Nokea
During a health interview by the home health nurse, which patient report 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 $3 \mathrm{lb}$ 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.'
Correct Answer: A
Rationale: Left ventricular failure is often among the first of 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.
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The nurse assesses pitting edema that can be depressed approximately $4 \mathrm{~mm}$ and refills in 15 seconds. The nurse would document this assessment as:
- A. +1 edema.
- B. +2 edema.
- C. +3 edema.
- D. +4 edema.
Correct Answer: B
Rationale: A +2 edema can be documented if the skin can be depressed $4 \mathrm{~mm}$ and respond within 15 seconds.
The patient, age 26, is hospitalized with cardiomyopathy. While assisting with data collection from the patient, 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?
- A. Cocaine use
- B. Viral infection
- C. Vitamin B1 deficiency
- D. Pregnancy
Correct Answer: A
Rationale: Cardiomyopathy caused by cocaine abuse triggers intense vasoconstriction of the coronary arteries and peripheral vasoconstriction. 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.
Which patient teaching would help to prevent venous stasis?
- A. Dangle legs when sitting.
- B. Avoid crossing the 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.
Correct Answer: B,C,E
Rationale: 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).
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
Correct Answer: D
Rationale: Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or 'cold spots' indicate tissues that have inadequate perfusion.
The nurse takes into consideration that age-related changes can affect the peripheral circulation because of which factor?
- A. sclerosed blood vessels.
- B. hypotension.
- C. inactivity.
- D. poor nutrition.
Correct Answer: A
Rationale: Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen.