ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 23 : Caring for Clients With Infectious and Inflammatory Disorders of the Heart
and Blood Vessels Questions
Question 1 of 5
Which common assessment question does the nurse use when admitting all clients that helps to screen for cardiomyopathy?
Correct Answer: B
Rationale: Having a family history of early cardiac deaths can indicate cardiomyopathy. Many individuals with cardiomyopathy are asymptomatic with the disorder not discovered until the affected person becomes acutely ill or dies.
Question 2 of 5
The nurse is caring for a five-client assignment on a cardiac unit. In caring for which client would the nurse be most correct to assess for an effusion?
Correct Answer: B
Rationale: An effusion, which is the accumulation of fluid between two layers of tissue, commonly occurs with pericarditis, which is the inflammation of the pericardium. Common causes of pericarditis include endocarditis, myocarditis, chest trauma, post heart surgery, or a myocardial infarction. Clients with chest pain, aortic stenosis, and mitral valve prolapse have conditions without current inflammation.
Question 3 of 5
The nurse is caring for clients on a busy cardiac unit. Following morning assessment, the nurse would notify the physician with which of the following symptoms?
Correct Answer: D
Rationale: Pulsus paradoxus is a difference of 10 mm Hg or more between the first Korotkoff sound noting systolic blood pressure heard during expiration and the first that is heard during inspiration. Pulsus paradoxus can signal a deteriorating condition including diminished stroke volume, compromised cardiac output, and death. This would be of high priority to notify the physician.
Question 4 of 5
The nurse is caring for a client with a deep vein thrombosis in the popliteal vein. Which component of a head-to-toe assessment is crucial?
Correct Answer: A
Rationale: Thrombi that form above the popliteal vein of the leg are at higher risk for migration toward the pulmonary circulation. Assessing lung sounds can identify changes quickly. A pulmonary embolus can be a life-threatening condition. The other options do not reflect on the most crucial assessment for this critical complication of DVT.
Question 5 of 5
The nurse is caring for a client who has history of thrombosis. The client asks, 'I never want to have another pulmonary embolus in the lung again. Is there something that can be done to prevent them?' Which option(s) would the nurse encourage the client to discuss with the health care provider? Select all that apply.
Correct Answer: A,B,D
Rationale: Prevention of thrombus development and moving to the lung is key. Prevention of thrombus development in the system can be obtained from anticoagulant therapy. Once a thrombus has formed, the vena caval filter and vena caval plication can interrupt the movement to the lungs. Thrombolytic therapy breaks a clot apart current thrombus travel through the system or wedged in a vessel, and a thrombectomy is a surgical procedure to remove a thrombus from a vessel. Both are following thrombus movement.