Question 1

2 out of 2 points

When advising a morbidly obese client about the benefits of weight reduction, which statement would be most accurate to share?

Selected Answer:	C. “A 10-pound loss of weight can produce a decrease in blood pressure.”
Answers:	A. “All you need to do is stop drinking sodas and sugary drinks.”
	B. “If your leptin [hormone] level is too low, you are at increased risk for developing high BP.”
	C. “A 10-pound loss of weight can produce a decrease in blood pressure.”
	D. “An increased waist-to-hip” ratio can lead to too much pressure on the liver and intestines.”

Response Feedback:

Rationale: Weight reduction of as little as 4.5 kg (10 lbs) can produce a decrease in BP in a large proportion of overweight people with hypertension. There is no data to suggest this client has a high intake of sodas. An increased waist-to-hip ratio is associated with hypertension. Leptin acts on the hypothalamus to increase BP by activating the SNS.

Question 2

2 out of 2 points

A nursing instructor is explaining the role of vascular smooth muscle cells in relation to increases in systemic circulation. During discussion, which neurotransmitter is primarily responsible for contraction of the entire muscle cell layer, thus resulting in decreased vessel lumen radius?

Selected Answer:	A. Norepinephrine
Answers:	A. Norepinephrine
	B. Fibroblast growth factor
	C. Nitric Oxide
	D. Adrenal glands

Response Feedback:

Rationale: Nerve cells and circulating hormones are responsible for vasoconstriction of the vessel walls. Because they do not enter the tunica media of the blood vessel, the nerves do not synapse directly on the smooth muscle cells. Instead, they release the neurotransmitter norepinephrine, which diffuses into the media and acts on the nearby smooth muscle cells; this results in contraction of the entire muscle cell layer and thus reduces the radius of the vessel lumen. This increases the systemic circulation.

Question 3

2 out of 2 points

During a routine physical exam for a client diagnosed with hypertension, the nurse practitioner will be most concerned if which assessment is found?

Selected Answer:	D. Noted hemorrhages and microaneurysms during evaluation of internal eye.
Answers:	A. Inability to locate kidneys with deep palpation to abdomen.
	B. Slight increase in number of varicose veins noted bilaterally.
	C. Unable to feel vibrations when tuning fork placed on skull.
	D. Noted hemorrhages and microaneurysms during evaluation of internal eye.

Response Feedback:

Rationale: Hypertension affects the eye in sometimes devastating ways. If there are acute increases in BP, hemorrhages, microaneurysms, and hard exudates can manifest. Vibrations relate to hearing loss. The kidneys should not be palpable to touch. Varicose veins are not associated with hypertension.

Question 4

2 out of 2 points

In which of the following hospital clients would the care team most realistically anticipate finding normal cholesterol levels?

Selected Answer:	B. A 51-year-old male with a diagnosis of hemorrhagic stroke and consequent unilateral weakness
Answers:	A. A 44-year-old male admitted for hyperglycemia and with a history of diabetic neuropathy
	B. A 51-year-old male with a diagnosis of hemorrhagic stroke and consequent unilateral weakness
	C. A morbidly obese 50-year-old female who is taking diuretics and a beta-blocker to treat her hypertension
	D. A 77-year-old female admitted for rheumatoid arthritis exacerbation who is receiving hormone replacement therapy and has a history of hypothyroidism

Response Feedback:

Rationale: Hemorrhagic stroke is not a pathology noted to be associated with secondary hypercholesterolemia. Diabetes, thyroid medications, estrogen therapy, obesity, and beta-blocker medications are all correlated with hypercholesterolemia.

Question 5

2 out of 2 points

Following physical assessment, which abnormality(ies) leads the health care provider to suspect the client has metabolic syndrome? Select all that apply.

Selected Answers:	C. Five foot (1.5 meter) tall female with abdominal waist measurement of 45 inches (114 cm)
	D. Sitting blood pressure reading of 145/96 mm Hg
	E. Fasting triglyceride level of 230 mg/dL 92.6 mmol/L)
Answers:	A. Fasting high-density lipoprotein (HDL) level of 80 mg/dL (2.07 mmol/L)
	B. Blood glucose level of 100 mg/dL (5.6 mmol/L)
	C. Five foot (1.5 meter) tall female with abdominal waist measurement of 45 inches (114 cm)
	D. Sitting blood pressure reading of 145/96 mm Hg
	E. Fasting triglyceride level of 230 mg/dL 92.6 mmol/L)

Response Feedback:

Rationale: Metabolic syndrome is defined as the presence of three or more of the following: elevated fasting blood glucose; elevated blood pressure; elevated waist circumference; and dyslipidemia reflected by increased triglycerides and/or decreased HDL. In this client, the glucose level is normal and the HDL level is elevated, which is good. The blood pressure is elevated, the waist is too high and the triglycerides are elevated as well.

Question 6

2 out of 2 points

A young woman has been diagnosed by her family physician with primary Raynaud disease. The woman is distraught, stating, “I’ve always been healthy and I can’t believe I have a disease now.” What would be her physician’s most appropriate response?

Selected Answer:	C. “If you make sure to keep yourself warm, it will have a fairly minimal effect; I’ll also give you pills to enhance your circulation.”
Answers:	A. “This likely won’t have a huge effect on your quality of life and I’ll prescribe anti-clotting drugs to prevent attacks.”
	B. “You need to make sure you never start smoking, and most of the symptoms can be alleviated by regular physical activity.”
	C. “If you make sure to keep yourself warm, it will have a fairly minimal effect; I’ll also give you pills to enhance your circulation.”
	D. “I’ll teach you some strategies to minimize its effect on your life, and minor surgery to open up your blood vessels will help too.”

Response Feedback:

Rationale: Ensuring total body warmth and the use of vasodilators are the normal treatment modalities for Raynaud disease.

