Cardiac/Vascular Nurse Exam Secrets Study Guide (43 page)

54. B. Semiformal support includes organizations or agencies (e.g., senior centers, religious and charitable organizations) that provide goods or services. Formal support is regulated by laws and statues and provides social (social workers), financial (Social Security) and medical (Medicare) assistance. Informal support derives from the social network and includes family and friends, but only those who actually provide assistance. Support systems are critical for patients, especially older adults, as they can provide physical as well as emotional support. Patients without this support may turn to health care providers to fill this need.

55. A. An open-ended question should be use to elicit a specific description of pain experienced by a patient. Questions such as, “Are you having pain?” that are answered by a simple “yes” or “no” provide little information. “What kind of pain are you having?” may be confusing to patients. The pain scale can be used after the patient has described the pain and after the nurse has explained in detail (with examples) what the pain scale means.

56. C. Endothelial dysfunction is a key factor in the development of atherosclerosis and hypertension. The ability of arteries and arterioles to dilate is impaired. As the impairment of the endothelium becomes greater, the blood pressure rises. The endothelium mediates hemostasis, coagulation, fibrinolysis, cell proliferation, and cell wall inflammatory mechanisms. Endothelial dysfunction is associated with hyperlipidemia, smoking, diabetes, and lack of exercise. Research has not yet indicated if endothelial dysfunction is the direct cause of hypertension or the result.

57. D. The “5 rights of delegation” include:

· Right task: The nurse determines an appropriate task to delegate for a specific patient.

· Right circumstance: The nurse has considered all relevant information to determine the appropriateness of delegation.

· Right person: The nurse chooses the right person based on education and skills to perform the task.

· Right direction: The nurse provides a clear description of the task, purpose, limits, and expected outcomes.

· Right supervision: The nurse can supervise, intervene as needed, and evaluate performance.

58. A. The most effective handout for patients is the poster-type handout with drawings and minimal text. Handouts should be helpful guides to remind the learner, but too much text can be distracting and confusing. A copy of a PowerPoint presentation is less helpful than a handout that summarizes the main points of the presentation. Smudged handouts or copies of newsprint are difficult to read. Minimizing a larger piece often results in text that is too small to read and pictures or diagrams that are unclear.

59. B. When a patient is confused and disoriented, the best response is to say what is true, “The sound was not a woman screaming but an ambulance siren,” calmly and without arguing. Saying “No one is screaming” challenges the patient without explanation and may increase the patient’s confusion. Distracting the patient may be helpful after the explanation but should not be the first response. “She has stopped screaming now, so everything is okay” acknowledges that the patient’s perception was correct and does nothing to alleviate confusion.

60. C. The goal of the exercise stress test is to raise the heart rate to 80%–90% of that predicted for age and gender. Cardiac stress testing is done to determine if the coronary arteries dilate adequately during exercise. Normal coronary arteries dilate four times the resting diameter when under stress, so testing when exercising is more accurate than when resting to determine if there is compromised blood flow. The Bruce protocol, in which the speed and grade of the treadmill increases every 3 minutes, is most common. Chemical stress tests, using adenosine or dipyridamole (Persantine), may be used for those who cannot exercise.

61. A. Janeway lesions, splinter hemorrhages, Roth’s spots, petechiae on oral mucosa, and glomerulonephritis are immunological responses associated with endocarditis, which is an infection of the endothelial surface and valves of the heart caused by invasion of the tissue by a pathogen, usually after surgery, intravenous (IV) catheterization, or IV drug abuse. Other manifestations include low-grade fever, anorexia, weight loss, malaise, splenomegaly, and anemia. Patients with pericarditis present with chest pain, mild fever, increased erythrocyte sedimentation rate, white blood cell count, and friction rub. It may cause aortic valve dysfunction or mitral valve insufficiency. Patients with myocarditis may present asymptomatically or with fatigue, dyspnea, and palpitations but also with sudden cardiac arrest.

