBB" sound of the
"LUBB/DUBB" of the cardiac cycle as the sound of the:
a. AV valves closing.
b. closure of the semilunar
valves.
c. contraction of the papillary muscles.
d.
contraction of the ventricles.
ANS: A
The LUBB is the first sound of a low pitch heard when the
AV valves close.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1535 OBJ: 4
TOP: Lubb sound KEY: Nursing Process Step: Assessment
A patient is admitted from the emergency department. The emergency
department physician notes the patient has a diagnosis of heart
failure with a New York Heart Association (NYHA) classification of IV.
This indicates the patient's condition as:
a. moderate heart
failure.
b. severe heart failure.
c. congestive heart
failure.
d. negligible heart failure.
ANS: B
Class IV: Severe; patient unable to perform any physical
activity without discomfort. Angina or symptoms of cardiac
inefficiency may develop at rest.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1565, Box 47-3
OBJ: 9 TOP: Classification of heart failure
KEY: Nursing Process
Step: Assessment
The nurse assesses that the home health patient has no signs or
symptoms of heart failure, but does have a history of rheumatic fever
and has been recently diagnosed with diabetes mellitus. The nurse is
aware that using the American College of Cardiology and the American
Heart Association (ACC/AHA) staging, this patient would be a:
a.
stage A.
b. stage B.
c. stage C.
d. stage D.
ANS: A
The ACC/AHA staging describes stage A as a person without
symptoms of heart failure, but with primary conditions associated with
the development of the disease.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3
OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment
The nurse caring for a patient recovering from a myocardial infarct
who is on remote telemetry recognizes the need for added instruction
when the patient says:
a. "I can ambulate in the hallway
with this gadget on."
b. "I always take off the
telemetry device when I shower."
c. "My EKG is being
watched by one of the nurses in CCU on the home unit."
d.
"I am able to sleep just fine with this device on."
ANS: B
Remote telemetry allows the patient to be on a separate
unit, but be monitored in a central location. The patients can be
ambulatory and can sleep with the monitor on. They should not remove
the monitor to shower.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ: 6
TOP: Remote telemetry
KEY: Nursing Process Step: Evaluation
The nurse assesses pitting edema that can be depressed approximately
inch and refills in 15 seconds. The nurse would document this
assessment as:
a. +1 edema.
b. +2 edema.
c. +3
edema.
d. +4 edema.
ANS: B
A +2 edema can be documented if the skin can be depressed
inch and respond within 15 seconds.
PTS: 1 DIF: Cognitive Level:
Analysis REF: Page 1565, Table 47-5 OBJ: 9 TOP: Pitting
edema
KEY: Nursing Process Step: Assessment
What do dark or "cold" spots on a thallium scan
indicate?
a. Tissue with adequate blood supply
b. Dilated
vessels
c. Areas of neoplastic growth
d. Tissue that has
inadequate perfusion
ANS: D
Thallium scans show adequate perfused areas by the
collection of thallium. Dark spots or "cold spots" indicate
tissues that have inadequate perfusion.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ: 6
TOP: Thallium scan
KEY: Nursing Process Step: Planning
The nurse recognizes the echocardiogram report that shows an ejection
factor of 42% as an indication of:
a. normal heart
action.
b. mild heart failure.
c. moderate heart
failure.
d. severe heart failure.
ANS: C
An ejection factor (cardiac output) of 42% indicates
moderate heart failure.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1540 OBJ: 6
TOP: Heart failure KEY: Nursing Process Step: Assessment
The nurse takes into consideration that age-related changes can
affect the peripheral circulation because of:
a. sclerosed blood
vessels.
b. hypotension.
c. inactivity.
d. poor nutrition.
ANS: A
Aging causes sclerotic changes in the blood vessels that
lead to decreased elasticity and narrowing of the vessel lumen.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542,
Lifespan OBJ: 16 TOP: Endocarditis KEY: Nursing Process Step: Planning
The nurse assessing a cardiac monitor notes that the cardiac
complexes each have a P wave followed by a QRS and a T. The rate is
120. The nurse recognizes this arrhythmia as:
a. sinus
bradycardia.
b. atrial fibrillation.
c. sinus
tachycardia.
d. ventricular tachycardia.
