Chapter 37
1. The client presents to the emergency department (ED) complaining of chest pain, fatigue, and dyspnea. The priority assessment for the ED nurse includes assessing the client’s:
1. Airway and oxygen status.
2. Medications.
3. Chest pain.
4. Activities.
Answer: Airway and oxygen status.
Rationale:
The priority assessment should be to first assess the airway and oxygen status of the client, with the goal to maintain an open airway and adequate oxygen levels. The next focus would be on assessing the client’s pain to determine the client’s description of the pain, its location, and its intensity. Assessing the client’s activities will provide clues as to what brought on the pain. The client’s medications will provide insight into the client’s past medical history as well as potential adverse effects from the medications.
2. A client is admitted to the telemetry unit. Which of the following nursing assessments would have the highest priority for further investigation?
1. The client complains of intermittent chest pain during mild exercise.
2. The client’s father has a history of smoking.
3. The client has a history of urinary retention.
4. The client complains of fatigue and dyspnea after walking up several flights of stairs.
Answer: The client complains of intermittent chest pain during mild exercise.
Rationale:
The client’s history of intermittent chest pain during mild exercise signals the highest need for the further investigation into the client’s cardiovascular status. The past history of urinary retention may be of concern if the client will be receiving medications that could cause urinary retention or if surgery is planned, but should not be a high priority initially. The complaint of fatigue and dyspnea with climbing stairs may need further investigation, but also may not be significant, depending upon how many flights of stairs the client climbs and whether chest pain or discomfort develops. The father’s history of smoking is relevant based upon second-hand smoke exposure.
3. A client presents to the medical−surgical unit confused and with a blood pressure of 90/50. The nurse does a quick physical assessment upon the client’s arrival to the unit to determine if the cause of confusion is cardiac in nature. Which of the following assessment findings might indicate low cardiac output?
1. Prolonged capillary refill and diminished peripheral pulses
2. Bounding peripheral pulses and pulse oximeter reading 90%
3. Pallor and peripheral edema
4. Skin tenting (poor turgor) and heart rate 102
Answer: Prolonged capillary refill and diminished peripheral pulses
Rationale:
The client with low cardiac output will have signs of poor circulation, such as prolonged capillary refill and diminished peripheral pulses. Bounding peripheral pulses indicates good output, though perhaps a rapid heart rate. Oxygen saturation of 90% is on the low side, but accompanied by bounding pulses will not indicate poor output. Pallor can be an indication of poor output; however, there are several causes of peripheral edema other than just poor cardiac output, so this answer choice is not definitive. Poor skin turgor and heart rate of 102 could indicate dehydration.
4. The nurse is taking care of a male client who comes to the health clinic for a wellness check. During the routine physical exam by the nurse, the assessment findings are as follows: The blood pressure is 148/88, heart rate is 92, waist circumference is 120 cm, weight is 80 kilograms, lungs clear. The lab results are: HDL 32mg/dL; glucose of 120 mg/dL. Which of the following is the priority teaching point for this client?
1. Advise the client to begin an exercise and weight-loss program because the client is at higher risk for development of cardiovascular disease.
2. Advise the client to continue with current practices because the client is experiencing no health problems.
3. Advise the client that there is a high risk for cardiovascular disease, but there is nothing that can be done until signs and symptoms of cardiovascular disease develop.
4. Advise the client to not smoke because tobacco is associated with cardiovascular disease.
Answer: Advise the client to begin an exercise and weight-loss program because the client is at higher risk for development of cardiovascular disease.
Rationale:
The client is at risk for developing cardiovascular disease because this client has metabolic syndrome based upon the elevated blood pressure, the abdominal fat, the low HDL, and the elevated glucose. Advising the client to continue with current practices is not sound advice, as a weight reduction and exercise plan could decrease the client’s risk factors. Once the client experiences signs of cardiovascular disease, it becomes too late to prevent cardiovascular disease. Advising the client to not smoke is a valid intervention and should be included in the overall plan to reduce the client’s risk for cardiovascular disease, but will not by itself reduce the factors that place this client in the category of metabolic syndrome.