62. D. Behavior modification and compliance rates are the best determinants of the effectiveness of patient education. Patients may be satisfied, may understand, and may be able to provide a demonstration, but if they do not use what they have learned, the education has not been effective. Behavior modification involves thorough observation and measurement, identifying behavior that needs to be changed, and then planning and instituting interventions. Compliance rates should be determined by observation on multiple occasions.

63. C. Palliative care provides comfort rather than curative treatment although sometimes treatment that may be considered curative—such as radiotherapy—may be used to relieve pain or symptoms. Palliative care is meant to improve the quality of life and relieve suffering but to neither prolong life nor hasten death. Palliative care provides adequate pain management and relief of symptoms (nausea, shortness of breath). Chemotherapy, intubation, ventilation, and total parenteral nutrition are not generally considered palliative care.

64. B. Changes on an electrocardiogram (ECG), such as a U wave more than 1 mm high after the T wave, AV block, and flat or inverted T waves, are characteristic of hypokalemia. Tall peaked T waves with widening and increased amplitude of QRS and prolongation of the QT interval are characteristic of hyperkalemia. Dysrhythmias with prolonged PR and QT intervals and broad flat T waves are characteristic of hypomagnesemia. Other electrolyte imbalances are not reflected by specific ECG changes although hypermagnesemia can lead to cardiac arrest, and hypercalcemia can cause dysrhythmias (similar to those of digitalis toxicity).

65. D. A hypertensive crisis is characterized by a marked elevation of blood pressure that can cause severe organ damage if left untreated. It may be related to either primary or secondary hypertension, dissection of aortic aneurysm, pulmonary edema, central nervous system disorders, eclampsia, and failure to take medications correctly. A hypertensive emergency (> 120 mm Hg diastolic) requires immediate treatment to prevent organ damage. Hypertensive urgency requires treatment within a few hours, but organs are not in immediate danger. Blood pressure is lowered more slowly to avoid hypotension and organ ischemia (one-half reduction in 6 hours, one-third reduction in the next 24 hours, and two-thirds reduction over 2–4 days).

66. B. The right to pain control is part of the Patients’ Bill of Rights. Affordable health care and access to the latest medical technology are not included. The right to sue is not directly included, but patients are entitled to a procedure for registering complaints or grievances. Other provisions include respect for the patient, informed consent, advance directives, end-of-life care, privacy and confidentiality, protection from abuse and neglect, protection during research, appraisal of outcomes, appeal procedures, organizational code of ethical behaviors, and procedures for donating and procuring organs or other body tissues.

67. C. The metabolic syndrome (insulin resistance) puts people at risk for the development of diabetes mellitus and cardiovascular disease; it is characterized by abdominal obesity (> 35 inches in women and > 40 inches in men), increased triglycerides (³ 150), decreased HDL level (< 40 in men and < 50 in women), elevation of blood pressure (³ 130/85 mm Hg), and increased fasting glucose (³ 110). Other indicators include elevation of C-reactive protein, evidence of a proinflammatory state, high levels of fibrinogen, and evidence of a prothrombotic state.

68. D. Under the Nursing Code of Ethics of the American Nurses Association, autonomy and self-determination are viewed within the broader context of diverse cultures. The idea of individualism is less important in some cultures, so the nurse must respect and appreciate the patient’s right to be guided by her family. Trying to convince the patient to assert herself may just lead to emotional conflict. This is not an appropriate concern for the ethics committee, as the woman is not being forced to comply with family decisions but chooses to do so.

69. D. In third-degree atrioventricular (AV) block, there are more P waves than QRS complexes with no clear relationship between them and an atrial rate two to three times the pulse rate, with an irregular PR interval. If the sinoatrial node malfunctions, the AV node fires at a lower rate, and if the AV node malfunctions, the pacemaker site in the ventricles takes over at a bradycardic rate: thus, with complete AV block, the heart still contracts but often ineffectually. The atrial P (sinus rhythm or atrial fibrillation) and the ventricular QRS (ventricular escape rhythm) are stimulated by different impulses, so there is AV dissociation. The heart cannot compensate with exertion.