Question 7

2 out of 2 points

When a 55-year-old client’s routine blood work returns, the nurse notes that the client’s C-reactive protein (CRP) is elevated. The client asks what that means. The nurse responds:

Selected Answer:	B. “This means you have elevated serum markers for systemic inflammation that has been associated with vascular disease.”
Answers:	A. “This means you have high levels of HDL to balance the LDL found in animal proteins.”
	B. “This means you have elevated serum markers for systemic inflammation that has been associated with vascular disease.”
	C. “You must eat a lot of red meat since this means you have a lot of fat floating in your vessels.”
	D. “You are consuming high levels of folate, which works with the B vitamins and riboflavin to metabolize animal protein.”

Response Feedback:

Rationale: CRP is a serum marker for systemic inflammation. Elevated levels are associated with vascular disease. The normal metabolism of homocysteine requires adequate levels of folate, vitamin B ₆, vitamin B ₁₂, and riboflavin. CRP is not associated with red meat consumption. LDL is an independent risk factor for development of premature coronary heart disease.

Question 8

2 out of 2 points

A number of older adults have come to attend a wellness clinic that includes both blood pressure monitoring and education about how to best control blood pressure. Which teaching point is most accurate?

Selected Answer:	D. “Too much alcohol, too little exercise, and too much body fat all contribute to high blood pressure.”
Answers:	A. “It’s important to minimize the amount of potassium and, especially, sodium in your diet.”
	B. “Hypertension puts you at a significant risk of developing type 2 diabetes later in life.”
	C. “High blood pressure is largely controllable, except for those with a significant family history or black persons.”
	D. “Too much alcohol, too little exercise, and too much body fat all contribute to high blood pressure.”

Response Feedback:

Rationale: Obesity, excess alcohol consumption, and a sedentary lifestyle are all linked with hypertension. Inadequate, rather than excessive, potassium intake is thought to be causative and while race and family influence an individual’s predisposition to hypertension, it does not render the condition untreatable or uncontrollable. Diabetes is thought to be a contributor to hypertension, not vice versa.

Question 9

2 out of 2 points

A 70-year-old male client presents to the emergency department reporting pain in his calf that is exacerbated when he walks. His pedal and popliteal pulses are faintly palpable and his leg distal to the pain is noticeably reddened. The nurse knows that the client is likely experiencing which medical diagnosis/possible treatment plan listed below?

Selected Answer:	C. Atherosclerotic occlusive disease necessitating thrombolytic therapy
Answers:	A. Raynaud disease that will require antiplatelet medications
	B. Acute arterial occlusion that will be treated with angioplasty
	C. Atherosclerotic occlusive disease necessitating thrombolytic therapy
	D. Giant cell temporal arteritis that will be treated with corticosteroids

Response Feedback:

Rationale: The client’s symptoms of calf pain with intermittent claudication and diminished pulses are the hallmarks of atherosclerotic occlusive disease. These signs and symptoms are not as closely associated with acute arterial occlusion or giant cell temporal arteritis and are not related to Raynaud disease.

Question 10

2 out of 2 points

A 78-year-old male client has undergone a total knee replacement. He just doesn’t feel like getting out of bed and moving around. After 3 days of staying in bed, the physical therapist encourages him to get out of bed to the chair for meals. He starts to complain of dizziness and lightheadedness. These symptoms are primarily caused by which pathophysiologic principle? Select all that apply.

Selected Answers:	B. Client is experiencing a reduction in plasma volume.
	D. Peripheral vasoconstriction mechanism has failed.
Answers:	A. Client has loss all of his muscle tone.
	B. Client is experiencing a reduction in plasma volume.
	C. Client is so stressed that he is releasing too many endorphins.
	D. Peripheral vasoconstriction mechanism has failed.
	E. Client is still bleeding from the surgical procedure.

Response Feedback:

Rationale: Prolonged bed rest promotes a reduction in plasma volume, a decrease in venous tone, failure of peripheral vasoconstriction, and weakness of the skeletal muscles that support the veins and assist in returning blood to the heart. Endorphins make one feel better in mood. After three days post-op, there should be no further bleeding from the surgical site. If there is, then this is a complication that must be addressed immediately. Loss of vascular and skeletal muscle tone is less predictable but probably becomes maximal after 2 weeks.

Question 11

2 out of 2 points

A physician is providing care for several clients on a medical unit of a hospital. In which situation would the physician be most likely to rule out hypertension as a contributing factor?

Selected Answer:	D. A 61-year-old man who has a heart valve infection and recurrent fever
Answers:	A. A 66-year-old woman with poorly controlled angina and consequent limited activity tolerance
	B. A 44-year-old man awaiting a kidney transplant who requires hemodialysis three times per week
	C. An 81-year-old woman who has had an ischemic stroke and has consequent one-sided weakness
	D. A 61-year-old man who has a heart valve infection and recurrent fever

Response Feedback:

Rationale: While cardiac complications are common sequelae of hypertension, a heart infection is less likely. Stroke, kidney failure, and angina are all identified as consequences of hypertension.

Question 12

2 out of 2 points

The nurse practitioner is working in an overnight sleep lab assessing and diagnosing clients with sleep apnea. During this diagnostic procedure, the nurse notes that a client’s blood pressure is 162/97 mm Hg. The nurse explains this connection to the client based on which pathophysiologic principle?

Selected Answer:	C. During apneic periods the client experiences hypoxemia, which stimulates chemoreceptors to induce vasoconstriction.
Answers:	A. When airways are obstructed, the body will retain extracellular fluid so that this fluid can be shifted to intravascular space to increase volume.
	B. When the client starts to snore, the epiglottis is closed over the trachea.
	C. During apneic periods the client experiences hypoxemia, which stimulates chemoreceptors to induce vasoconstriction.
	D. Specialized cells are located in the back of the throat that signal when the airway is obstructed; this sends signals to the kidney to increase the pulse rate.

Response Feedback:

Rationale: People with sleep apnea also may experience an increase in BP because of the hypoxemia that occurs during the apneic periods. The specialized chemoreceptors are located in carotid bodies and aortic bodies of the aorta. Retention of fluid is not the cause of increased BP during sleep apnea episodes.

