Cardiac/Vascular Nurse Exam Secrets Study Guide (44 page)

79. B. Syncope associated with exertional exercise is a manifestation of aortic stenosis. With aortic stenosis, exercise results in reduced cerebral blood flow because of peripheral dilation without increased cardiac output. In some cases, the hypotension related to syncope may result in ventricular fibrillation or ventricular tachycardia and death. Syncope, a sudden brief loss of consciousness, may also be caused by carotid sinus sensitivity (vasovagal syndrome), dysrhythmias (tachycardia, bradycardia). In older adults, syncope often occurs with postural hypotension, sometimes related to medications or alcohol.

80. A. Averting the eyes as practiced by the Chinese patient being interviewed is probably a sign of respect toward the nurse. In many Asian cultures, it is considered disrespectful to look someone directly in the eyes. Although what is true for the group is not always true for the individual, the fact that the woman seems relaxed rather than anxious and is forthcoming with her responses suggest that she is not fearful, depressed, or dishonest.

81. C. Kinesthetic learners who learn best by handling, doing, and practicing should be allowed to handle supplies and equipment with minimal directions. They demonstrate their understanding by doing the procedure. Visual learners who learn best by seeing and reading benefit from written directions, videos, diagrams, pictures, and demonstrations. Auditory learners who learn best by listening and talking benefit best from verbal demonstrations, audiotapes, and extra time for questions.

82. D. Symptoms typical of a dissecting descending aortic aneurysm include severe, intense, knife-like pain posteriorly between the scapulae and nausea and vomiting. In addition, patients may be cold and clammy. Dissection of the ascending thoracic aorta results in similar symptoms, but the pain is in the anterior chest. Pain with dissection does not generally increase in intensity, as it is severe at onset when the tearing occurs. Peripheral arteries may be involved, which can cause numbness, tingling, and evidence of vascular insufficiency in the affected limb.

83. B. The expected outcome for a patient with hyperlipidemia who has been taught about the proper diet for this condition should be able to list the foods that contain saturated and non-saturated fats. While explaining the difference between low-density and high-density lipoproteins is important, this information does not relate to the stated goals and should not be the expected outcome for this activity. Patients with hyperlipidemia should use olive oil when cooking and should decrease their triglyceride levels to 150 or below. In some cases, one class or session may cover multiple topics with multiple outcomes, but a patient may be overwhelmed by too much information.

84. A. The most likely cause of nausea, vomiting, and tachycardia is digitalis toxicity. Most cases of digitalis toxicity can be traced to drug interactions. In this case, both furosemide (Lasix) and tetracycline can cause digitalis toxicity when taken with digoxin (Lanoxin). Digoxin levels should be monitored to ensure that therapeutic levels (0.5–2.0 ng/mL) are maintained. Early signs of digitalis toxicity include fatigue, lethargy, depression, nausea, and vomiting. Sudden changes in heart rhythm, atrioventricular or sinoatrial block, new ventricular dysrhythmias, or tachycardia may occur. Digoxin immune FAB (Digibind) may be given to inactivate digoxin, if necessary.

85. C. The legal document that designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent is a durable power of attorney. This is a type of advance directive, which can include living wills or specific requests of the patient regarding treatment. A do-not-resuscitate order indicates that the patient does not want resuscitative treatment for a terminal illness or condition. A general power of attorney allows a designated person to make broad decisions, including financial decisions, for an incapacitated person.

86. B. Risk management is an organized and formal method of decreasing liability, financial loss, and risk or harm to patients, staff, or others. Duties of the risk-management staff include risk:

· identification.

· analysis.

· prevention.

· assessment and evaluation.

87. A. The best method to evaluate an expected educational outcome relating to a procedure is to ask the patient to demonstrate his or her knowledge. Patient feedback is not a reliable indicator of ability to perform a given task. Tests, whether oral or written, can identify what a patient knows and may be appropriate for testing general knowledge about a subject, but a demonstration is critical and allows the nurse to provide feedback or additional training if needed.

