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The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?
- A. Possible hypovolemia
- B. Possible myocardial infarction (MI)
- C. Left-sided heart failure
- D. Aortic valve regurgitation
Correct Answer: A
Rationale: Hypovolemia may cause a decreased CVP. MI, valve regurgitation, and heart failure are less likely causes of decreased CVP.
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The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?
- A. Decreased left ventricular ejection time
- B. Decreased connective tissue in the SA and AV nodes and bundle branches
- C. Thinning and flaccidity of the cardiac valves
- D. Widening of the aorta
Correct Answer: D
Rationale: Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection time (prolonged systole).
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence?
- A. SA node to bundle of His to AV node to Purkinje fibers
- B. SA node to AV node to Purkinje fibers to bundle of His
- C. SA node to bundle of His to Purkinje fibers to AV node
- D. SA node to AV node to bundle of His to Purkinje fibers
Correct Answer: D
Rationale: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers.
The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
- A. Whether the patient and involved family members understand the role of genetics in the etiology of the disease
- B. Whether the patient and involved family members understand dietary changes and the role of nutrition
- C. Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
- D. Whether the patient and involved family members understand the importance of social support and community agencies
Correct Answer: C
Rationale: During the health history, the nurse needs to determine if the patient and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely and appropriate response to a cardiac emergency is paramount.
The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what?
- A. Development of an atrial-septal defect
- B. Myocardial ischemia
- C. Formation of a pulmonary embolism
- D. Release of potassium ions from cardiac cells
Correct Answer: B
Rationale: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.
The nurses assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patients plan of care?
- A. Risk for ineffective breathing pattern related to hypotension
- B. Risk for falls related to orthostatic hypotension
- C. Risk for ineffective role performance related to hypotension
- D. Risk for imbalanced fluid balance related to hemodynamic variability
Correct Answer: B
Rationale: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The patients ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.