Question 13

2 out of 2 points

An autopsy is being performed on a 44-year-old female who died unexpectedly of heart failure. Which components of the pathologist’s report is most suggestive of a possible history of poorly controlled blood pressure?

Selected Answer:	B. “Arterial sclerosis of subcortical brain regions noted.”
Answers:	A. “Bilateral renal hypertrophy noted.”
	B. “Arterial sclerosis of subcortical brain regions noted.”
	C. “Vessel wall changes suggestive of venous stasis are evident.”
	D. “Scarring of urethra suggestive of recurrent urinary tract infections is evident.”

Response Feedback:

Rationale: Neurological consequences of hypertension include narrowing and sclerosis of subcortical regions. Urethral scarring and impaired venous return would be less likely to derive from hypertension, and while nephrosclerosis and glomerular damage are associated with hypertension, hypertrophy of the kidneys themselves is not noted as an indicator.

Question 14

2 out of 2 points

Which client on the nurse’s team will be given priority for cardiac monitoring based on medical history?

Selected Answer:	C. Adolescent client resuscitated following drowning in a swimming pool that required CPR at the scene
Answers:	A. Postoperative client who has a history of diabetes for the last 10 years
	B. Adult client who had a pacemaker implanted 5 years ago admitted with chronic obstructive pulmonary disorder (COPD)
	C. Adolescent client resuscitated following drowning in a swimming pool that required CPR at the scene
	D. Older adult client admitted with pneumonia for a few days of IV antibiotics

Response Feedback:

Rationale: Examples of clients categorized as class I are those who have been resuscitated from a cardiac arrest, are in the early phase of acute coronary syndrome, have unstable coronary syndromes or newly diagnosed high-risk coronary lesions, or have had recent cardiac surgery. Given these guidelines, the adolescent client who was resuscitated by CPR at the pool is the priority of this group of clients. A client with diabetes is at risk for coronary disease but this client underwent surgery without mention of cardiac abnormalities, which places the client at a lower priority for a monitor. The client with COPD is not the priority for monitoring, even though the client has a pacemaker. An older adult client needing IV antibiotics is also a lower priority for continuous monitoring of cardiac rhythm.

Question 15

2 out of 2 points

A physician has ordered the measurement of a cardiac client’s electrolyte levels as part of the client’s morning blood work. Which statement best captures the importance of potassium in the normal electrical function of the client’s heart?

Selected Answer:	B. Potassium is central to establishing and maintaining the resting membrane potential of cardiac muscle cells.
Answers:	A. Potassium catalyzes the metabolism of ATP, producing the gradient that results in electrical stimulation.
	B. Potassium is central to establishing and maintaining the resting membrane potential of cardiac muscle cells.
	C. The impermeability of cardiac cell membranes to potassium allows for action potentials achieved by the flow of sodium ions.
	D. The reciprocal movement of one potassium ion for one sodium ion across the cell membrane results in the production of an action potential.

Response Feedback:

Rationale: The selective permeability of cell membranes to potassium, and its near-impermeability to sodium ions, produces the resting membrane potential of cardiac cells. Potassium does not catalyze the metabolism of ATP, and sodium and potassium ions do not move across the cell membrane in a 1:1 ratio.

Question 16

2 out of 2 points

A client is believed to be in cardiac arrest and defibrillation is being performed. What is an aspect of the rationale and physiology of defibrillation treatment?

Selected Answer:	A. The goal is to depolarize the entire heart during the passage of current.
Answers:	A. The goal is to depolarize the entire heart during the passage of current.
	B. Defibrillation can be achieved using either a transcutaneous or transvenous pacemaker.
	C. Interruption of disorganized impulses by the current allows the AV node to readopt its normal pacemaker role.
	D. Defibrillation must be coincided with the R wave of the ECG in order to be successful.

Response Feedback:

Rationale: The benefits of defibrillation are achieved by depolarizing the heart during the passage of current, allowing the SA node to regain control. It is not achieved by the use of a pacemaker. Cardioversion, not defibrillation, is coincided with the R wave. The SA node, not the AV node, is the source of cardiac conduction and the natural pacemaker.

Question 17

2 out of 2 points

The nurse has completed an automated blood pressure and pulse reading on a client with persistent atrial fibrillation. The client’s baseline values are blood pressure 130/85 mm Hg and heart rate of 80 bpm and irregular. The current result is blood pressure is 98/47 mm Hg, the heart rate is 77 bpm, and the client denies feeling differently. What is the nurse’s priority action?

Selected Answer:	B. Perform a manual blood pressure and apical heart rate reading.
Answers:	A. Have the client lie flat and with the legs elevated (modified Trendelenburg position).
	B. Perform a manual blood pressure and apical heart rate reading.
	C. Hold all antihypertensive medications and notify the health care provider.
	D. Analyze the client’s most recent electrocardiogram.

Response Feedback:

Rationale: The ventricular response in atrial fibrillation is completely irregular. Because of changes in stroke volumes resulting from varying periods of diastolic filling, not all ventricular beats produce a palpable pulse. Using an automated machine means some of the pulses required to assess blood pressure may be inaudible and result in an inaccurate reading. The nurse should verify the results using a manual reading of both blood pressure and apical heart rate. The nurse would also use the client’s current symptoms as a guide to decision making but should not change the position, or notify the health care provider until the reading is verified. Analyzing a past electrocardiogram would also be unnecessary until the reading is confirmed.

Question 18

2 out of 2 points

Which statement describes phase 4 of the action potential of cells in the sinoatrial (SA) node?

Selected Answer:	C. A slow depolarization occurs when Na ⁺ is transported out of the cell and K ⁺ moves back in, resulting in resting membrane potential.
Answers:	A. The cells are capable of responding to a greater-than-normal stimulus before the resting membrane potential is reached.
	B. Potassium permeability is allowing the cell membrane to remain depolarized and the Ca⁺⁺ channel opens, moving Ca⁺⁺ back into the cell.
	C. A slow depolarization occurs when Na⁺ is transported out of the cell and K⁺ moves back in, resulting in resting membrane potential.
	D. The fast sodium channels in the cellular membranes close, causing an abrupt decrease in intracellular positivity.

