ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 22 : Introduction to the Cardiovascular System Questions
Question 1 of 5
When caring for a client with dysfunction in the conduction system, at which period would the nurse note that cells are resistant to stimulation?
Correct Answer: D
Rationale: The refractory period is the time when cells are resistant to electrical stimulation. Repolarization is when the ions realign themselves to wait for an electrical signal. Depolarization occurs during muscle contraction when positive ions move inside the myocardial cell membrane and negative ions move outside. Before an impulse is generated, the cells are in a polarized state.
Question 2 of 5
The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?
Correct Answer: C
Rationale: Baroreceptors sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.
Question 3 of 5
Which suggestion can the nurse provide to an older adult client to reduce the symptoms associated with sarcopenia?
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.
Question 4 of 5
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?
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.
Question 5 of 5
In which client does the nurse consider the presence of an S3 heart sound to be normal?
Correct Answer: A
Rationale: A heart sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. Although an abnormal finding for many clients, this finding is considered normal in many pediatric clients, including a school-age client. In adults, the presence of S3 may signify heart failure, so this is not considered normal. Additionally, S3 is not considered normal for older adult clients nor for a client who has an indwelling pacemaker.