Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s contraction, is the: a. endocardium. b. pericardium. c. mediastinum. d. myocardium. ANS: D The myocardium is the specialized muscle layer that allows the heart to contract. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1533 OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2.The nurse clari es that the master pacemaker of the heart is the: a. left ventricle. b. atrioventricular (AV) node. 1/21/2018 Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder | Nursing Test Banks c. sinoatrial (SA) node. d. bundle of His. ANS: C The SA node is the master pacemaker of the heart. PTS: 1 DIF: Cognitive Level: Application REF: Page 1533 OBJ:10TOP:Acute myocardial infarction KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3.The nurse is aware that the symptoms of an impending myocardial infarction (MI) di er in women because acute chest pain is not present. Women are frequently misdiagnosed as having: a. hepatitis A. b. indigestion. c. urinary infection. d. menopausal complications. ANS: B Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI. PTS: 1 DIF: Cognitive Level: Application REF: Page 1559 OBJ:16TOP:MIs in women KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4.The nurse identi es the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the sound of the: a. AV valves closing. b. closure of the semilunar valves. c. contraction of the papillary muscles. 1/21/2018 Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder | Nursing Test Banks d. contraction of the ventricles. ANS: A The LUBB is the rst sound of a low pitch heard when the AV valves close. PTS: 1 DIF: Cognitive Level: Application REF: Page 1535 OBJ: 4 TOP: Lubb sound KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classi cation of IV. This indicates the patient’s condition as: a. moderate heart failure. b. severe heart failure. c. congestive heart failure. d. negligible heart failure. ANS: B Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac ine ciency may develop at rest. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1565, Box 47-3 OBJ:9TOP:Classi cation of heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a: a. stage A. 1/21/2018 Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder | Nursing Test Banks b. stage B. c. stage C. d. stage D. ANS: A The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3 OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7.The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says: a. “I can ambulate in the hallway with this gadget on.” b. “I always take o the telemetry device when I shower.” c. “My EKG is being watched by one of the nurses in CCU on the home unit.” d. “I am able to sleep just ne with this device on.” ANS: B Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower. PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ:6TOP:Remote telemetry KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8.The nurse assesses pitting edema that can be depressed approximately inch and re lls in 15 seconds. The nurse would document this assessment as: a. +1 edema. 1/21/2018 Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder | Nursing Test Banks b. +2 edema. c. +3 edema. d. +4 edema. ANS: B A +2 edema can be documented if the skin can be depressed inch and respond within 15 seconds. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Table 47-5 OBJ:9TOP:Pitting edema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9.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 ANS: D Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or “cold spots” indicate tissues that have inadequate perfusion. PTS: 1 DIF: Cognitive Level: Application REF: Page 1539 OBJ:6TOP:Thallium scan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10.The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of: a. normal heart action. b. mild heart failure.