Exam (elaborations)
CHAPTER 48 CARE OF PATIENT WITH A CARDIOVASCULAR OR A PERIPHERAL VASCULAR
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CHAPTER 48 CARE OF PATIENT WITH A CARDIOVASCULAR OR A PERIPHERAL VASCULAR
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CHAPTER 48 CARE OF PATIENTWITH A CARDIOVASCULAR OR A
PERIPHERAL VASCULAR DISORDER
QUESTIONS AND ANSWERS 2025
LATEST UPDATE
The nurse is aware that the muscle layer of the heart, which is responsible
for the heart's contraction, is the:
a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium. - answer d. myocardium.
The myocardium is the specialized muscle layer that allows the heart to
contract.
The nurse clarifies that the master pacemaker of the heart is the:
a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His. - answer c. sinoatrial (SA) node.
The SA node is the master pacemaker of the heart.
The nurse is aware that the symptoms of an impending myocardial
infarction (MI) differ in women because acute chest pain is not present.
Women are frequently misdiagnosed as having:
a. hepatitis A.
b. indigestion.
,c. urinary infection.
d. menopausal complications. - answer b. indigestion.
Indigestion, gallbladder attack, anxiety attack, and depression are
frequent misdiagnoses for women having an MI.
The nurse identifies the "LUBB" sound of the "LUBB/DUBB" of the cardiac
cycle as the sound of the:
a. AV valves closing.
b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles. - answer a. AV valves closing.
The LUBB is the first sound of a low pitch heard when the AV valves close.
A patient is admitted from the emergency department. The emergency
department physician notes the patient has a diagnosis of heart failure
with a New York Heart Association (NYHA) classification of IV. This
indicates the patient's condition as:
a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure. - answer b. severe heart failure.
Class IV: Severe; patient unable to perform any physical activity without
discomfort. Angina or symptoms of cardiac inefficiency may develop at
rest.
The nurse assesses that the home health patient has no signs or
symptoms of heart failure, but does have a history of rheumatic fever and
has been recently diagnosed with diabetes mellitus. The nurse is aware
that using the American College of Cardiology and the American Heart
Association (ACC/AHA) staging, this patient would be a:
a. stage A.
, b. stage B.
c. stage C.
d. stage D. - answer a. stage A.
The ACC/AHA staging describes stage A as a person without symptoms of
heart failure, but with primary conditions associated with the
development of the disease.
The nurse caring for a patient recovering from a myocardial infarct who is
on remote telemetry recognizes the need for added instruction when the
patient says:
a. "I can ambulate in the hallway with this gadget on."
b. "I always take off the telemetry device when I shower."
c. "My EKG is being watched by one of the nurses in CCU on the home
unit."
d. "I am able to sleep just fine with this device on." - answer b. "I always
take off the telemetry device when I shower."
Remote telemetry allows the patient to be on a separate unit, but be
monitored in a central location. The patients can be ambulatory and can
sleep with the monitor on. They should not remove the monitor to shower.
The nurse assesses pitting edema that can be depressed approximately
inch and refills in 15 seconds. The nurse would document this assessment
as:
a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema. - answer b. +2 edema.
A +2 edema can be documented if the skin can be depressed inch and
respond within 15 seconds.
What do dark or "cold" spots on a thallium scan indicate?
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