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The nurse notes that the client has had a change in mental status. Why would it be important for the nurse to report extremes in the thought process of a client with cardiovascular disorder to the physician?
- A. It is an indication of an impending heart failure.
- B. The client may develop anxiety disorder.
- C. It may indicate a problem with oxygenation.
- D. It creates anxiety during the diagnostic testing.
Correct Answer: C
Rationale: The nurse should report extremes in thought processes to the physician because such effects may interfere with the client's safety and prescribed therapy. Chest pain and impaired breathing may create anxiety. Extremes of emotions or disturbances in thought processes are not the indications of an impending heart failure. The client will not develop any anxiety disorder.
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The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?
- A. A 48-year-old policemen with history of knee replacement 4 years ago
- B. A 68-year-old housewife with history of osteoporosis
- C. A 72-year-old retired janitor obtaining a cardiac baseline
- D. A 55-year-old recovering from a fall and broken femur
Correct Answer: D
Rationale: An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
- A. Fluoroscopy
- B. Nuclear cardiology
- C. Serum blood work
- D. Chest radiography
Correct Answer: B
Rationale: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.
Which suggestion can the nurse provide to an older adult client to reduce the symptoms associated with sarcopenia?
- A. Maintain hydration.
- B. Avoid heavy lifting.
- C. Practice brisk walking.
- D. Limit the use of caffeine.
Correct Answer: C
Rationale: Sarcopenia refers to changes in composition of muscle tissue that can occur in aging because of deconditioning; therefore, increasing daily exercise helps to improve muscle strength, including the heart. Maintaining hydration is important for a client who requires cardiac catheterization to flush the dye used during the procedure from the system and is not an intervention supported by evidence-based practice guidelines for the client who experiences sarcopenia. Heavy lifting is discouraged following cardiac catheterization; however, avoiding lifting is not an activity that reduces symptoms associated with sarcopenia. The nurse discourages the use of caffeine for clients who experience tachycardia; however, this is not an appropriate suggestion to reduce the symptoms associated with sarcopenia.
In which client does the nurse consider the presence of an S3 heart sound to be normal?
- A. In a client who is in elementary school
- B. In a client who is an older adult
- C. In a client with an indwelling pacemaker
- D. In a client who is diagnosed with heart failure
Correct Answer: A
Rationale: A heart sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. Although an abnormal finding for many clients, this finding is considered normal in many pediatric clients, including a school-age client. In adults, the presence of S3 may signify heart failure, so this is not considered normal. Additionally, S3 is not considered normal for older adult clients nor for a client who has an indwelling pacemaker.
The nurse is caring for a client with a damaged tricuspid valve. The nurse knows that the tricuspid valve is held in place by which of the following?
- A. Chordae tendineae
- B. Atrioventricular tendons
- C. Semilunar tendineae
- D. Papillary tendons
Correct Answer: A
Rationale: Attached to the mitral and tricuspid valves are cordlike structures known as chordae tendineae, which in turn attach to papillary muscles, two major muscular projections from the ventricles. Neither atrioventricular tendons, semilunar tendineae, nor papillary tendons hold the tricuspid valve in place.