Cardiac/Vascular Nurse Exam Secrets Study Guide (42 page)

29. D. Patient’s with Raynaud’s disease typically exhibit “red, white, and blue” symptoms in the extremities: the pallor is in response to a trigger, such as cold or tobacco, which causes vasoconstriction, followed by cyanosis, and then rubor in response to hyperemia from compensatory vasodilation. Patients may experience pain, numbness, and tingling, and in severe cases, muscles and skin may atrophy, and (rarely) ulceration may occur. Patients must be taught to avoid cold and all forms of nicotine, including tobacco, nicotine gum, or nicotine patches.

30. C. While wearing a Holter monitor, patients should maintain an activity diary so that any abnormality can be linked to this activity. Conversely, the diary may demonstrate that no abnormality occurs with certain activities. Patients should continue with prescribed medications and carry out normal activities since the primary purpose of a Holter monitor is to assist in diagnosis and to determine triggers for abnormal electrocardiogram readings. The monitor should be used during the night as some cardiac abnormalities may occur during sleep.

31. B. The best approach for severe mitral valve prolapse with heart failure is to repair the valve rather than to replace it because of the connective tissue abnormalities associated with Marfan syndrome. These abnormalities may result in dehiscence when prosthetic valves are used. Severe mitral valve prolapse can result in complications, such as heart failure, endocarditis, and cardiac arrest, so delaying surgery increases the risk; therefore, delaying surgery and not operating are options only for mild cases of mitral valve prolapse.

32. A. Using a blood pressure (BP) cuff that is somewhat small usually results in a false high reading while a cuff that is somewhat large results in a false low reading. Thus, using the same BP cuff size for all patients increases the likelihood of inaccurate readings. To fit correctly, the BP cuff should have a bladder width at least 40% of the limb circumference and a length at least 80% of limb circumference. Standard adult cuffs range from 12–14 cm wide and 30 cm long.

33. C. According to Knowles, adult learners tend to be practical and goal-oriented, so they are likely to be organized, keeping their goals in mind while learning. Many adult learners are also:

· Self-directed as they like active involvement and responsibility

· Knowledgeable as they can relate new material to life experience or past education

· Relevancy-oriented as they like to know how they can apply new information

· Motivated as they generally like to see evidence of their own achievements, such as by receiving a certificate or a degree

34. D. The health belief model is used to predict health behavior when a person takes a health action to avoid negative consequences if the person believes the action will prevent a negative outcome. The theory is based on six basic perceptions:

· Susceptibility, the belief that a person may get a negative condition

· Severity, an understanding of how serious a condition is

· Benefit, a belief that action will reduce risk

· Barriers, such as direct or psychological costs

· Action cues or strategies, such as education, to encourage action

· Self-efficacy, the confidence in the ability to take action and to achieve positive results

35. B. Smoking the first cigarette within 5 minutes of awakening is one of the primary signs of a high level of nicotine dependence as is smoking 31 or more cigarettes daily. Patients who are dependent on cigarettes also often smoke in areas where it is prohibited (e.g., at work) and smoke even if they are extremely ill. Patients may benefit from keeping a smoking diary to help to identify their smoking patterns

36. A. An atrial-septal defect is characterized by the shunting of blood returning from the lungs from the left atrium back to the right atrium and into the pulmonary circulation. Ventricular-septal defect is characterized by a left-to-right shunt and with Eisenmenger’s syndrome (in 10%), causing increased pulmonary hypertension and right-sided heart failure. Pulmonic stenosis causes right ventricular hypertrophy from increased pressure in the right ventricle and decreased pulmonary blood flow. Aortic stenosis causes left ventricular wall hypertrophy as pressure increases to overcome valvular resistance.