5. A 66-year-old client arrives in the emergency department complaining of crushing chest pain following a large meal 4 hours before the onset. The pain has been recurring over the last several hours. The nurse assesses the client for presence of cardiac risk factors and finds none. The client asks the nurse if this means that there is no chance the client is having a cardiac event. How should the nurse respond?
1. “Even though you have no cardiac risk factors, it is still possible to have cardiac problems. We will want to completely evaluate you before we discharge you to home.”
2. “Since you have no cardiac risk factors, you probably have a respiratory illness, such as a cold, that is causing your chest pain. We will draw some blood, but will let you go home soon.”
3. “You have no cardiac risk factors, so the only reason you would be having chest pain now is related to how much you have eaten recently.”
4. “Since you have no cardiac risk factors, your chest pain is likely related to gallbladder disease, so there is no need to draw lab work.”
Answer: “Even though you have no cardiac risk factors, it is still possible to have cardiac problems. We will want to completely evaluate you before we discharge you to home.”
Rationale:
A client may still have cardiac problems even though there are no apparent risk factors. Even though there is no family history, age increases the potential for cardiac problems. Giving the client a false sense of security by stating it could be due to a respiratory illness, overeating, or gallbladder disease could be misleading. It is important, however, for the nurse to ask probing questions about the chest pain, such as when it started, what it feels like, and so on, to evaluate the various causes of chest pain.
6. A client comes into the health clinic asking for advice on lowering the individual’s risk of heart disease. The nurse’s best response is to:
1. Conduct a health history and physical exam to determine the client’s area of risks and then educate the client based upon these findings.
2. Discuss the client’s perceived area of health risks.
3. Determine the client’s risks based upon a prior chart for the client.
4. Conduct a physical exam of the client and discuss the findings.
Answer: Conduct a health history and physical exam to determine the client’s area of risks and then educate the client based upon these findings.
Rationale:
A thorough health history and physical exam should disclose a client’s risk factors. Modifiable risk factors can be evaluated and discussed with the client. Discussing the client’s perceived area of health risks will not be inclusive and may only capture those risks the client is aware of. Using the client’s old chart may disclose some risk factors, but would not include any recent concerns. Conducting a physical exam would discover some risk factors, but is not inclusive of the health history.
7. An elderly client arrives in the clinic complaining of dyspnea, weight gain, chest pain, and increasing edema of the lower extremities. The client’s blood pressure is elevated. The nurse discovers the client has a history of heart failure. The nurse questions the client regarding which of the following that may best help with determining why the client is currently having health problems?
1. “Have you attended any recent family or social gatherings?”
2. “Have you been out of the country lately?”
3. “Are you married?”
4. “Do you have grandchildren that you babysit?”
Answer: “Have you attended any recent family or social gatherings?”
Rationale:
If the client has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the client anticipated. The other answer options do not apply to helping determine why the client may suddenly be experiencing an exacerbation of the heart failure.
8. A client who is employed as the president of a well-known bank has been having intermittent chest pain and has been concerned she is at risk for heart disease. The client asked the nurse to help decrease her risk factors for cardiovascular disease. The nurse determines that the client holds a high-stress job and is a Type A personality. What is the best explanation for the nurse to give to the client regarding decreasing her risk factors?
1. The exposure to chronic stress causes increased workload for the heart. Managing stress will help decrease the risk factors for cardiovascular disease.
2. Some stress is healthy for the heart. If constant chest pain develops, the client needs to have it investigated.
3. Stress is an everyday occurrence, but should be managed by resting frequently.
4. Type A personalities tend to seek out higher-stress jobs. Advise the client to seek different employment.
Answer: The exposure to chronic stress causes increased workload for the heart. Managing stress will help decrease the risk factors for cardiovascular disease.