Response Feedback:

Rationale: During phase 4 in the cells of the SA node, a slow leakage of current through the slow channels of the cellular membrane leads to spontaneous depolarization; this slow response enables pacemaker function. The cells responding to greater-than-normal stimulus describes the relative refractory period of the action potential curve, which occurs at the end of phase 3 in cardiac cells. The fast sodium channels in the cellular membranes closing describes phase 1 of the action potential, which signals the end of depolarization. The sodium-potassium pump transports sodium out of the cell, and a smaller amount of potassium into it, contributing to the negative intracellular charge of the resting membrane potential in phase 4.

Question 19

2 out of 2 points

A client with a new automatic implantable cardioverter-defibrillator (AICD) asks the nurse what happens if he goes into that deadly heart rhythm again. The nurse will base her response knowing the AICD will:

Selected Answer:	A. respond to ventricular tachydysrhythmia by delivering a shock within 10-20 seconds of its onset.
Answers:	A. respond to ventricular tachydysrhythmia by delivering a shock within 10-20 seconds of its onset.
	B. use radiofrequency energy to deliver an electrical shock through the site where the lethal rhythm originates.
	C. remove scar tissue and aneurysm during placement of electrodes and then will shock if paradoxical ventricular movement is located.
	D. periodically fire just to test for lead placement and battery life.

Response Feedback:

Rationale: AICD successfully treats individuals with life-threatening ventricular tachydysrhythmias by use of intrathoracic electrical countershock. It senses and detects ventricular dysrhythmias. It responds by delivering an electrical shock between intrathoracic electrodes within 10 to 20 seconds of its onset. It does not periodically fire to test lead placement. It does not utilize radiofrequency energy (this is used in ablations). The procedure does not remove scar tissue or aneurysms. This is a ventriculotomy.

Question 20

2 out of 2 points

An ECG technician is placing leads on a client who has presented to the emergency department with a sudden onset of chest pain. The technician would recognize which fact about the placement of leads and the achievement of a clinically accurate ECG?

Selected Answer:	B. The chest leads measure electrical activity on the horizontal plane, while limb leads measure it on the vertical plane.
Answers:	A. The electrical potential recorded by a lead on an extremity will vary significantly depending on where the lead is placed on the extremity.
	B. The chest leads measure electrical activity on the horizontal plane, while limb leads measure it on the vertical plane.
	C. Limb leads measure the electrical activity of the heart indirectly through the activity of adjacent skeletal muscle.
	D. A total of 12 chest leads is necessary to attain the most accurate ECG.

Response Feedback:

Rationale: A complete ECG is obtained by combining data from chest leads, which measure activity on the horizontal plane, and limb leads, corresponding to the vertical or frontal plane. The electrical potential recorded by a lead on an extremity should not vary significantly depending on where the lead is placed on the extremity. Limb leads do not measure electrical activity by way of skeletal muscle activity. A total of 12 leads, only six of which are on the chest, is necessary for a complete ECG.

Question 21

2 out of 2 points

A number of clients on an acute cardiac care unit of a hospital have diagnoses of impaired cardiac conduction. Which client is most deserving of immediate medical attention?

Selected Answer:	C. A 69-year-old woman who has entered ventricular fibrillation
Answers:	A. A 46-year-old man whose cardiac telemetry shows him to be in ventricular tachycardia
	B. A 60-year-old man with premature ventricular contractions (PVC) and a history of atrial fibrillation
	C. A 69-year-old woman who has entered ventricular fibrillation
	D. A 60-year-old woman who has just been diagnosed with a first-degree AV block

Response Feedback:

Rationale: Ventricular fibrillation, or ventricular flutter, is a life-threatening emergency that would necessitate immediate intervention. Ventricular tachycardia is also a serious condition, but less so than ventricular fibrillation. PVCs and a first-degree AV block would not normally require emergency intervention.

Question 22

2 out of 2 points

A nurse is caring for four clients with the diagnosis of atrial fibrillation. Which client will likely require cardioversion related to complications?

Selected Answer:	C. Newly diagnosed client with atrial fibrillation and has developed pulmonary edema
Answers:	A. Client who fainted because of a very low pulse rate due to an antiarrhythmic medication
	B. Client experiencing bleeding related to anticoagulants prescribed for the atrial fibrillation
	C. Newly diagnosed client with atrial fibrillation and has developed pulmonary edema
	D. Client admitted with blood clots in the lungs from undiagnosed atrial fibrillation

Response Feedback:

Rationale: Cardioversion may be considered in clients with atrial fibrillation, particularly when pulmonary edema and unstable cardiac status is present. The other clients have a complication related to lack of diagnosis or adverse reactions to prescribed treatments.

Question 23

2 out of 2 points

A client arrives reporting feeling “faint and dizzy” when standing and on telemetry the client’s heart rate is 25 beats/min. On electrocardiogram, the rate is fairly consistent and lacks the normal “P” wave and the QRS is wider than normal. This client’s heart rhythm is being controlled by which cardiac structure?

Selected Answer:	A. Purkinje system
Answers:	A. Purkinje system
	B. Sinoatrial (SA) node
	C. Atrioventricular (AV) node
	D. Bundle of His

Response Feedback:

Rationale: When the SA node is not conducting impulses, the AV node can assume the pacemaker function at a rate of 40 to 60 times/min. Should the SA node and AV node fail to conduct impulses from the atria to the ventricles, the Purkinje system can assume the pacemaker function of the ventricles at a rate of 15 to 40 times/min. The bundle of His is an important part of the electrical conduction system of the heart, because it transmits impulses from the atrioventricular node, located at the inferior end of the interatrial septum, to the ventricles of the heart.

Question 24

2 out of 2 points

Assuming that they have not responded to drug therapy, which client is likely to be the best candidate for surgical cardiac ablation?

