Deck 53: Circulation

Question 1

Indigenous Australians have the highest documented rates of ________.

Answer 1

rheumatic heart disease

Question 2

The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take?

A) Prepare to resuscitate the infant.
B) Stimulate the infant gently.
C) Immediately contact the infant's paediatrician.
D) Note this normal finding in the infant's medical record.

Answer 2

Note this normal finding in the infant's medical record.

Question 3

The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this child's blood pressure?

A) No, blood pressure measurements are not required until age 13.
B) Only if the child complains of headache or has an elevated pulse rate.
C) Yes, blood pressure is measured for all children over the age of 3 years.
D) Yes, but the measurement must be taken in the child's thigh.

Answer 3

Yes, blood pressure is measured for all children over the age of 3 years.

Question 4

Match the following terms and statements.
1. Preload
2. Afterload
3. Contractility
4. Stroke volume
A. Amount of blood ejected from the heart with each beat
B. Stretch of the myocardium
C. Resistance against heart
D. Strength of contraction

Question 5

The older person has physiological changes that affect the body's baroreceptors. If undertaking exercise this can result in:

A) decrease in nutrients.
B) dizziness and falls.
C) stiffness and calcification.
D) All of the above.

Question 6

Cardiac catheterisation has shown that the infant has a malformation of the mitral valve. The nurse specifically monitors the client for the development of problems associated with delivery of which of the following?

A) Oxygenated blood to the body.
B) Deoxygenated blood to the left ventricle.
C) Oxygenated blood to the right atrium.
D) Deoxygenated blood to the lung.

Question 7

The nurse is collecting equipment to assess a newly admitted client's ankle/brachial index (ABI). What equipment should be taken to the client's bedside?

A) Reflex hammer and tuning fork.
B) None, as no special equipment is needed.
C) Blood pressure cuff and a Doppler ultrasound device.
D) Stethoscope and penlight.

Question 8

The nurse is assessing a newly admitted client for the presence of impaired peripheral vascular circulation. Which finding would be significant to this condition?

A) Ruddy skin colour over legs.
B) Decreased hair on the legs.
C) Hot spots on the feet and legs.
D) Decreased peripheral pulses.

Question 9

Which of the following is a modifiable risk factor for coronary heart disease?

A) Age.
B) Culture.
C) Cholesterol.
D) Gender.

Question 10

The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication?

A) Myocardial infarction.
B) Pulmonary embolism.
C) Renal failure.
D) Pneumonia.

Question 11

The client is on strict bed rest following hip surgery. What nursing intervention would support vascular health?

A) Place pillows under the unaffected knee for support.
B) Keep the client in a prone position for at least 20 minutes twice a day.
C) Have the client alternately flex and extend the feet several times a day.
D) Position the bed to flex the knees at least 20 degrees.

Question 12

What dietary teaching should the nurse provide to the client who has homocysteine elevation?

A) Avoid alcohol intake.
B) Take a B complex vitamin supplement daily.
C) Reduce salt intake.
D) Increase fluid intake to 2,000 mL per day.

Question 13

Stress causes a neurohormonal response that increases the force of heart contractions, the rate and increases oxygen demand. What is the name of the hormone responsible?

Question 14

The client exhibits confusion, decreased capillary refilling time, low oxygen saturation readings, and decreased renal output. What NANDA-I nursing diagnosis problem statement would the nurse choose for this client?

A) Ineffective Tissue Perfusion (Cardiopulmonary).
B) Activity Intolerance.
C) Risk for Injury.
D) Decreased Cardiac Output.

Question 15

The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the medical practitioner?

A) Increased troponin.
B) Decreased creatine kinase.
C) High normal potassium.
D) Increased haemoglobin.

Question 16

The client has a history of recurrent transient ischaemic attack (TIA). Based upon this history, the nurse is most concerned about the client's potential to develop which of the following?

A) Stroke.
B) Renal failure.
C) Myocardial infarction.
D) Gangrene.

Question 17

The 50-year-old client who is postmenopausal asks the nurse about the use of oestrogen replacement therapy to protect the heart. How should the nurse respond?

A) "Oestrogen replacement therapy is helpful to reduce the sleep disturbances and hot flushes associated with menopause, but does not protect the heart."
B) "This therapy is well proven to protect the heart in postmenopausal women."
C) "Oestrogen replacement therapy has been proven to have no effect on any postmenopausal symptoms and is not protective of the heart."
D) "The use of oestrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks."

Question 18

The nurse is planning care for a client who was admitted after having a myocardial infarction. Based upon this history, the nurse's greatest concern is that this client might develop which of the following?

A) Chronic renal failure.
B) A gastric ulcer.
C) A cerebral vascular accident.
D) Decreased perfusion.

Question 19

Because the client is receiving a diuretic, the nurse closely monitors laboratory levels of which electrolyte?

Question 20

The client is admitted to the emergency department with the chief complaint of, "My heart is racing". Upon initiated cardiac monitoring, the nurse discovers that the client has a sustained heart rate of 170 beats per minute. The nurse then assesses the client for which of the following?

A) Decreased afterload.
B) Increased preload.
C) Increased cardiac output.
D) Decreased cardiac output.

Question 21

The nurse has calculated the client's toe brachial pressure index (TBPI) as 0.58. This client is at risk for the development of ________.

Question 23

A client has been ordered low molecular weight heparin to prevent deep vein thrombosis. The nurse needs to educate the client:

A) that regular pathology tests will be required.
B) how to administer the intramuscular injection.
C) that it absorbs best from the arm or leg.
D) not to massage the injection site.

Question 24

The nurse is caring for a client who has severe cardiovascular disease. In an attempt to decrease preload and to reduce pulmonary congestion, the nurse places the client in which position?

Question 25

The nurse finds an adult client who has had a sudden decrease in the Glasgow Coma Scale from 13 to 11. The priority action for the nurse is to:

A) summon the MET to the ward.
B) wait 15 minutes and re-evaluate the client status.
C) check for an advanced health directive.
D) ask a colleague to check the assessment.

Question 26

The nurse is planning morning care for a client who has sequential compression devices (SCDs) in place. How should the nurse instruct the Assistant in Nursing (AIN) who will be giving the bath?

A) "Put the devices on as quickly as possible after the bath."
B) "Come and get me when it is time to remove the devices, since that must be done by a nurse."
C) "You may remove the devices, but standards require that only a nurse put them back on the client."
D) "You may leave the devices off until the client's legs air-dry."

Question 27

A doctor has ordered a thigh-length sequential compression device (SCD) for an at risk client. The nurse will:

A) need to measure the thigh circumference to ascertain the right size.
B) apply the SCD with patient in a dorsal position as one size fits all.
C) make sure that there are no openings or spaces between SCD and leg.
D) tell the client there is no need for alarm.

Question 28

According to the Australian Resuscitation Council guidelines for basic life support, place the following into the correct order.

A) Open airway.
B) Send for help.
C) Start CPR.
D) Check responsiveness.
E) Check for any dangers.
F) Check breathing.
G) Attach defibrillator.

Question 29

The early calling criteria for a possible cardiac arrest for an 8-month-old child include:

A) pulse rate 150.
B) respiratory rate 30.
C) systolic blood pressure 60.
D) unresponsive to touch.

Question 30

A distinguishing feature between fainting and a cardiac arrest is ________ and ________.