ANS: C
Sinus tachycardia has a P wave followed by the QRS and
the T. All the components of the complex are present and in the
correct order, but the rate is over 100 beats a minute.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1545 OBJ: 8
TOP: Arrhythmias KEY: Nursing Process Step: Assessment
After an influenza-like illness, the patient complains of chills and
small petechiae in his mouth and his legs. A heart murmur is
detectable. These are characteristic signs of:
a. congestive
heart failure.
b. heart block.
c. aortic stenosis.
d.
infective endocarditis.
ANS: D
Collection of subjective data includes noting patient
complaints of influenza-like symptoms with recurrent fever, undue
fatigue, chest pain, and chills. Objective data may reveal the
significant signs of petechiae in the conjunctiva and mouth. Both
subjective data and objective data are indicative of infective endocarditis.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1576 OBJ: 13
TOP: Endocarditis KEY: Nursing Process Step: Assessment
The nurse notes a run of three ventricular contractions (PVC) that
are not preceded by a P wave. This particular arrhythmia can progress
into:
a. atrial fibrillation and possible emboli.
b. sinus
tachycardia and syncope.
c. ventricular tachycardia and death.
d. sinus bradycardia
and fatigue.
ANS: C
PVCs are capable of progressing into ventricular
tachycardia and death.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1547 OBJ: 10
TOP: PVCs KEY: Nursing Process Step: Assessment
The nurse reminds the patient who is on Coumadin for the treatment of
atrial fibrillation that the ideal is to maintain the international
normalized ratio (INR) at between:
a. 1 and 2.
b. 2 and
3.
c. 3 and 4.
d. 4 and 5.
ANS: B
The desired INR for the monitoring of anticoagulant
therapy is between 2 and 3.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1546
OBJ:
8 TOP: INR KEY: Nursing Process Step: Implementation
What should a person with unstable angina avoid?
a. Walking
outside
b. Eating red meat
c. Swimming in warm pool
d.
Shoveling snow
ANS: D
The person with angina should avoid exposure to cold,
heavy exercise, eating heavy meals, and emotional stress.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1552 OBJ: 9
TOP: Angina KEY: Nursing Process Step: Planning
The elderly patient with angina pectoris says she is unsure how she
should take nitroglycerin when she has an attack. The nurse's most
helpful response would be:
a. "Continue to take
nitroglycerin sublingually at 5-minute intervals until the pain
is
relieved."
b. "If the pain is not relieved
after three doses of nitroglycerin at 5-minute intervals,
call
your physician and come to the hospital."
c. "When
nitroglycerin is not relieving the pain, lie down and
rest."
d. "Use oxygen at home to relieve pain when
nitroglycerin is not successful."
ANS: B
Administer prescribed nitroglycerin. Repeat every 5
minutes, three times. If pain is unrelieved, notify the physician.
Nitroglycerin administered sublingually usually relieves angina
symptoms but does not relieve the pain from an MI. Administering
nitroglycerin more than three times will probably not relieve the pain.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1545 OBJ: 9
TOP: Angina pectoris
KEY: Nursing Process Step: Implementation
The patient has been hospitalized for hypertensive episodes three
times in the last months. While preparing the discharge teaching plan,
the nurse assesses that he does not comply with his medication
regimen. The nurse's immediate course of action would be to:
a.
reteach him about his medications.
b. have a serious talk with
him and his family about compliance.
c. arrange for home visits
after discharge.
d. collect more information to identify his
reasons for noncompliance.
ANS: D
Nursing interventions include measures to prevent disease
progression and complications. Reteaching about medication will not
identify the cause of noncompliance.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1556 OBJ: 18
TOP: Noncompliance
KEY: Nursing Process Step: Planning
What is the major cause of cardiac valve disease?
a. Rheumatic
fever
b. Long history of malnutrition
c. Drug abuse
d. Obesity
ANS: A
Rheumatic fever, a streptococcal infection, is the major
cause of cardiac valve disease.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1572 OBJ:
10 TOP: Valvular disease
KEY: Nursing Process Step: Implementation
The patient has a total cholesterol of 190 with a high-density lipid
(HDL) of 110 and a low-density lipid (LDL) of 80. The nurse's reaction
is one of:
a. satisfaction. This is good cholesterol
control.
b. determination. This is evidence that more instruction
is necessary.
c. inquiry. This needs to clarified as to the cause
of noncompliance with the drug
protocol.
d. regret. This
shows very poor cholesterol control.
ANS: A
Total cholesterol of less than 200 is desirable. The
higher the number of HDLs the better. A high number of LDLs puts the
patient at risk for heart disease.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1541, Box 47-1
OBJ: 6 TOP: Lipid studies
KEY: Nursing Process Step: Planning
A patient, age 72, was admitted to the medical unit with a diagnosis
of angina pectoris. Characteristic signs and symptoms of angina
pectoris include:
a. substernal pain that radiates down the left
arm.
b. epigastric pain that radiates to the jaw.
c.
indigestion, nausea, and eructation.
d. fatigue, shortness of
breath, and dyspnea.
ANS: A
The pain often radiates down the left inner arm to the
little finger and also upward to the shoulder and jaw.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1553,
figure 47-1 OBJ: 9 TOP: Angina pectoris
KEY: Nursing Process
Step: Assessment
A patient admitted to the emergency room with a possible myocardial
infarction (MI) has reports back from the laboratory. Which laboratory
report is specific for myocardial damage?
a. CK-MB
b.
Elevated white count
c. Elevated sedimentation rate
d. Low
level of sodium
ANS: A
The CK-MB is elevated when there is infarcted myocardial
muscle. The elevated white count, low sodium, and ESR are nonspecific.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1559 OBJ: 6
TOP: CK-MB KEY: Nursing Process Step: Assessment
The patient, age 26, is hospitalized with cardiomyopathy. While
obtaining a nursing history from her, the nurse recognizes that the
increased incidence of cardiomyopathy in young adults who have minimal
risk factors for cardiovascular disease is related to which
factor(s)?
a. Cocaine use
b. Viral infections
c.
Vitamin B1 deficiencies
d. Pregnancy
ANS: A
Cardiomyopathy caused by cocaine abuse is seen more
frequently than ever before. Cocaine also causes high circulating
levels of catecholamines, which may further damage myocardial cells,
leading to ischemic or dilated cardiomyopathy. The cardiomyopathy
produced is difficult to treat. Interventions deal mainly with the HF
that ensues.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1578 OBJ: 14
TOP: Cardiomyopathy
KEY: Nursing Process Step: Assessment
The patient has become very dyspneic, respirations are 32, and the
pulse is 100. The patient is coughing up frothy red sputum. What
should be the initial nursing intervention?
a. Lay the patient
flat to reduce hypotension and the symptoms of cardiogenic
shock.
b. Place patient in side-lying position to reduce the
symptoms of atrial fibrillation.
c. Place patient upright with legs in dependent position to
reduce the symptoms of
pulmonary edema.
d. Lay the patient
flat and elevate the feet to increase venous return in cardiogenic
shock.
ANS: C
Signs and symptoms of pulmonary edema are restlessness;
vague uneasiness; agitation; disorientation; diaphoresis; severe
dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing
large quantities of blood-tinged, frothy sputum; audible wheezing and
crackles; and cold extremities. The legs in a dependent position will
decrease venous return and ease the pulmonary edema.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1572 OBJ: 12
TOP: Pulmonary edema
KEY: Nursing Process Step: Implementation
The nurse caring for a patient recovering from a myocardial
infarction (MI) teaches which method to avoid the Valsalva maneuver
during a bowel movement?
a. Mouth breathing
b. Pursing the
lips and whistling
c. Taking a deep breath and holding it
d.
Breathing rapidly through the nose
ANS: A
Mouth breathing will lessen the severity of straining and
will decrease the effect of the Valsalva maneuver on intrathoracic pressure.
PTS: 1 DIF: Cognitive Level: Application REF: Page
1562
OBJ: 9 TOP: MI KEY: Nursing Process Step: Implementation
The nurse reminds the patient that the National Heart, Lung, and
Blood Institute recommends a lipid study every years.
a.
2
b. 3
c. 4
d. 5
ANS: D
The National Heart, Lung, and Blood Institute recommend a
lipid study every 5 years for all Americans, but especially for the
older adult.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542 OBJ: 6
TOP: Lipid studies
KEY: Nursing Process Step: Implementation
During a health interview by the home health nurse, which patient
complaint suggests left-sided heart failure?
a. "I have to
sleep in my recliner and I have this hacking cough."
b.
"I have no appetite and I have lost 3 lb in the last week."
c. "I have to urinate every 2 hours, even during the
night."
d. "I go barefoot most of the time because my
feet are so hot."