Selected Answer:	C. A 46-year-old man with unstable angina and a history of myocardial infarction who is found to have long Q-T syndrome and episodes of frequent ventricular dysrhythmias
Answers:	A. A 22-year-old woman with an atrial septal defect who has recurrent paroxysmal atrial flutter with rapid ventricular rate associated with her caffeine intake.
	B. A 75-year-old man with diabetes but no previous heart disease that suddenly develops syncope due to sick sinus syndrome
	C. A 46-year-old man with unstable angina and a history of myocardial infarction who is found to have long Q-T syndrome and episodes of frequent ventricular dysrhythmias
	D. A 62-year-old woman with peripheral vascular disease who has experienced multiple episodes of torsades des pointes

Response Feedback:

Rationale: Due to his history of MI, the 46-year-old man probably has several areas of necrotic tissue that are interfering with conduction and ventricular function, and would probably benefit from having them removed. The 62-year-old woman may have little or no myocardial tissue damage, so a less invasive procedure to improve her cardiac circulation would be a better choice for her. The 75-year-old man may not have any areas of infarction and is a risky surgical candidate because of his age and diabetes. The 22-year-old woman’s tachycardia is likely to be non-ischemic in origin.

Question 25

2 out of 2 points

During a sleep study in the laboratory, the health care provider notices one client has a prolonged period of asystole. Which term will the nurse use to describe this event in the documentation?

Selected Answer:	B. Sinus arrest
Answers:	A. Long QT syndrome
	B. Sinus arrest
	C. Junctional rhythm
	D. Bradycardia-tachycardia syndrome

Response Feedback:

Rationale: Sinus arrest or pause refers to failure of the sinoatrial (SA) node to discharge and results in an irregular pulse. Sinus arrest may result in prolonged periods of asystole and can be caused by sleep apnea. Bradycardia-tachycardia syndrome is where the disease is caused in the sinus node and the tachycardia is caused by paroxysmal atrial or junctional arrhythmia. Most of the time, these clients do not know they have this arrhythmia because it is asymptomatic. Junctional rhythms usually have a rate of 40 to 60 beats/minute and can serve as a pacemaker of the heart in the event the SA node fails to initiate an impulse. The long QT syndrome is characterized by a prolongation of the QT interval that may result in a characteristic type of polymorphic ventricular tachycardia.

Question 26

2 out of 2 points

The nurse is prioritizing clients based on the risk for falls. Which client would be at greatest risk for sudden falls and related injury? The client:

Selected Answer:	D. with uncontrolled sick sinus syndrome.
Answers:	A. with atrial fibrillation and on anticoagulants.
	B. with poorly controlled type 1 diabetes.
	C. who is immobile due to recent stroke.
	D. with uncontrolled sick sinus syndrome.

Response Feedback:

Rationale: The client with sick sinus syndrome is at risk for syncope related to sudden onset bradyarrhythmias that will decrease cardiac output and result in decreased perfusion of the brain. This loss of consciousness is unpredictable and would place the client at risk for injury. The person with type 1 diabetes may develop hyperglycemia but is not at risk for falls. A client who is immobile is less likely to fall because he or she is dependent on others for mobility (i.e., unable to get up unsupervised). Atrial fibrillation is generally asymptomatic unless a rapid ventricular response is present. The likelihood of a negative effect from the atrial fibrillation or use of anticoagulants resulting in a fall is far less likely than it is for the client with sick sinus syndrome.

Question 27

2 out of 2 points

A pathologist is examining histological (tissue) samples from a client with an autoimmune disease. Which characteristic of muscle samples would signal the pathologist that the samples are cardiac rather than skeletal muscle?

Selected Answer:	D. The muscle cells are arranged as an interconnecting lattice-work.
Answers:	A. The cell samples lack intercalated disks.
	B. The muscles are striated and composed of sarcomeres.
	C. The muscle cells have small and few mitochondria.
	D. The muscle cells are arranged as an interconnecting lattice-work.

Response Feedback:

Rationale: Cardiac muscle cells are arranged as an interconnecting lattice-work. Cardiac cells have a more defined sarcoplasmic reticulum than do skeletal muscles. They also have intercalated disks and large, numerous mitochondria. Both types of muscle are striated and composed of sarcomeres.

Question 28

2 out of 2 points

When explaining to a client why there was only minimal muscle damage following 99% occlusion of the left anterior descending artery, the nurse will explain that this is primarily due to:

Selected Answer:	B. development of collateral circulation that build channels between some of the smaller arteries, usually when the flow is decreased gradually.
Answers:	A. the possibility that the person has elevated INR levels that prevents blood from backlogging in the vessel.
	B. development of collateral circulation that build channels between some of the smaller arteries, usually when the flow is decreased gradually.
	C. the release of substances formed by special glands that transport the blood cell by cell through smaller spaces.
	D. good genetic makeup that allows occluded arteries to keep vasodilating to meet metabolic needs.

Response Feedback:

Rationale: Collateral circulation is a mechanism for the long-term regulation of local blood flow. Anastomotic channels exist between some of the smaller arteries. These channels permit perfusion of an area by more than one artery. When the artery becomes occluded, these anastomotic channels increase in size, allowing blood from a patent artery to perfuse the area supplied by the occluded vessel.

Question 29

2 out of 2 points

A client in the emergency department is experiencing a massive stroke with extremely low blood flow to the brain exhibited by a BP <60 mm Hg. The nurse suddenly notes there is a sharp rise in the BP to 250 mm Hg. This high BP lasts about 5 minutes and then the BP drops sharply again. The pathophysiologic principle behind this is likely due to the:

Selected Answer:	D. CNS ischemic response.
Answers:	A. release of mineralocorticoids.
	B. activation of the autonomic nervous system.
	C. protective homeostatic mechanism.
	D. CNS ischemic response.