37. B. Sclerotherapy is used to treat varicose veins. A chemical substance, such as sodium tetradecyl sulfate, is injected into the vein, causing local inflammation and fibrosis, which eventually obliterates the lumen. It is especially effective for the treatment of spider veins or small surface varicosities. Microfoam sclerosants, in which the chemical is mixed with air or carbon dioxide to increase surface coverage, is sometimes used for deeper and larger varicosities. Compression dressings are applied to the limb after sclerotherapy, and compression stockings are worn for about 5 weeks.

38. C. Varenicline (Chantix) must be monitored as it can cause mood or behavioral changes, seizures, psychiatric manifestations, and suicidal thoughts. Varenicline is one of the most lethal drugs in terms of injury and death associated with a drug. Other prescription medications include the nicotine inhaler, nicotine nasal spray, and bupropion (Zyban). Bupropion can cause insomnia and dry mouth. Over-the-counter smoking-cessation medications include nicotine gum, the nicotine patch, and nicotine lozenges; these can cause local irritation.

39. D. Making a referral to a home health agency to provide in-home care is the best solution for an elderly man with a draining wound and poor eyesight, as this ensures that the man will receive skilled nursing care and still be able to stay at home with his grandson. The grandson is too young to take responsibility for wound care. In-home care is a more cost-effective solution than transferring the patient to an extended care facility. Keeping the patient in the hospital is not generally an option, as Medicare will not pay for extended care for long-term wound treatment.

40. C. A patient with an internal locus of control probably believes that he is in control of his health and that the actions he takes can make a significant difference. This type of patient generally wants to participate in decision-making concerning his health. Patients with an external locus of control are much more likely to believe that their health is related to bad luck or fate and to leave decision-making and control in the hands of physicians and nurses.

41. B. Clinical pathways should be based on evidence-based research, which is the use of current research and patient values in practice to establish a plan of care. Research may be the result of large studies of best practices or from individual research from observations in practice about the effectiveness of treatment. Evidence-based research requires a commitment to ongoing research and outcomes evaluation as well as a thorough understanding of research methods, including internal and external validity.

42. A. The primary benefit of drug-eluting coronary stents over standard stents is that they inhibit cell proliferation and inflammation and reduce the incidence of restenosis. They are not used to elute antibiotics or anticoagulants, and they are inorganic and are, therefore, not rejected. Drug-eluting stents are more costly than standard stents. Most coronary stents are premounted on an inflatable balloon delivery system, which is carried by a catheter to the site of the lesion.

43. C. The most effective and efficient method of teaching a group about lifestyle changes is the group lecture and discussion. These allow the nurse to provide information and for people with shared concerns to interact and discuss issues. Computer-assisted instruction is not effective for all patients, especially older adults, and lectures only may not address specific concerns of the patients. One-on-one instruction is good for teaching specific processes or information, but it does not allow patients to share their concerns with others.

44. B. The best time to initiate conflict resolution is when conflict first emerges but before open conflict and hardening of positions occur. Important steps toward conflict resolution include the following:

· Allowing both parties to present their sides without bias

· Encouraging cooperation through negotiation and compromise

· Maintaining focus and avoiding arguments

· Evaluating the need for renegotiation, formal resolution process, or third party

· Using humor and empathy to diffuse tension

· Summarizing and outlining key arguments

· Avoiding forced resolutions if possible

45. A. The goals of the 2100-calorie DASH diet include:

· Total fat: 27%.

· Saturated fat: 6%.

· Protein: 18%

· Carbohydrates: 55%.

Cholesterol is limited to 150 mg/day and sodium to 1500–2300 mg/day. People are encouraged to eat six to eight servings of whole grains, four to five servings of fruit and vegetables, 30 g of fiber, and 6 oz of lean meat daily as well as four to five servings of nuts, seeds, or legumes each week. Sweets and added sugars are limited to five or fewer servings each week.

46. C. Hypovolemic shock occurs when there is inadequate intravascular fluid. The loss is absolute if caused by internal shifting of fluid or external loss of fluid, such as with massive hemorrhage, thermal injuries, severe vomiting and diarrhea, or a ruptured spleen. The loss is relative if related to vasodilation, increased capillary membrane permeability from sepsis or injuries, and decreased colloidal membrane permeability from loss of sodium or from diseases, such as hypopituitarism or cirrhosis.