ANS: A
Left ventricular failure; the first is signs and symptoms
of decreased cardiac output. The second is pulmonary congestion. Signs
and symptoms of this condition include dyspnea, orthopnea, pulmonary
crackles, hemoptysis, and cough.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3
OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Planning
The home health nurse caring for a patient with infective
endocarditis overhears the patient making a dental appointment for an
extraction next month. Which question is most important for the nurse
to ask?
a. "Do you have a toothache?"
b.
"Have you contacted your physician about your dental
appointment?"
c. "Is your dentist board
certified?"
d. "Do you think you should wait that long
for your tooth extraction?'
ANS: B
Patients with endocarditis are put on a protocol of
prophylactic antibiotics for any invasive procedure. The dentist and
physician should be contacted before the extraction.
PTS: 1 DIF: Cognitive Level: Application REF: Page
1574
OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Implementation
The home health nurse warns the patient who is taking warfarin
(Coumadin) for anticoagulant therapy for thrombophlebitis to stop
taking the herbal remedy of ginkgo because ginkgo can:
a. cause
severe episodes of diarrhea.
b. cause a severe skin eruption if
taken with Coumadin.
c. increase the action of the
Coumadin.
d. cause the Coumadin to be less effective.
ANS: C
Herbal remedies such as ginkgo, garlic, angelica, and red
clover can increase (potentiate) the action of the Coumadin.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page
1589
OBJ: 21 TOP: Coumadin KEY: Nursing Process Step: Implementation
What is the difference between primary and secondary
hypertension?
a. Secondary hypertension is caused by another
disorder like renal disease.
b. Secondary hypertension is related
to hereditary factors.
c. Secondary hypertension cannot be
treated effectively.
d. Secondary hypertension is no real threat
to healt
ANS: A
Secondary hypertension is a consistently elevated blood
pressure that is caused by another disorder, such as renal disease,
diabetes, or Cushing syndrome.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1584 OBJ: 18
TOP: Secondary hypertension
KEY: Nursing Process Step: Planning
The nurse is treating a patient who has had a pacemaker inserted for
the correction of atrial fibrillation. Which diagnostic test is no
longer available to the patient because of the implanted
device?
a. MRI
b. CT scan
c. Thallium scan
d. PET
ANS: A
Because of the large magnets in the MRI cabinet, the
pacemaker may be reset to a fixed mode and interfere with the
functioning of the pacemaker.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1551 OBJ: 10
TOP: Pacemaker KEY: Nursing Process Step: Planning
Which assessment would lead the nurse to examine the leg closely for
evidence of a stasis ulcer?
a. Cool dry lower limb
b.
Edematous, red scaly skin on medial surface of the leg
c. Lack of
hair and shiny appearance of the lower leg
d. Lack of a pedal pulse
ANS: B
Suggestion of a stasis ulcer in the making is an
edematous, dry scaly area on the medial surface of the lower leg that
has a darker pigmentation (rubor). Cool hairless limbs with absent or
weak pedal pulses are indicative of arterial insufficiency.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1582 OBJ: 21
TOP: Medications KEY: Nursing Process Step: Assessment
What is the patient goal of the walking exercise program designed for
the rehabilitation of a post-MI patient?
a. Walk 2 miles in less
than 60 minutes after 12 weeks.
b. Jog mile in less than 30
minutes after 12 weeks.
c. "Fast walk" 1 mile in less
than 20 minutes after 12 weeks.
d. Walk 1 mile in 15 minutes
without dyspnea after 12 weeks.
ANS: A
The goal of the 12-week walking program is that the
patient can walk 2 miles in less than 60 minutes.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1563, Home Care
OBJ: 11 TOP: Cardiac rehab
KEY: Nursing Process Step: Planning
The postsurgical patient has a painful and swollen right calf that
appears to be larger than the calf of the left leg. What is the nurse
assessing for when she flexes the patient's right leg and dorsiflexes
the foot?
a. Pain, which would be a positive Homans sign
b.
Muscular spasm, which would be a sign of hypocalcemia
c.