Response Feedback:

Rationale: When blood flow to the brain has been sufficiently interrupted to cause ischemia of the vasomotor center, these vasomotor neurons become strongly excited. This causes massive vasoconstriction as a means of raising the blood pressure to levels as high as the heart can pump against. This response is called the CNS ischemic response and can raise BP to levels as high as 270 mm Hg for as long as 10 minutes.

Question 30

2 out of 2 points

The nurse is caring for a client with small veins. The nurse can improve the chance of successfully drawing a blood sample by applying the principle of critical closing pressure and:

Selected Answer:	B. using minimal negative pressure when drawing the sample into the syringe.
Answers:	A. using a small syringe and drawing the sample quickly.
	B. using minimal negative pressure when drawing the sample into the syringe.
	C. having the client raise the limb being used to draw the sample.
	D. flushing the vein with saline immediately before withdrawing the sample.

Response Feedback:

Rationale: The critical closing pressure refers to the point at which blood vessels collapse so that blood can no longer flow through them. The nurse should not withdraw the blood quickly as this can cause the vein to contain too little blood to keep the walls patent. Raising the limb would cause less blood to be present due to the effects of gravity. Flushing the vein prior to drawing the sample would dilute the sample and make the results inaccurate.

Question 31

2 out of 2 points

In which situation would blood most likely be rapidly relocated from central circulation to the lower extremities?

Selected Answer:	B. A client is helped out of bed and stands up.
Answers:	A. A client undergoes a stress test on a treadmill.
	B. A client is helped out of bed and stands up.
	C. A client does isotonic exercises in a wheelchair.
	D. A client reclines from a sitting to supine position.

Response Feedback:

Rationale: During a change in body position, blood is rapidly relocated from the central circulation (when the client is recumbent) to the lower extremities (when the client stands up). This results in a temporary drop in blood pressure known as postural hypotension and reflects the redistribution of blood in the body.

Question 32

2 out of 2 points

While intubated for surgery, a client has inadvertently had his vagus nerve stimulated. What effect would the surgical team expect to observe?

Selected Answer:	D. Decreased heart rate as a result of parasympathetic innervation of the heart
Answers:	A. Decreased heart rate as a result of impaired acetylcholine reuptake
	B. Decreased heart rate, contractility, and afterload
	C. Decreased vascular perfusion due to parasympathetic stimulation
	D. Decreased heart rate as a result of parasympathetic innervation of the heart

Response Feedback:

Rationale: Vagal stimulation results in a lowered heart rate as a result of parasympathetic stimulation. Vascular perfusion, contractility, and afterload would not be under direct effect. Acetylcholine reuptake would not be influenced.

Question 33

2 out of 2 points

During an automobile accident where the client is bleeding heavily, which vascular component is the most distensible and can store large quantities of blood that can be returned to the circulation at this time of need?

Selected Answer:	C. Veins
Answers:	A. Liver and pancreas
	B. Kidneys
	C. Veins
	D. Aorta

Response Feedback:

Rationale: Compliance refers to the total quantity of blood that can be stored in a given portion of the circulation for each mm Hg rise in pressure. The most distensible of all vessels are the veins, which can increase their volume with only slight changes in pressure. This allows the veins to function as a reservoir for storing large quantities of blood that can be returned to the circulation when it is needed. Liver, pancreas, and kidneys are not vascular components.

Question 34

2 out of 2 points

A client is experiencing impaired circulation secondary to increased systemic arterial pressure. Which statement is the most relevant phenomenon?

Selected Answer:	C. High afterload because of backpressure against the left ventricle
Answers:	A. Systolic impairment because of arterial stenosis
	B. Increased preload due to vascular resistance
	C. High afterload because of backpressure against the left ventricle
	D. Impaired contractility due to aortic resistance

Response Feedback:

Rationale: Increased pressure in the aorta and other arteries constitutes a greater amount of afterload work. This situation is not indicative of increased preload or impaired contractility. Systolic impairment is not a recognized characterization of inadequate cardiac performance.

Question 35

2 out of 2 points

A 72-year-old female has been told by her physician that she has a new heart murmur that requires her to go visit a cardiologist. Upon examination, the cardiologist informs the client that she has aortic stenosis. After the cardiologist has left the room, the client asks, “What caused this [aortic stenosis] to happen now?” The clinic nurse responds:

Selected Answer:	B. “Heart murmurs result from tumultuous flow through a diseased heart valve that is too narrow and stiff. This flow causes a vibration called a murmur.”
Answers:	A. “Aortic stenosis is commonly seen in older adult clients. Basically, there is a blockage in the valve that is causing blood to pool, causing decreased velocity of flow.”
	B. “Heart murmurs result from tumultuous flow through a diseased heart valve that is too narrow and stiff. This flow causes a vibration called a murmur.”
	C. Because of the high amount of energy it takes to push blood through the aortic valve to the body, your valve just had to work too hard and it is weakening.
	D. “This is caused by a tear in one of the papillary muscles attached to the valve. They can do a procedure where they thread a catheter into the heart and reattach the muscle ends.”

Response Feedback:

Rationale: Heart murmur results from turbulent flow through a diseased heart valve that may be narrow, too stiff, or too floppy. This turbulent flow causes a vibration called a murmur.

Question 36

2 out of 2 points

Analysis has shown that a client’s right atrial pressure is 30 mm Hg. What is the most likely conclusion that the client’s care team will draw from this piece of data?

Selected Answer:	B. The pressure is excessive given that the right atrium should be at atmospheric pressure.
Answers:	A. Pressure pulsations are likely to be undetectable given the low atrial pressure.
	B. The pressure is excessive given that the right atrium should be at atmospheric pressure.
	C. The pressure is insufficient to provide adequate stroke volume and cardiac output.
	D. The result is likely normal and gravity-dependent given the lack of valves in thoracic and central veins.

Response Feedback:

Rationale: Normal right atrial pressure is around 0 mm Hg, or atmospheric pressure. Right atrial pressure does not have a direct influence on stroke volume or pulse pressure.

