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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.
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One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?
- A. Distention of the jugular vein
- B. Effort to lie down to breathe
- C. Right-sided heart failure
- D. Blood congestion in neck veins
Correct Answer: C
Rationale: If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.
The nurse instructor is teaching a group of nursing students about adventitious heart sounds. The instructor explains that auscultation of the heart requires familiarization with normal and abnormal heart sounds. What would the instructor tell these students a ventricular gallop indicates in an adult?
- A. Heart failure
- B. Hypertensive heart disease
- C. Normal functioning
- D. Pericarditis
Correct Answer: A
Rationale: A sound that follows S1 and S2 is called an S3 heart sound or a ventricular gallop. An S3, normal in children, often is an indication of heart failure in an adult. An extra sound before S1 is an S4 heart sound, or atrial gallop. An S4 sound often is associated with hypertensive heart disease. A friction rub may cause a rough, grating, or scratchy sound that is an indication of pericarditis or inflammation of the pericardium.
The nurse provides care for a dying client following a massive myocardial infarction (MI). The nurse notes the client is experiencing dyspnea and has a barely palpable pulse. Which documentation of pulse quality by the nurse is appropriate?
- A. The client's pulse is full.
- B. The client is exhibiting a thready pulse.
- C. The client is experiencing a pulse deficit.
- D. The client's pulse indicates a regular rhythm.
Correct Answer: B
Rationale: When taking a client's pulse, the nurse notes its rate, rhythm, and quality. The pulse quality refers to its palpated volume. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. Documentation that the client's pulse is full is inaccurate. The nurse also determines any pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Documenting that the client's pulse indicates a regular rhythm is inaccurate because the documentation in this scenario focuses on the quality, not rhythm.
A client needs additional information about a heart condition. The client asks the nurse 'What is considered the pacemaker of the heart?'
- A. The AV node
- B. The bundle of HIS
- C. The Purkinje fibers
- D. The SA node
Correct Answer: D
Rationale: The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute.
The nurse is caring for an elderly client with left-sided heart failure. When auscultating lung sounds, which adventitious sound is expected?
- A. Whistling
- B. Rhonchi
- C. Crackles
- D. Coarseness
Correct Answer: C
Rationale: When the left side of the heart is pumping inefficiently, blood backs up into the pulmonary veins and lung tissue. Auscultation reveals a crackling sound. Wheezes and gurgles may also be heard.