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NSG 6001
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NSG 6001 Midterm Exam 2 – Question with Answers and Explanations
NSG 6001 Midterm Exam 2 – Question with Answers and Explanations NSG 6001 Midterm Exam 2 – Question with Answers and Explanations N.B (Explanations a... [Show More] re in brackets) Question 1. A 35 year old female arrives at your clinic. She has had diabetes and peripheral artery disease for the past 5 years. You decide to obtain an ETT. The insurance company argues that this is inappropriate. You justify the ETT because you are planning secondary strategies to prevent future heart disease. Where could one find the supporting data for these guidelines? Medicare guidelines Framingham risk score (These guidelines come from the Framingham risk score.) Medicaid guidelines Do not exist Question 2. You are counseling a patient diagnosed with stress-induced ischemia. You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by what phenomena? Diet and exercise Heart muscle dysfunction Too many carbonated drinks Endothelial dysfunction of the microvascular (You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by endothelial dysfunction of the microvascular.) Question 3. What happens to coronary flow related to CAD? Hyper profusion of the myocardium Cerebral vascular infarction Hypo profusion of the myocardium (Because of the restrictive flow of blook through the coronary arteries, hypo profusion of the myocardium results from coronary flow related to CAD which causes the presenting symptoms) Functional systolic pressures Question 4: A 47-year old female with general complaints of fatigue and shortness of breath shows up in your clinic as a referral from another nurse practitioner. Several blood tests and chest x-rays have been completed without any diagnosis or outstanding abnormalities. You decide to order an ETT despite the fact that the recent ECG does not show any abnormalities. From the answers below, which would be the best answer to support your decision? You are out of other options Women present with the same pattern of CAD as do males CAD in women is under diagnosed (You make this choice because you are aware that CAD in women is under diagnosed.) To please the patient Question 5: You are in the clinic with your mentor observing the Echocardiogram exercise test of a 45-year old male that has been experiencing slight chest pressure almost daily during exercise. While observing your patient, your mentor points out that the left ventricle wall is thinning and there is some hyperkinesias of the ventricular wall. From your time in the clinic, you know that this test will be considered to be what type of result? Impossible Negative Positive (From your time in the clinic, you know because of wall thinning and hyperkinesis that this test will be considered to be positive.) Non-readable Question 6: On the echocardiography during the ETT you notice the following change: abnormal left ventricular ejection fraction. What do these changes suggest related to this patient? Non-ischemic changes of the baseline ECG Ischemia of the myocardium (Abnormal left ventricular ejection fraction suggests ischemia of the myocardium.) Rise in heart rate without evidence of ischemia Weak ventricular muscles Question 7: Population disease management is a term used to describe: High specificity disease states Low specificity diseases states Low prevalence specific diseases High prevalence specific diseases (Population disease management is a term used to describe the high prevalence of specific diseases.) Question 8: Why would inability to exercise reduce the specificity of the routine ETT? Causes ST-segment changes and P-wave abnormalities Will not produce any changes in ECG Produces persistent ST-segmental changes and T-wave abnormalities (The inability to exercise reduces the specificity of the routine ETT because it produces persistent ST-segmental changes and T-wave abnormalities.) Produces QRS changes that cannot be interpreted Question 9: All patients, even if asymptomatic, require risk stratification according to the Farmingham risk score. At present, ACC/AHA guidelines, however, do not normally support stress tests for asymptomatic patients without additional justification. From the list below, what could be used to justify an ETT in an asymptomatic patient? Sedentary and wishes to begin aggressive exercise (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended to obtain an ETT to rule out underlying CAD.) A smoker of 3 weeks A member of congress Developmentally challenged Question 10: What is the leading cause of death for women in the United States? Heart disease (Heart disease is the leading cause of death for women in the United States.) Breast cancer Lung cancer Complications of childbirth Question 11: In women, you need to know the limitations of certain tests for CAD. For example, single-photon emissions CT imaging, while an acceptable test for most men and some women, is technically limited in women for two reasons. From the following, choose the best possible answer. Smoking rates and lack of uptake of photons Multiple vessel disease and fat deposits Breasts and fat deposits in abdomen Breasts and smaller coronary arteries (Single-photon emissions CT imaging is technically limited in women due to breasts and smaller coronary arteries.) Question 12. What are two of the most common forms of Exercise Stress Tests used today? Unicycle and Running in pace Thallium and Dobutamine Bicycle and rowing