Question 37

2 out of 2 points

An 81-year-old female client of a long-term care facility has a history of congestive heart failure. The nurse practitioner caring for the client has positioned her sitting up at an angle in bed and is observing her jugular venous distention. Why is jugular venous distention a useful indicator for the assessment of the client’s condition?

Selected Answer:	A. Blood backs up into the jugular vein because there are no valves at the point of entry into the heart.
Answers:	A. Blood backs up into the jugular vein because there are no valves at the point of entry into the heart.
	B. Peripheral dilation is associated with decreased stroke volume and ejection fraction.
	C. Heart valves are not capable of preventing backflow in cases of atrial congestion.
	D. Increased cardiac demand causes engorgement of systemic blood vessels, of which the jugular vein is one of the largest.

Response Feedback:

Rationale: Because there are no valves at the entry points to the atria, congestion can result in engorgement of the jugular veins which are proximal to the heart. Increased cardiac demand is not associated with engorgement of vessels or peripheral dilation.

Question 38

2 out of 2 points

When trying to explain to a client on dialysis the movement of substances through the capillary pores, the nurse will explain that in the kidneys, the glomerular capillaries have:

Selected Answer:	B. Small openings that allow large amounts of smaller molecular substances to filter through the glomeruli.
Answers:	A. Large pores so that substances can pass easily through the capillary wall.
	B. Small openings that allow large amounts of smaller molecular substances to filter through the glomeruli.
	C. Endothelial cells that are joined by tight junctions that form a barrier to medication filtration.
	D. no capillary openings since this would lead to extensive hemorrhage.

Response Feedback:

Rationale: The glomerular capillaries in the kidneys have small openings called fenestrations that pass directly through the middle of the endothelial cells. This allows large amounts of small molecular and ionic substances to filter through the glomeruli without having to pass through the clefts between the endothelial cells.

Question 39

2 out of 2 points

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which phenomenon is most likely taking place?

Selected Answer:	C. The man’s alpha- and beta-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate.
Answers:	A. Bronchoconstriction and hyperventilation are initiated as a compensatory mechanism.
	B. Intracellular potassium and extracellular sodium levels are rising as a result of sodium-potassium pump failure.
	C. The man’s alpha- and beta-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate.
	D. Hemolysis and blood pooling are taking place in the man’s peripheral circulation.

Response Feedback:

Rationale: Alpha- and beta-adrenergic receptor activation is a central response to all types of shock. Hemolysis is not a noted accompaniment to shock. Bronchodilation, not bronchoconstriction, often results from adrenergic stimulation. Sodium-potassium pump failure results in increased extracellular potassium and intracellular sodium.

Question 40

2 out of 2 points

A nurse is administering morning medications to a number of clients on a medical unit. Which medication regimen is most suggestive that the client has a diagnosis of heart failure?

Selected Answer:	B. Diuretic, ACE inhibitor, beta-blocker
Answers:	A. Antihypertensive, diuretic, antiplatelet aggregator
	B. Diuretic, ACE inhibitor, beta-blocker
	C. Beta-blocker, potassium supplement, anticoagulant
	D. Anticoagulant, antihypertensive, calcium supplement

Response Feedback:

Rationale: Diuretics, ACE inhibitors, and beta-blockers are all commonly used in the treatment of heart failure. Antiplatelet aggregators, calcium and potassium supplements, and anticoagulants are less likely to relate directly to a diagnosis of heart failure.

Question 41

2 out of 2 points

A 77-year-old client with a history of coronary artery disease and heart failure has arrived in the emergency room with a rapid heart rate and feeling of “impending doom.” Based on pathophysiologic principles, the nurse knows the rapid heart rate could:

Selected Answer:	A. be a result of catecholamines released from SNS, which could increase the myocardial oxygen demand.
Answers:	A. be a result of catecholamines released from SNS, which could increase the myocardial oxygen demand.
	B. decrease renal perfusion and result in development of ascites.
	C. prolong the electrical firing from the SA node resulting in development of a heart block.
	D. Desensitize the alpha-adrenergic receptors leading to increase in norepinephrine levels.

Response Feedback:

Rationale: An increase in sympathetic activity by stimulation of the beta-adrenergic receptors of the heart leads to tachycardia, vasoconstriction, and dysrhythmias. Acutely, tachycardia significantly increases the workload of the heart, thus increasing myocardial O ₂ demand and leading to cardiac ischemia, myocyte damage, and decreased contractility. Decrease renal perfusion would activate the RAAS system, increasing heart rate and BP further. Ventricular dysrhythmias are primarily seen at this stage of HF.

Question 42

2 out of 2 points

In which client situations would a physician be most justified in preliminarily ruling out pericarditis as a contributing pathology to the client’s health problems?

Selected Answer:	A. A 77-year-old with diminished S ₃ and S ₄ heart tones, irregular heart rate, and a history of atrial fibrillation
Answers:	A. A 77-year-old with diminished S₃ and S₄ heart tones, irregular heart rate, and a history of atrial fibrillation
	B. A 56-year-old obese man who is reporting chest pain that is exacerbated by deep inspiration and is radiating to his neck and scapular ridge
	C. A 61-year-old man whose ECG was characterized by widespread T-wave inversions on admission but whose T waves have recently normalized
	D. A 60-year-old woman whose admission blood work indicates elevated white cells, erythrocyte sedimentation rate, and C-reactive protein levels

Response Feedback:

Rationale: S ₃ and S ₄ irregularities and irregular heart rate are not noted symptoms of pericarditis. Widespread T-wave inversions that later normalize; chest pain radiating to the neck and scapula that is worse on inspiration; and high white cells, erythrocyte sedimentation rate, and C-reactive protein levels are all indicators of pericarditis.

Question 43

2 out of 2 points

A nurse who works on a pediatric cardiology unit of a hospital is providing care for an infant with a diagnosis of tetralogy of Fallot. Which pathophysiologic result should the nurse anticipate?

