ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 22 : Introduction to the Cardiovascular System Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse monitors a client with dark skin for signs of cyanosis. Which manifestation, documented by the nurse, indicates cyanosis for this client?
Correct Answer: B
Rationale: A good light is necessary when monitoring skin color. Many clients with cardiac disorders exhibit changes in skin color (e.g., cyanosis, pallor). Cyanosis can be detected by carefully noting color changes in the oral mucous membranes as well as in the lips, earlobes, skin, and nail beds. In dark-skinned clients, a grayish cast to the skin indicates pallor. In clients who are light skinned, extreme pallor is easy to detect because the skin appears almost bloodless. Dark red lips and tongue are not manifestations associated with cyanosis. A pale appearance can indicate cyanosis for a client with light skin. The presence of pale pink mucous membranes is a normal or expected finding and is not associated with cyanosis.
Question 5 of 5
The nurse is caring for a client with ECG changes consistent with a myocardial infarction. Which of the following diagnostic test does the nurse anticipate to confirm heart damage?
Correct Answer: B
Rationale: Nuclear cardiology uses a radionuclide to detect areas of myocardial damage. Chest radiography and fluoroscopy determine the size and position of the heart and condition of the lungs. Serum blood work notes elevations in enzymes suggesting tissue damage.