Rigidity, which would be a sign of ankylosis
d. Crepitus, which
would be a sign of a joint disorder
ANS: A
A positive Homans sign for deep vein thrombosis (DVT) is
a report of pain when the affected leg is flexed and the foot is dorsiflexed.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1595 OBJ: 21
TOP: DVT KEY: Nursing Process Step: Assessment
How should the nurse advise a patient with an international
normalized ratio (INR) of 5.8?
a. Make arrangements to go to the
emergency room immediately
b. Increase fluid intake to 2000
mL/day
c. Stop taking the anticoagulant and notify health care
provider
d. Add more leafy green vegetables to patient diet
ANS: C
The INR that is desired should be maintained between 2
and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The
patient should stop taking the anticoagulant and contact the physician
for further instruction.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1546 OBJ: 6
TOP: Myocardial infarction
KEY: Nursing Process Step: Assessm
The nurse making a teaching plan for a patient with Buerger disease
(thromboangiitis obliterans) will focus on the need for:
a.
reduction of alcohol intake.
b. avoiding cold remedies.
c.
cessation of smoking.
d. weight reduction.
ANS: C
The hazards of cigarette smoking and its relationship to
Buerger disease are the primary focus of patient teaching. None of the
palliative treatments are effective if the patient does not stop
smoking. Nowhere are the cause and effect of smoking so dramatically
seen as with Buerger disease.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1594 OBJ: 20
TOP: Buerger disease
KEY: Nursing Process Step: Assessment
Which statement would lead the nurse to offer more instruction about
taking warfarin (Coumadin)?
a. "I eat a banana every morning
with breakfast."
b. "I try to eat more green leafy
vegetables, especially broccoli, spinach, and kale."
c. "I try to eat a well-balanced, low-fat
diet."
d. "I don't drink alcohol or caffeine."
ANS: B
Avoid marked changes in eating habits, such as
dramatically increasing foods high in vitamin K (e.g., broccoli,
spinach, kale, greens). Limit alcohol intake to small amounts.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page
1597
OBJ: 10 TOP: Warfarin KEY: Nursing Process Step: Implementation
The nurse caring for a 92-year-old patient with pneumonia who is
receiving IV carefully monitors the flow rate of the IV infusion
because rapid infusion can cause:
a. hypotension.
b.
thrombophlebitis.
c. pulmonary emboli.
d. heart failure.
ANS: D
Heart failure can result from rapid infusion of
intravenous fluids in older adults.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1542, Lifespan
OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment
The nurse making the schedule for the daily dose of furosemide
(Lasix) would schedule the administration for which of the following
times?
a. Late in the afternoon
b. At bedtime
c. With
any meal
d. In the morning
ANS: D
Diuretics should be scheduled for morning administration
to avoid causing the patient nocturia.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1567, Table 47-6
OBJ: 12 TOP: Lasix KEY: Nursing Process Step: Planning
The nurse would assess closely for signs of right-sided heart failure
which include (select all that apply):
a. cough.
b.
increasing abdominal girth.
c. shortness of breath.
d. edema
of feet and ankles.
e. distended jugular veins.
f. orthopnea.
ANS: B, D, E
Indicators of right-sided heart failure are distended jugular
veins, anorexia, abdominal distention from ascites, liver enlargement
with right upper quadrant pain, and edema of feet and ankles.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1563, Box 47-4
OBJ: 9 TOP: Right-sided heart failure
KEY: Nursing Process Step: Assessment
The nurse would design teaching for a patient with Raynaud disease to
include which of the following? (Select all that apply.)
a.
Warming hands and feet with a heating pad
b. Using mittens in
cold weather
c. Practicing stress-reducing techniques
d.
Complete smoking cessation
e. Using caution when cleaning the
refrigerator or freezer
ANS: B, C, D, E
Nursing interventions include patient teaching
in techniques for stress reduction, avoiding exposure to cold, and
techniques for smoking cessation.
PTS: 1 DIF: Cognitive Level: Analysis
REF: Page 1595,
Nursing Care Plan OBJ: 20 TOP: Raynaud disease KEY: Nursing Process
Step: Planning
Which information should be taught to patients starting on
anticoagulant therapy for a valvular disorder? (Select all that
apply.)
a. Increase the dose of aspirin for better
therapy.
b. Take medication at the same time each day.
c.
Report to physician cuts that do not stop bleeding with direct
pressure.
d. No restrictions for food or drink.
e. Report
for prescribed blood tests (PTT, INR, CBC, blood sugar).
