high acuity nursing 7th edition by kathleen dorman
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Test bank for High Acuity Nursing 7th Edition by Kathleen
Dorman Wagner, Melanie Hardin-Pierce, Darlene Welsh |
9780134459295 | Chapter 1-39 | All Chapters with Answers
and Rationals
what are the assessment findings that point towards an MI? - ANSWER: chest pain not relieved by rest
diaphoresis, agitation, SOB, pain radiating to arm (or back), feeling of impending doom
what does the pain associated with an MI feel like? - ANSWER: pressure, squeezing, fullness, crushing
in substernal area (NOT stabbing)
it may radiate to shoulders, one or both arms, jaw, back, or epigastrum
MI signs in women - ANSWER: nausea, indigestion, epigastric pain that feels like heartburn, back pain
dizziness, syncope, fatigue, flu symptoms
diagnostic tests for MI - ANSWER: ECG, cardiac enzyme biomarkers (troponin, creatinine kinase, and
myoglobin).
ECG changes with an MI - ANSWER: t wave inversion, ST segment elevation and development of
abnormal q wave
ST elevation means cardiac damage is occuring
inverted t wave is caused by necrosis which delays repolarization
NSTEMI - ANSWER: the cardiac biomarkers are elevated but no ECG evidence of acute MI
STEMI - ANSWER: evidence of MI on ECG and cardiac biomarkers
troponin I and troponin T - ANSWER: protein in myocardial cells
increase can be detected within 2-4 hours after MI and peaks at 10-24 hours. It can remain elevated
x2 weeks
it is specific to muscle injury or infarction
creatinine kinase (CK-MB) - ANSWER: elevated is an indicator of acute MI
it increases within 6 hours of an acute MI
normal= 5-25
>25 means ischemia or damage to cardiac muscle
what are the complications of an MI? - ANSWER: disruptions in rate or rhythm (sinus bradycardia,
sinus tachycardia, atrial dysrhythmias, ventricular dysrhythmias, AV heart block)
HF- which leads to a decrease in CO and can lead to shock (cardiogenic shock).
,organ damage (decreased urinary output or LOC due to decreased perfusion)
ventricular aneurysm (stretching or bulging of a vessel because it is weak)
ventricular septal rupture (hole in septum that creates communication between R & L ventricles)- can
happen as a result of ventricular aneurysm causing a weak area that tears.
papillary muscle rupture (muscle that opens and closes mitral valve ruptures- EMERGENCY)
pericarditis (inflammation around pericardial sac)
valve problems that can lead to HF (mitral valve stenosis, mitral valve regurgitation, pulmonic valve
disease, mixed valvular lesions)
priority interventions for patient with cardiac chest pain? - ANSWER: nursing process: assess then
treat (so vitals and EKG are first)
control the pain, if it does not resolve, it means ischemia is occurring
Nitro first x3, then morphine if not relieved, vitals, then get an EKG
DO ABCs- start w/ airway, then move to oxygen (breathing), then nitro (circulation), then morphine,
then aspirin.
cardiac catheterization (PCI) - ANSWER: used to dx structural and functional diseases of heart and
great vessels
performed in a cath lab, contrast is used to visualize patency of coronary arteries and L ventricular
function (ask about allergies!!). fluoroscopy is used to guide the advancement of the catheters
through R and L heart
cardiac cath procedure - ANSWER: need consent
done in cath lab, they have local anesthesia + relaxation meds but NOT general anesthesia
cath is inserted into the radial or femoral artery and advanced through the blood vessels of the heart
(vena cava)
dye is then squirted to see where blockage is. They can use a balloon and leave a stent or can squirt
tPA, or fish out the clot
once done, hold pressure x10-20 mins and bandage up
nursing priorities when patient comes back from cardiac cath - ANSWER: look for bleeding, check
vitals q15 mins x 1 hour and then q30, keep leg/extremity extended and straight to prevent
bleeding/hematoma, look and feel for a hematoma in the groin, tell pt not to bend leg, elevate HOB
15-30 degrees or put pt in reverse Trendelenburg
nursing considerations post PCI - ANSWER: observe catheter access site for bleeding or a hematoma
and assess peripheral pulses in affected extremity (dorsalis pedis, posterior tibia for LE and radial for
UE), vitals q15 mins and check bleeding, monitor for orthostatic hypotension
, screen for dysrhythmias, maintain bed rest x6 hours post op w/ leg straight and HOB elevated to 15-
30
monitor elevated serum creatinine levels for contrast induced nephropathy
IV hydration to increase UO to flush contrast out`
administering nitroglycerine - ANSWER: patient can take 1 tab (up to 3) every 5 mins. If pain not
resolved after 1st tab call 911.
assess for hypotension, HA, and dizziness and don't administer if SBP is <90.
pt needs to be in a sitting position and get up slowly
can cause a headache bc of vasodilation, check exp date, keep bottle away from light
if nirto doesn't work, what is the next step - ANSWER: morphine
after they may need a nitro drip and a beta blocker
endocarditis - ANSWER: a microbial infection and inflammation of inner lining of heart and valves
can be caused by staph, strep or fungal
common among drug users
priority assessments for endocarditis (s/sx) - ANSWER: assess for fever, auscultate for heart murmur,
lesions, weakness, dizzines
may see clusters of petechiae on body, small painful nodules on pads of fingers and toes, irregular
purple macules on palms, fingers, hands, toes, and soles
cardiomyopathy - ANSWER: disease of heart muscle that makes it harder for heart to pump and
causes a decrease in cardiac output
it causes structural and functional abnormalities of the heart muscle
pts can remain asymptomatic for years but as it progresses so do the symptoms (symptoms are same
as HF)
nursing interventions for cardiomyopathy - ANSWER: rest when symptomatic, assess O2 sat at rest
and during activity, assure adherence to medication regimen to assure adequate CO
low sodium diet, check daily weight and note any change, assess for SOB after activity, assess how
many pillows they need to sleep with, avoid dehydration
have pt anticipate voiding every 4 hours if awake and if urge isn't there or urine is deeep yellow they
need more fluid
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