1. The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected?

ANS: B

The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer can result in decreased cardiac output. This most likely would result in decreased blood pressure and strength of peripheral pulses. Absent peripheral pulses would be caused by an arterial occlusion. S₁ and S₂ most likely would not be affected.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client’s mean arterial blood pressure decreases below 60 mm Hg?

ANS: C

Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP) of 60 mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70 mm Hg is necessary for adequate perfusion to major body organs. If MAP decreases to below 60 mm Hg, the client with cardiac disease may have chest pain. Cardiac output most likely would decrease, and blood pressure also would decrease. Heart rate may increase as the body initiates compensatory mechanisms.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does the nurse expect?

ANS: A

When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia is an early response and is seen even when blood pressure is not critically low.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect?

ANS: D

Beta blockers block the stimulation of beta₁-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta₂-adrenergic receptor sites. Cardiac output will drop because of decreased heart rate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)

5. The nurse is assessing clients at a community health center. Which client does the nurse determine is at high risk for cardiovascular disease?

ANS: C

The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity.

DIF: Cognitive Level: Knowledge/Remembering REF: pp. 692-693

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is obtaining a client’s health history. Which illness alerts the nurse to the possibility of abnormal heart valves?

ANS: C

Rheumatic fever is an inflammatory disease that typically is caused by infection with group A beta-hemolytic streptococci that can affect the endocardium.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 694

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

7. A nurse is performing an admission assessment on an older adult client with multiple chronic diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first?

ANS: C

Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine to be needed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A