An older client is admitted to an acute care floor with the diagnosis of heart failure. Upon further
workup the health care provider informs the nurse that the client has right-sided heart failure. Which
symptom should the nurse expect to find in this client? - correct answer ✔✔Signs of right sided heart
failure include dependent edema, jugular vein distention and weight gain. Crackles are a sign of left sided
heart failure and weight loss is not an indication of heart failure.
A client is seen in the emergency department and the health care provider suspects an abdominal aortic
aneurysm. Which nursing actions should be performed? - correct answer ✔✔The nurse should monitor
and record vital signs, monitor input and output as well as lab values, and observe client for hypovolemic
shock in case the aneurysm has ruptured.
A nurse is screening clients for their risk of developing cardiovascular disease. The nurse identifies which
clients to be at the greatest risk? - correct answer ✔✔African Americans are two to three times more
likely to develop hypertension than Caucasians. Males have more myocardial infarctions than women
until women are post menopause when their risk increases.
The nursing student is caring for a client who is symptomatic for coronary artery disease. Which
symptom does the student expect to find when obtaining data for this client. - correct answer ✔✔Chest
pain, arm pain, jaw pain, and back pain are key signs and symptoms of Coronary artery disease. These
can occur after exertion, emotional stress, or exposure to cold but can also develop when the client is at
rest.
A client with a family history of heart disease is diagnosed with coronary artery disease. The client asks
the nurse, "How it can affect my future health status?" What is the nurse's best response? - correct
answer ✔✔Coronary artery disease causes decreased perfusion of myocardial tissue and inadequate
myocardial oxygen supply which can cause hypertension, angina, MI, heart failure or death.
The nurse is obtaining data from a client who has just been diagnosed with coronary artery disease.
Which findings does the nurse anticipate observing? - correct answer ✔✔Symptoms for coronary artery
disease occur when the artery is occluded to the point that inadequate blood supply to the muscle
occurs. Assessment findings include possible normal findings during asymptomatic progression, chest
pain, palpitations, syncope, and excessive fatigue.
, The client is informed that elevated serum total cholesterol levels significantly increases the risk of
coronary artery disease? Which intervention is best for the nurse to suggest to a client who has an
elevated serum total cholesterol level? - correct answer ✔✔A change in diet would be the best
intervention and should include limited fats and carbohydrates. Total cholesterol levels above 200 mg/dL
are considered borderline high; they require dietary restrictions and perhaps medication.
Which action by the nurse is the priority for a client exhibiting signs and symptoms of coronary artery
disease? - correct answer ✔✔Enhancing myocardial oxygenation is always the priority when a client
exhibits signs or symptoms of cardiac compromise.
The nurse explains to the client who has coronary artery disease that there are different types of
treatment for the disease. Which method of treatment is considered to be the initial treatment for
coronary artery disease? - correct answer ✔✔Oral medication administration is a noninvasive, medical
treatment for CAD and is usually the initial treatment for coronary artery disease.
A client diagnosed with acute arterial occlusive disease is scheduled to undergo an atherectomy. What is
the priority nursing intervention for this client immediately after the procedure? - correct answer
✔✔Atherectomy is a surgical treatment used for acute arterial occlusive disease. After the procedure,
the client should be monitored frequently for bleeding at the catheter site and vital signs should be
taken every 15 minutes times four, and then every hour for the first few hours.
A client is suspected to be experiencing a myocardial infarction. Which symptom reported by the client
would lead the nurse to this conclusion? - correct answer ✔✔The most common symptom of an MI is
chest pain resulting from the deprivation of oxygen to the heart.
The nursing student voices an understanding of correct anatomy when properly identifying the following
areas on the precordium that are used for auscultation of heart sounds. - correct answer ✔✔The correct
landmarks that can be used for auscultation of heart sounds are the aortic area, pulmonic area, ERB
point, tricuspid area and mitral area. 'APETM' acronym to remember, 'All People Enjoy Time Magazine'.
A client with coronary artery disease comes to the clinic with an elevated total serum cholesterol level
above 240. Which medication does the nurse expect the health care provider to prescribe? - correct
answer ✔✔Cholestyramine and Lovastatin help to lower total cholesterol.
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