ANS: B, C
Aspirin should not be used with anticoagulant therapy
because it will increase bleeding. Gums, nosebleeds, excessive
bruising, and cuts that do not stop bleeding with direct pressure
should be reported to the physician. Alcohol and dark green and yellow
vegetables should be avoided because they contain vitamin K. Normal
blood tests for anticoagulant therapy are PTT, INR, and PT.
PTS: 1 DIF: Cognitive Level: Analysis
REF: Page 1591,
Nursing Care Plan OBJ: 10 TOP: Anticoagulant therapy KEY: Nursing
Process Step: Planning
What is the transesophageal echocardiogram (TEE) used for? (Select
all that apply.)
a. Detect thrombi before a cardioversion
b.
Check for cardiac arrhythmias
c. Visualize vegetation on the
heart valves
d. Measure effectiveness of diuretic therapy
e.
Visualize abscesses on the heart valves
ANS: A, C, E
The TEE is used to check for thrombi before cardioversion, and
to visualize vegetation and abscesses on the valves of the heart.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1592 OBJ: 16
TOP: TEE KEY: Nursing Process Step: N/A
Which patient teaching would help to prevent venous stasis? (Select
all that apply.)
a. Dangle legs when sitting
b. Avoid
crossing legs at the knee
c. Elevate legs when lying in bed or
sitting
d. Massage extremities to help maintain blood
flow
e. Wear elastic stockings when ambulating
ANS: B, C, E
Avoid prolonged sitting or standing. Avoid crossing
the legs at the knee.
Elevate legs when sitting. Wear elastic
stockings when ambulatory. Do not massage extremities because of
danger of embolization of clots (thrombus breaking off and becoming an embolus).
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1597 OBJ: 16
TOP: Thrombophlebitis
KEY: Nursing Process Step: Planning
The nurse points out which of the following as modifiable risks for
coronary artery disease (CAD)? (Select all that apply.)
a.
Diabetes mellitus
b. Heredity
c. Smoking
d.
Hypertension
e. Hyperlipidemia
f. Age
ANS: A, C, D, E
Modifiable risks for the development of CAD
include smoking, hyperlipidemia, hypertension, diabetes mellitus,
obesity, sedentary lifestyle, and stress.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1544-1545 OBJ: 7
TOP: Modifiable risks for CAD
KEY: Nursing Process Step: Implementation
The nurse outlines which of the following as conditions that would
disqualify a candidate for a heart transplant? (Select all that
apply.)
a. Recent malignancy
b. Dilated
cardiomyopathy
c. Peptic ulcer disease
d. Diabetes type
2
e. Severe obesity
f. Inoperable coronary artery disease
ANS: A, C, E
Contraindications for candidacy for cardiac transplant include
recent malignancy, active peptic ulcer disease, severe obesity,
diabetes type 1 with end-organ damage. Dilated cardiomyopathy and
inoperable coronary artery disease are indications for transplant.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1579, Box
47-7 OBJ: 15 TOP: Contraindications for cardiac transplant
KEY:
Nursing Process Step: Implementation
When assessing a patient with a possible MI, what should the nurse
assess for? (Select all that apply.)
a. Pain radiating to left
arm and jaw
b. Hypertension
c. Pallor
d.
Diaphoresis
e. Erratic behavior
f. Cardiac rhythm changes
ANS: B, C, D, E, F
Hypertension, vomiting, diaphoresis,
hypotension, pallor, and cardiac rhythm changes are objective data
seen in patients with an MI.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1558, Table 47-2
OBJ: 10 TOP: Myocardial infarction
KEY: Nursing Process Step: Assessment
Which of the following are signs of digoxin (Lanoxin) toxicity?
(Select all that apply.)
a. Ringing in the ears
b.
Bradycardia
c. Headache
d. Visual disturbance
e.
Hematuria
f. Gastrointestinal complaints
ANS: B, C, D, F
Major signs of digoxin toxicity are nausea,
bradycardia (HR <60), headache, and visual disturbances, as well as
fatigue and arrhythmias.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1548, Table
47-1 OBJ: 10 TOP: Digitoxin toxicity
KEY: Nursing Process Step: Assessment
The nurse encourages the patient who is recovering from a myocardial
infarct (MI) to ask the health care provider to prescribe a cardiac
rehabilitation series in order to learn to (select all that
apply):
a. improve stamina.
b. strengthen muscles.
c.
plan an appropriate diet.
d. select herbal remedies.
e.
reduce risk of further problems.
f. understand heart condition.