88. D. The newly hired nurse, knowing that a contaminated catheter could cause a serious infection, must prevent possible injury to a patient; thus, by stating that the catheter was contaminated when it fell and asking if she could get another setup states the problem and suggests a solution without assigning blame. Reporting the team leader’s behavior to the supervisor, while appropriate, does not protect the patient. Saying nothing protects only the first nurse from possible repercussions but is unprofessional conduct.

89. C. The 5-P approach to questioning is used to obtain sexual histories of patients and to assess risk of sexually transmitted disease (STD) to identify infected people, diagnose and treat, prevent infection of partners, provide pre-exposure vaccination to those at risk, and educate those at risk to make changes in sexual practices. 5-Ps include:

· Partners: gender and number of partners.

· Prevention of pregnancy: methods of contraception.

· Protection from STDs: methods used to prevent STDs.

· Practices: oral, anal, vaginal sex, and use of condoms.

· Past history (STDs): self-history or partner history, injectable drug use, and sex for money.

90. B. While the international normalized ratio (INR) is individualized, depending on baseline readings, a normal INR is usually about 1. Patients receiving warfarin (Coumadin) for atrial fibrillation are usually maintained at an INR of 2–3. The INR for prophylaxis for deep vein thrombosis is 1.5–2 and for pulmonary emboli and mechanical heart values is 3–4. The higher the number, the greater the anticoagulation effect, so a level over 4 may put the patient at risk for hemorrhage.

91. D. Cultural sensitivity should take precedence over gender equality, so the nurse should reassure the patient and make arrangements for a female nurse to do the dressing change. Patients from Middle Eastern countries come from cultures that segregate men and women; in addition, this surgery may threaten the patient’s body image. Furthermore, because nurses care for both men and women, they are not always held in high esteem by these cultures. Also, the men in the patient’s family may be very upset that the patient allowed a man to change her dressings, which could add to her stress and discomfort.

92. B. Hiccups are an indication that a pacemaker lead has become dislodged and is causing phrenic nerve or muscle stimulation. Other complications include infection; bleeding; hematoma; puncture of the subclavian vein or internal mammary artery, causing hemothorax; irritation of the ventricular wall by the endocardial electrode, causing ectopic beats or tachycardia; malfunction or perforation of the myocardium from dislodgement of a transvenous lead; and cardiac tamponade, resulting from removal of epicardial wires used for temporary pacing.

93. A. Chest pain that radiates down the left arm and lasts about 5 minutes or less is classic for stable angina. Unstable angina (preinfarction), a medical emergency, is a progression of coronary artery disease. Pain may increase and last for 5 minutes or more. Coronary artery spasm can cause angina pain and ischemia and is sometimes related to cocaine use. Variant (Prinzmetal’s) angina is also related to coronary artery spasm, but symptoms are more predictable. It is usually cyclical, occurring at rest and at the same time each day, and is characterized by elevation of ST segments. It may be associated with substance abuse.

94. C. “You are shaking and seem worried” acknowledges what is true and evident and leaves an opening for the patient to discuss his feelings if he wants to. “What’s wrong?” requires a direct response the patient may not feel like giving. “Do you want me to call your family” does not deal with the patient’s anxiety and is an escape for the nurse. “You do not need to worry; everything will be all right” is a platitude that has little meaning and may not, in fact, be true.

95. B. National guidelines recommend that adults exercise with moderate intensity (e.g., walking, bicycling, gardening) 30 minutes daily to a minimum of 150 minutes weekly or 20 minutes of vigorous intensity exercises (e.g., running, aerobics, heavy physical work) to a minimum of 60 minutes a week. In addition, adults should engage in strengthening exercises (e.g., pushups, sit-ups, weight-lifting) at least twice a week. Exercise sessions should be at least 10 minutes long to achieve health benefits.