47. D. Videos are appropriate educational tools for illiterate patients. Material should be at an adult level, so a children’s book is not appropriate, and material at a third-grade level may be too difficult for someone who cannot read. Computerized instruction almost always involves some reading for instructions, so this also may not be appropriate. Allowing patients and their families to watch a video demonstration can help them to grasp the fundamentals before they must apply them. Videos are much more effective than written materials for those with low literacy or poor English skills.

48. A. Each state has separate regulations regarding advance directives, so the patient should check state regulations and fill out two advance directives if necessary. Most require two witnesses, but some do not. Some states invalidate an advance directive if the person is pregnant. Telling family members is not adequate as these people may not be available or may be unwilling to carry out the patient’s wishes. Advance directives should not be placed in a safety deposit box where access is limited.

49. C. The greatest risk of cardiovascular disease for people over 50 years of age is from a systolic blood pressure (BP) of 140 mm Hg or more rather than an increased diastolic pressure. However, increased diastolic pressure (> 80 mm Hg) is a greater risk factor for people younger than 50 years of age. Pulse pressure of 40 mm Hg is normal for people at rest. Patients should avoid caffeine, exercise, and smoking for 30 minutes before a BP examination:

· Normal BP: < 120/80 mm Hg

· Prehypertension: 120–130/80–90 mm Hg

· Stage 1 hypertension: 140–159/90–99 mm Hg

· Stage 2 hypertension: ³ 160/100 mm Hg

50. B. Heparin-induced thrombocytopenia can cause a thrombosis syndrome that increases the patient’s risk for thrombosis and vessel occlusion rather than hemorrhage. A platelet count below 50,000 mm3 indicates a type II reaction (rather than transient type I reaction), an autoimmune reaction to heparin; the reaction causes heparin-antibody complexes to form and a release of platelet factor 4, which, in turn, attracts heparin molecules that adhere to platelets and endothelial lining, stimulating thrombin and platelet clumping. Discontinuation of the heparin and treatment with direct thrombin inhibitors (lepirudin [Refludan], argatroban [Argatroban]) are indicated.

51. D. A hemoglobin A1C (HbA1C) value of 5.5% most likely indicates dietary compliance. Hemoglobin A1C is comprised of hemoglobin A plus a glucose molecule because hemoglobin holds onto excess blood glucose; thus, HbA1C levels show the average blood glucose levels over a 3-month period and are used to monitor long-term diabetic therapy. Normal values of HbA1C are less than 6%, and elevated values are more than 7%. Fasting blood sugar (FBS) results can vary widely but show current serum levels; thus, a person who stays on a diet for a few days and fasts may show a near-normal FBS for a short period even though the patient is frequently noncompliant. Normal FBS is 70–99 mg/dL.

52. A. The jugular venous pulse, observing the right internal jugular vein, can be used to assess right atrial function. The “a” wave that occurs with the atrial contraction can be observed in the internal jugular vein, preceding the carotid pulsation. The “v” wave, after the carotid pulsation, occurs with atrial filling. The “a” wave is absent in atrial fibrillation. Large “a” waves indicate obstructed atrial blood flow. Very large (cannon) “a” waves may indicate closed tricuspid valve, atrioventricular block, junctional bradycardia, and supraventricular tachycardia, and ventricular tachycardia. Large “v” waves occur with an incompetent tricuspid valve.

53. C. A nurse who delegates a task to an unlicensed assistant is accountable for patient outcomes and for supervision of the person to whom the task was delegated. The scope of nursing includes delegation of tasks to unlicensed assistive personnel, providing those personnel have adequate training and knowledge. Delegation can be used to manage the workload and to provide adequate and safe care. Delegation should be done in a manner that reduces liability by providing adequate communication.