ANS: A, B, E, F
Cardiac rehabilitation offers exercise programs
to increase strength and increase stamina. Educational opportunities
are offered on reduction of risk and understanding the disease process.
PTS: 1 DIF: Cognitive Level: Application REF: Page 1563 OBJ: 11
TOP: Cardiac rehab
KEY: Nursing Process Step: Implementation
Following an angiogram with the insertion site of the left groin, the
nurse will include in the plan of care provisions for (select all that
apply):
a. checking pedal pulses.
b. ambulating with
assistance 2 hours after recovery.
c. checking color and warmth
of left leg frequently.
d. sandbagging over insertion
site.
e. placing patient in semi-Fowler position.
ANS: A, C, D
The pulses below the insertion site are checked to
ensure patency of the vessels; the color and warmth of the left
extremity is checked to ensure adequate circulation. A sandbag or
other pressure device is placed over the insertion site. The patient
is maintained in a supine position for several hours postprocedure.
PTS: 1 DIF: Cognitive Level: Application REF: Page
1537
OBJ: 6 TOP: Angiogram KEY: Nursing Process Step: Implementation
The cardiac marker rises 3 hours after a myocardial infarct and measures myocardial contractile protein.
ANS:
troponin I
Troponin I is a serum cardiac marker that rises 3 hours after an
MI and can measure myocardial contractile tissue. Troponin I is not
affected by skeletal muscle injury as is troponin T.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1541 OBJ: 6
TOP: Troponin I KEY: Nursing Process Step: Assessment
The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is .
ANS:
advanced cardiac life support (ACLS) advanced cardiac life support
ACLS
ACLS is a life support system that uses special techniques,
ventilation equipment, and therapies for emergency situations.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1550 OBJ: 9
TOP: ACLS KEY: Nursing Process Step: N/A
The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called ___________.
ANS:
automaticity
Automaticity is the special ability of the myocardium to
contract in a rhythmic pattern.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1534 OBJ: 2
TOP: Automaticity
KEY: Nursing Process Step: Assessment
The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost L of fluid.
ANS:
3
A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the
loss of 3 L of fluid.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1564 OBJ: 9
TOP: Fluid loss KEY: Nursing Process Step: Assessment
The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is __________________.
ANS:
intermittent claudication
Intermittent claudication is a pain caused by ischemia when a
person with arterial insufficiency exerts to the point that the
tissues have inadequate oxygen-rich blood. The pain is relieved by rest.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1581 OBJ: 9
TOP: Intermittent claudication
KEY: Nursing Process Step: Assessment
The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a ________.
ANS:
cardioversion
Cardioversion is the restoration of the heart's normal sinus
rhythm with the delivery of synchronized electric shock.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1540
OBJ:
10 TOP: Cardioversion KEY: Nursing Process Step: N/A
Trace the impulse pattern of conduction in sequence through the
heart. (Separate letters by a comma and space as follows: A, B, C, D)
a. Atrial wall
b. Atrial-ventricular (AV) node
c.
Purkinje fibers
d. Sinoatrial (SA) node
e. Bundle
branches
f. Bundle of His
ANS:
B, A, D, F, E, C
The conduction begins with the impulse from the SA node that
travels down the atrial wall to the AV node, to the Bundle of His, to
the bundle branches, and finally to the Purkinje fibers.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535-1534 OBJ: 3
TOP: Conduction KEY: Nursing Process Step: N/A
Arrange in sequence the path of the blood through the coronary
circulation. (Separate letters by a comma and space as follows: A, B,
C, D)
a. Right atrium
b. Pulmonary artery
c. Tricuspid
valve
d. Right ventricle
e. Superior and inferior vena
cava
f. Pulmonary vein
g. Left atrium
h. Mitral
valve
i. Left ventricle
j. Lungs
ANS:
E, A, C, D, B, J, F, G, H, I
The blood travels through the vena cava to the right atrium,
through the tricuspid valve to the right ventricle, through the
pulmonary artery to the lungs. The pulmonary veins deliver the blood
to the left atrium, then through the mitral valve to the left
ventricle and out the aorta to the body.
PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535, Figure
47-4 OBJ: 5 TOP: Path of blood through heart KEY: Nursing Process
Step: N/A