96. A. Contraindications to thrombolytic therapy include an aortic aneurysm, hemorrhagic stroke, recent surgery, or bleeding. While ideally, thrombolytic therapy should be administered within 90 minutes of the onset of symptoms, some thrombolytics (tenecteplase) may be given within 6 hours and some within 12 hours. A history of any type of stroke within 2 months precludes thrombolytic therapy. Severe hypertension (> 210/130 mm Hg) that is uncontrolled by medications or that occurs with retinal-vascular disease is also a contraindication. Relative contraindications include age over 75 years, pregnancy, pericarditis, and endocarditis.

97. D. The CAGE tool is a quick assessment tool to determine if people are drinking excessively or have become problem drinkers:

· C = cutting down: Do you think about trying to cut down on drinking?

· A = annoyed at criticism: Are people starting to criticize your drinking?

· G = guilty feeling: Do you feel guilty or try to hide your drinking?

· E = eye opener: Do you increasingly need a drink earlier in the day?

98. A. Digoxin should be withheld for a minimum of 48 hours before cardioversion. Anticoagulation, usually with warfarin (Coumadin), is prescribed at least 3 weeks before cardioversion to prevent emboli. Sometimes drug therapy is used in conjunction with cardioversion: for example, antiarrhythmics (Cardizem, Cordarone) may be given before the procedure to slow the heart rate. Insulin should not be withheld for 48 hours, but the patient must fast before cardioversion and may be asked to delay the insulin injection on the morning of the procedure.

99. B. Symptoms that do not occur with rest but with physical exertion, limitations with the activities of daily living (ADLs), and slight pulmonary edema are typical of class II heart failure:

· Class I: Asymptomatic during normal activities and no pulmonary congestion or peripheral hypotension. Prognosis is good.

· Class II: No symptoms at rest but symptoms appear with physical exertion, limiting ADLs. Slight pulmonary edema may be evident. Prognosis is good.

· Class III: Obvious limitations of ADLs and discomfort on any exertion. Prognosis is fair.

· Class IV: Symptoms are present. Prognosis is poor.

100. B. Advocacy is working for the best interests of the patient despite a conflict with personal values and assisting patients with access to appropriate resources. Moral agency is the ability to recognize needs and take action to influence the outcome of a conflict or decision. Agency is openness and recognition of issues and a willingness to act. Collaboration is working together to achieve better results.

101. C. Balloon valvuloplasty is the treatment of choice for significant pulmonary stenosis, resulting in a narrowing of the valve or the area above or below the valve. Closed valvotomy (without cardiopulmonary bypass) is no longer done, but open valvotomy with cardiopulmonary bypass may be needed if the balloon valvuloplasty is unsuccessful and symptoms recur. Valve replacement with a homograft valve is sometimes required, usually as an intervention after previous failure to correct the disorder.

102. D. The barriers to self-care that this patient faces are psychological, physical, and cognitive:

· Psychological: She is very anxious, and this may interfere with her ability to manage care.

· Physical: Her arthritis has impaired her mobility, and this may prevent her from carrying out necessary activities or procedures.

· Cognitive: This patient is forgetful, so she may require repeated instructions or may not be able to manage care.

103. B. Dobutamine is used to treat low cardiac output after cardiac surgery. Nitroprusside decreases blood pressure and afterload. Dopamine is used to treat shock and hypotension for patients who require volume resuscitation. Isoproterenol is used to stimulate the heart in patients with severe bradycardia. Other drugs include nitroglycerine, which is used to prevent spasm in arterial grafts and to reduce preload and afterload, and epinephrine, which is used to treat low cardiac output related to shock. Milrinone is also used to treat low cardiac output. Phenylephrine, norepinephrine, and vasopressin increase systemic vascular resistance and blood pressure and are used to treat shock.

104. B. The best reading level for a group of adults from an affluent area is grade six. The average American reads effectively at the sixth-to eighth-grade level, regardless of education achieved, and research shows that even people with high reading skills learn health information most effectively when the material is presented at the sixth-to eighth-grade reading level. Grade-three reading level is too simple for native English speakers but might be appropriate for an immigrant population with limited English.