70. A. The patient with an aortic aneurysm should be provided with a list of possible treatment options, as required by the guidelines of the American Medical Association for informed consent. Arrhythmias may be treated in different ways, so providing one option limits patients’ right to choose. Telling patients there is nothing to worry about is a platitude that may be wrong in any case. Patients have a legal right to information about their condition, even if it may cause anxiety. Patients cannot give informed consent without adequate and accurate information.

71. D. Cor pulmonale (also known as pulmonary heart disease) is characterized by changes in the right ventricle because of a pulmonary disorder, such as chronic obstructive pulmonary disease. Cor pulmonale begins with endothelial dysfunction, resulting in vasoconstriction and vessel wall thickening, with sustained pulmonary hypertension, resulting in right ventricular hypertrophy in chronic cor pulmonale and right ventricular dilation in acute cor pulmonale. The end result is right-sided heart failure.

72. B. The primary reason for completing continuing education courses is to remain current in the field of nursing. It is every nurse’s responsibility to be informed and aware of changes in practice. Many states require continuing education for licensure, and some institutions require continuing education for employment. Taking courses to meet requirements for salary increase is a personal reason that does not obviate professional responsibility for learning.

73. C. A good strategy for helping patients overcome feelings of low self-esteem includes providing opportunities for these patients to make decisions. Other strategies include providing companionship and encouraging patients to express their feelings and concerns. Positive feedback and praise should be given when earned rather than praising everything. Telling patients that there is no reason to be depressed invalidates feelings and further lowers self-esteem. Low self-esteem is common among older adults because they have to deal with so many losses. They may become depressed, passive, and dependent.

74. A. In renovascular disease, activation of the renin-angiotensin-aldosterone system results in increased blood pressure (BP) from retention of sodium, chloride, and water. Antidiuretic hormone, a pituitary hormone, stimulates the kidneys to conserve volume. Renin is released when blood volume, BP, or osmolarity are reduced, causing the renin-angiotensin-aldosterone response that changes angiotensin to angiotensin I and then to angiotensin II, a vasoconstrictor that increases BP. Renin also stimulates the adrenals to release aldosterone, which conserves sodium, resulting in higher fluid volume and increased BP.

75. B. Cognitive changes associated with aging may result in the decline of explicit memories (facts) while implicit memories (skills) remaining intact. Older adults may have difficulty in completing complex tasks that require processing of new information and may become easily distracted and less able to focus attention. Working memory declines, making it more difficult for older adults to complete mental processes that require keeping facts in memory (e.g., calculating costs); they may also have difficulty retrieving words, such as the names of people or objects.

76. D. High doses of tacrolimus (an immunosuppressive macrolide antibiotic) can result in nephrotoxicity (similar to cyclosporine) with elevated blood urea nitrogen and creatinine. Other effects include hyperkalemia, insomnia, and malaise. Tacrolimus is often used instead of cyclosporine because it is generally well tolerated and is also effective for rescue therapy during cardiac rejection. Hypertension is an adverse effect of cyclosporine and corticosteroids. Facial dysmorphism is related to cyclosporine use. Hirsutism and acne are common adverse effects of corticosteroids.

77. A. The nurse should provide acceptance and show no revulsion or negative feelings about the appearance of patients that was changed by surgery or disease. A disturbed body image can result in depression, disgust, and refusal to participate in care or look at the altered part. The nurse can teach patients to dress to minimize exposure, encourage patients to touch and look at the altered body part, engage patients in self-care, and help patients to stay well groomed. An interdisciplinary approach should be used to help these patients. Telling patients that they are lucky to be recovering avoids the real issue.

78. C. The automatic implantable cardioverter defibrillator (AICD), used to control tachycardia and fibrillation, provides on-demand (synchronous) small electrical impulses to the atrial or ventricular myocardium to slow the heart when the pulse rate increases to a preset rate. If fibrillation occurs, a high-energy shock is delivered. It takes 5–15 seconds for the device to detect abnormalities in the pulse rate, and more than one shock may be required, so fainting may occur. Some devices can function as both a pacemaker and an ICD for patients with episodes of both bradycardia and tachycardia.