Lewis Chapter 35: Assessment: Cardiovascular System

Which age-related cardiovascular changes would the nurse assess for when providing care to an older adult patient? (Select all that apply.)

Systolic murmur

Diminished pedal pulses

Increased maximal heart rate

Decreased maximal heart rate

Increased recovery time from activity

Systolic murmur

Diminished pedal pulses

Decreased maximal heart rate

Increased recovery time from activity

The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. Which age-related change contributes to this finding?Stenosis of the heart valves

Decreased adrenergic sensitivity

Increased parasympathetic activity

Loss of elasticity in arterial vessels

Loss of elasticity in arterial vessels

While auscultating the patient’s heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How would the nurse document the finding?

Diastolic murmur

Third heart sound (S3)

Fourth heart sound (S4)

Normal heart sounds (S1, S2)

Third heart sound (S3)

Which anatomic feature of the heart directly stimulates ventricular contractions?

SA node

AV node

Bundle of His

Purkinje fibers

Purkinje fibers

A nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which assessments would the nurse plan for this patient? (Select all that apply.)

Assess for return of gag reflex.

Assess groin for hematoma or bleeding.

Monitor vital signs and oxygen saturation.

Position patient supine with head of bed flat.

Assess lower extremities for circulatory compromise.

Assess for return of gag reflex.

Monitor vital signs and oxygen saturation.

Which explanation would the nurse to give to a patient about the purpose of intermittent pneumatic compression devices after a surgical procedure?

The devices keep the legs warm while the patient is not moving much.

The devices maintain the blood flow to the legs while the patient is on bed rest.

The devices keep the blood pressure down while the patient is stressed after surgery.

The devices provide compression of the veins to keep the blood moving back to the heart.

The devices provide compression of the veins to keep the blood moving back to the heart.

The nurse is providing care for a patient who has decreased cardiac output due to heart failure. Which information would the nurse need to understand about cardiac output (CO) when developing the plan of care?CO is calculated by multiplying the patient’s stroke volume by the heart rate.CO is the average amount of blood ejected during one complete cardiac cycle.CO is determined by measuring the electrical activity of the heart and the heart rate.CO is the patient’s average resting heart rate multiplied by the mean arterial blood pressure.

CO is calculated by multiplying the patient's stroke volume by the heart rate.

The nurse is admitting a patient who is scheduled to undergo a cardiac cathertization. What allergy is most important for the nurse to asses and document before this procedure?

Iodine

A patient presents to the emergency department reporting chest pain for 3 hours. What component of the blood work is the most indicative of a myocardial infarction (MI)?

CK-MB

Troponin

Myoglobin

C-reactive protein

Troponin

The nurse is caring for a patient with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment indicates the patient’s condition is improving?Cardiac output (CO) is 3.5 L/min.Central venous pressure (CVP) is 10 mm Hg.Pulmonary artery wedge pressure (PAWP) is 10 mm Hg.Systemic vascular resistance (SVR) is 1500 dynes/sec/cm−5.

A patient with a history of myocardial infarction (MI) is scheduled for a transesophageal echocardiogram (TEE) to visualize a suspected clot in the left atrium. Which information would the nurse include when teaching the patient about a TEE?

IV sedation may be administered to help the patient relax.

Food and fluids are restricted for 2 hours before the procedure.

Ambulation is restricted for up to 6 hours before the procedure.

Contrast medium is injected into the esophagus to enhance images.

IV sedation may be administered to help the patient relax.

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. Which information would the nurse include in the teaching plan?

Women are less likely to delay seeking treatment than men.

Women are more likely to have noncardiac symptoms of heart disease.

Women are often less ill when presenting for treatment of heart disease.

Women have more symptoms of heart disease at a younger age than men.

Women are more likely to have noncardiac symptoms of heart disease.

A patient is being admitted for valve replacement surgery. Which assessment finding indicates aortic valve stenosis?

Pulse deficit

Systolic murmur

Distended neck veins

Splinter hemorrhages

Systolic murmur

The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate?

Increased viscosity of the patient’s blood

Turbulent blood flow across a heart valve

Friction between the heart and the myocardium

A deficit in conductivity impairs normal contractility

Turbulent blood flow across a heart valve

A patient who has a history of heart failure and chronic obstructive lung disease is admitted with severe dyspnea. Which laboratory value would be elevated if the cause of dyspnea was cardiac related?

Serum potassium

Serum homocysteine

High-density lipoprotein

B-type natriuretic peptide (BNP)

B-type natriuretic peptide (BNP)

A patient is about to undergo Holter monitoring. Which instructions would the nurse provide to the patient?

“You may remove the monitor only to shower or bathe.”

“You should connect the monitor whenever you feel symptoms.”

“You should refrain from exercising while wearing this monitor.”

“You will need to keep a diary of your activities and symptoms.”

"You will need to keep a diary of your activities and symptoms."

What position would the nurse place the patient in to auscultate for signs of acute pericarditis?

Supine without a pillow

Sitting and leaning forward

Left lateral side-lying position

Head of bed at a 45-degree angle

Sitting and leaning forward

Which aspect of the heart’s action does the QRS complex on the ECG represent?

Depolarization of the atria

Repolarization of the ventricles

Depolarization from atrioventricular (AV) node throughout ventricles

The length of time it takes for the impulse to travel from the atria to the ventricles

Depolarization from atrioventricular (AV) node throughout ventricles

Which action would the nurse implement with auscultation during a patient’s cardiovascular assessment?

Position the patient supine.

Ask the patient to hold their breath.

Palpate the radial pulse while auscultating the apical pulse.

Use the bell of the stethoscope when auscultating S1 and S2.

Palpate the radial pulse while auscultating the apical pulse.

Which hematologic problem significantly increases the risks associated with pulmonary artery (PA) catheter insertion?

Leukocytosis

Hypovolemia

Hemolytic anemia

Thrombocytopenia

Thrombocytopenia

The nurse is caring for a patient who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation requires emergency intervention?

Arterial pressure bag is inflated to 250 mm Hg.

Calculated mean arterial pressure is 74 mm Hg.

Patient’s head of bed elevation is at 30 degrees.

Capillary refill time in the right hand is 5 seconds.

Capillary refill time in the right hand is 5 seconds.

The patient tells the nurse that he does not understand how there can be a blockage in the left anterior descending artery (LAD), but damage to the right ventricle. What is the bestresponse by the nurse?

“One coronary vessel curves around and supplies the entire heart muscle.”

“The LAD supplies blood to the left side of the heart and part of the right ventricle.”

“The right ventricle is supplied during systole primarily by the right coronary artery.”

“It is actually on the right side of the heart, but we call it the left anterior descending vessel.”

"The LAD supplies blood to the left side of the heart and part of the right ventricle."

The nurse determines that a patient’s pedal pulses are absent. Which factor could contribute to this finding?

Atherosclerosis

Hyperthyroidism

Atrial dysrhythmias

Arteriovenous fistula

Atherosclerosis