Selected Answer:	B. Blood outflow into the pulmonary circulation is restricted by pulmonic valve stenosis.
Answers:	A. The right ventricle is atrophic as a consequence of impaired myocardial blood supply.
	B. Blood outflow into the pulmonary circulation is restricted by pulmonic valve stenosis.
	C. There is a break in the normal wall between the right and left atria that results in compromised oxygenation.
	D. The aortic valve is stenotic, resulting in increased afterload.

Response Feedback:

Rationale: Tetralogy of Fallot is marked by obstruction or narrowing of the pulmonary outflow channel, including pulmonic valve stenosis, a decrease in the size of the pulmonary trunk, or both. The characteristic septal defect is ventricular, not atrial. Aortic valve stenosis and right ventricular atrophy are not associated with the diagnosis.

Question 44

2 out of 2 points

A 3-year-old child with right-sided heart failure has been admitted for worsening of their condition. Which assessment would be considered one of the earliest signs of systemic venous congestion in this toddler?

Selected Answer:	A. Enlargement of liver
Answers:	A. Enlargement of liver
	B. Excessive crying
	C. Breathlessness with activity
	D. Increased urine output

Response Feedback:

Rationale: With RV function impaired, systemic venous congestion develops. Hepatomegaly due to liver congestion often is one of the first signs of systemic venous congestion in infants and children.

Question 45

2 out of 2 points

Four clients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which client most likely experienced myocardial infarction?

Selected Answer:	A. An 80-year-old woman whose pain started at 6 AM shortly after awakening and was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose
Answers:	A. An 80-year-old woman whose pain started at 6 AM shortly after awakening and was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose
	B. A 33-year-old man whose pain started at 7 AM during moderate exercise and was relieved by nitrates; ECG was normal; cardiac markers remained stable
	C. A 61-year-old man whose pain started at 9 AM during a short walk and responded to nitrates, but not to rest; ECG and cardiac markers remained stable, but anginal pattern worsened
	D. A 67-year-old female whose pain started at 2 AM while she was asleep and which responded to nitrates; the ECG showed dysrhythmias and ST-segment elevation; cardiac markers remained stable

Response Feedback:

Rationale: The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other clients have angina of varying severity.

Question 46

2 out of 2 points

A number of clients have presented to the emergency department in the last 32 hours with reports that are preliminarily indicative of myocardial infarction. Which client is least likely to have an ST-segment myocardial infarction (STEMI)?

Selected Answer:	A. A 71-year-old man who has moist skin, fever, and chest pain that is excruciating when he moves but relieved when at rest
Answers:	A. A 71-year-old man who has moist skin, fever, and chest pain that is excruciating when he moves but relieved when at rest
	B. A 43-year-old man who woke up with substernal pain that is radiating to his neck and jaw
	C. A 70-year-old woman who is reporting shortness of breath and vague chest discomfort
	D. A 66-year-old man who has presented with fatigue, nausea and vomiting, and cool, moist skin

Response Feedback:

Rationale: STEMI pain is not normally relieved by rest, nor would fever be a common symptom. Shortness of breath, vague chest discomfort, fatigue, GI symptoms and radiating substernal pain are all associated with STEMI.

Question 47

2 out of 2 points

Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue. Vital signs reveal heart rate 112, respiratory rate 36, and pulse oximeter reading of 81%. He starts coughing up frothy, pink sputum. The priority intervention is:

Selected Answer:	B. Call for emergency assistance utilizing hospital protocol.
Answers:	A. Have medical supply department bring up suction equipment.
	B. Call for emergency assistance utilizing hospital protocol.
	C. Apply oxygen via nasal cannula at 3 pm.
	D. Page respiratory therapy to come give him a breathing treatment.

Response Feedback:

Rationale: Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, skin moist, lips/nail beds cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The client needs the emergency responder team (including ICU nurses, physicians, respiratory therapy, etc) to intervene. Applying O ₂ by mask will not increase his oxygen level fast enough and he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course, respiratory therapy will arrive with the emergency assistance team.

Question 48

2 out of 2 points

The nurse working in the ICU knows that chronic elevation of left ventricular end-diastolic pressure will result in the client displaying which clinical manifestation?

Selected Answer:	B. Dyspnea and crackles in bilateral lung bases.
Answers:	A. Muscle cramping and cyanosis in the feet.
	B. Dyspnea and crackles in bilateral lung bases.
	C. Petechia and spontaneous bleeding.
	D. Chest pain and intermittent ventricular tachycardia.

Response Feedback:

Rationale: Although it may preserve the resting cardiac output, the resulting chronic elevation of left ventricular end-diastolic pressure is transmitted to the atria and the pulmonary circulation, causing pulmonary congestion.

Question 49

2 out of 2 points

Which teaching point would be most appropriate for a group of older adults who are concerned about their cardiac health?

Selected Answer:	A. “The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel.”
Answers:	A. “The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel.”
	B. “Infections of any sort are often a signal that plaque disruption is in danger of occurring.”
	C. “People with plaque in their arteries experience attacks of blood flow disruption at seemingly random times.”
	D. “The impaired function of the lungs that accompanies pneumonia or chronic obstructive pulmonary disease is a precursor to plaque disruption.”

Response Feedback:

Rationale: Stable plaque is associated with obstruction of blood flow, while unstable plaque may dislodge and result in thrombus formation. Plaque disruption is noted to correlate with sympathetic events and is not seemingly random; infections and respiratory problems are not noted to be associated, however.

Question 50

2 out of 2 points

A 30-year-old woman presents at a hospital after fainting at a memorial service and she is diagnosed as being in neurogenic shock. Which signs/symptoms is she most likely to display?

Selected Answer:	C. Dry and warm skin
Answers:	A. Faster than normal heart rate
	B. Increased thirst
	C. Dry and warm skin
	D. Pain

Response Feedback:

Rationale: In contrast to hypovolemic shock, in which the heart rate is faster than normal and the skin is cold and clammy, a person in neurogenic shock is likely to have a slower than normal heart rate and dry, warm skin. Fainting due to emotional causes is a transient form of neurogenic shock, while increased thirst is an early sign of hypovolemic shock.