Rationale:
Current and previous job stress can contribute to an increased risk for cardiovascular disease by increasing the workload on the heart. Intermittent chest pain can be an early indication of upcoming problems. The advice to the client should be to lower stress by utilizing stress reduction techniques. Resting often encourages decreased exercise, while the client should be encouraged to increase her activity. Type A personalities may tend to seek out higher-stress jobs, but instead of advising the client to change jobs, a better choice would be to employ stress reduction techniques first.
9. The nurse has just received the report at the beginning of the shift. Which of the following clients would the nurse see first based upon the report?
1. Newly admitted client complaining of substernal chest pain. Client has recently had a father die from heart disease.
2. Client complaining of hyperventilation after a family member leaves the room following an argument. Client has a history of anxiety-related disorders and had a similar episode on the prior shift.
3. Client with occasional chest pain who has recently been diagnosed with gallbladder disease. Client requires frequent pain medication.
4. Client concerned with multiple cardiac risk factors (smoking, obesity, family history and high cholesterol) develops sudden onset of nausea and vomiting.
Answer: Newly admitted client complaining of substernal chest pain. Client has recently had a father die from heart disease.
Rationale:
The top priority for this nurse is the new admit who has developed substernal chest pain with a family history of cardiac disease. The nurse would want to assess this client and initiate any interventions that are appropriate. The client with hyperventilation and a history of anxiety could be having an anxiety attack, but still needs to be assessed as soon as possible. The client with occasional chest pain and gallbladder disease may have chest pain that is not cardiac related. The client with multiple risk factors and sudden onset of nausea and vomiting, but no pain, would need evaluation, but after the new admission is evaluated.
10. A nurse is assessing the heart and believes a pericardial friction rub is present, but it is very faint. Which of the following, if utilized, might help the nurse hear this sound more clearly?
1. Have the client lean on the overbed table.
2. Push the stethoscope tighter against the client’s skin.
3. Have the client turn his or her head to the right.
4. Have the client hold his or her breath while the nurse is listening.
Answer: Have the client lean on the overbed table.
Rationale:
Having the client lean forward may help the nurse hear a pericardial rub more clearly. Pushing the stethoscope harder against the client’s skin will be more uncomfortable for the client and may not reveal any clearer quality. Turning the client’s head to either side and having the client hold his or her breath will not produce better results.
11. The nurse observes a client who is entering the health facility. One of the first indications by the nurse that the client may be experiencing a problem is:
1. The client’s facial features and body posture.
2. How fast the client enters the facility.
3. The client’s clothing.
4. The client’s speech.
Answer: The client’s facial features and body posture.
Rationale:
One of the first observations the nurse is able to make is of the client’s facial features and the body posture. How fast the client enters the facility may be helpful, but only if the nurse can determine that there is urgency by the client’s appearance. A slow gait does not necessarily indicate a problem. The client’s clothing may be neat and clean or disheveled and dirty, but that will not give clues of a client problem. The client’s speech may indicate problems, but will not be the first observation.
12. A nurse is completing a physical assessment on a clinic client who has been complaining of fatigue and intermittent chest pain over the last several weeks. Upon auscultation of the chest, the nurse hears an S1, S2, and an S3. Because of these findings, the nurse will also be certain to check for:
1. Lung sounds for crackles.
2. Absence of bowel sounds.
3. Diminished pulses.
4. Sluggish pupil response.
Answer: Lung sounds for crackles.
Rationale:
An S3 indicates excess fluid, and the nurse would want to evaluate the client for crackles in the lungs. S1 and S2 heart sounds are normal. The nurse might also check for JVD, peripheral edema, ascites, and other signs of fluid overload. The absence of bowel sounds and sluggish pupil response does not correlate with an S3 heart sound. Diminished pulses could be a result of excess fluid, but could also be related to other cardiac problems.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