machine Bicycle and treadmill (Bicycle and treadmill are the two most common forms of exercise stress tests used today. ) Question 13. Improvements in the delivery and management of healthcare are necessary if we are to improve the overall health of this nation’s population. Which of the following are identified in your readings as strategic in the movement to improve the healthcare system? Socialized medicine and governmental controls Population management and healthcare practice (Population management and healthcare practice are strategic in the movement to improve the nation’s healthcare system. ) Monetary savings and limited disruption in healthcare delivery President and Congress Question 14. For women with known CAD and diabetes, which is most appropriate to assess CAD risk? ETT ETT with imaging (ETT with imaging is most appropriate to assess CAD risk.) Coronary catheterization Coronary bypass surgery Question 15. What is considered the first-line initial approach to test for CAD? EKG Exercise Stress Test (Exercise stress test is considered the first-line initial approach to test for CAD. ) Cardiac Catheterization Echocardiogram Question 16: Encouragement of patients to take effective actions in their own healthcare refers to the concept of: Interprofessional support Family care givers Physician or provider-driven care Self-management support (Encouragement of patients to take effective actions in their own healthcare refers to the concept of self-management support. ) Question 17. Ischemic changes on ECG during ETT is highly predictive of CAD. What is another important strong predictor of CAD that you might see during an ETT? Exercise-induced hypertension Rapid heart rate Exercise-induced hypotension (Another important strong predictor of CAD that you might see during an ETT is exercise-induced hypotension. ) Slow heart rate Question 18. Maintenance of an Isoelectric ST-segment during exercise is the response of? Hypo profusion CAD An abnormal heart A normal heart (Maintenance of an Isoelectric ST-segment during exercise is the response of a normal heart. ) Question 19. What ECG changes can reduce the specificity of the ETT? Paced rhythm and exercise induced bundle branch blocks Exercise induced bundle branch blocks Low voltage up sloping of the ST-segment Paced rhythm and resting bundle branch block (The ECG changes that can reduce the specificity of the ETT are paced rhythm and resting bundle branch block. ) Question 20. Your patient has a maximum age-predicted heart rate of 180. During the exercise, he reaches a heart rate of 140 and then states he can no longer exercise. You see no evidence of ischemia on the ECG. This would be diagnostic for what condition? Predictive of no CAD Diagnostic of laziness Has no diagnostic value to rule out CAD (This scenario has no diagnostic value to rule out CAD.) Diagnostic for impending Myocardial Infarction Question 21. We all know that collaboration is integral to becoming a successful nurse practitioner. Among collaborations, however, only one can be considered as the most important. While each example below is important, which is the most important collaboration? The one that occurs: Between the nurse practitioner and their physician mentor Between two healthcare providers about a single patient Between the patient and their family Between the patient and the nurse practitioner (The collaboration that is most important is the one that occurs between the patient and the nurse practitioner. ) Question 22. As patients that entrust our care to another individual, we always expect honesty to avoid leading us down a deceptive pathway in our healthcare decisions. Adherence to which principle compels providers to be truthful? Fidelity Self-reflection Finance Veracity (Adherence to veracity compels providers to be truthful with patients). Question 23. What do you know regarding ischemia that is confined to only the posterior and or lateral segments of the left ventricle? Easier to detect by ETT Requires both for detection of changes by ETT Difficult to detect by ETT (Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. ) ETT cannot be used for detection Question 24. Your patient is morbidly obese and cannot sit on a bicycle or walk a treadmill. She also has marked and severe emphysema. You need to make an assessment of the risk of significant CAD and your patient’s family says that their relative had their diagnosis based on an ultrasound echocardiography. What facts would influence your decision regarding the family request for echo assessment? Specificity would be reduced because of obesity and lung disease Specificity would be increased because of obesity Sensitivity would be increased because of lung disease Sensitivity would be reduced because of obesity and lung disease (Sensitivity would be reduced because of obesity and lung disease.) Question 25. Your mentor says that you should be prepared to know how to determine the maximum heart rate for your patient during the ETT. How is the age-predicted maximum heart rate during an ETT determined? 220-age (The age-predicted maximum heart rate during an ETT determined by subtracting the patient’s age from 220 (220 – age). ) 65+age 120-age 220+age Question 26. You are considering adding an adjunctive form of testing to detect wall motion abnormalities during the ETT. You select Echocardiography as the added testing. You choose this test because you know that echocardiography does what when added to a standard ETT? Enhances sensitivity and specificity of CAD detection (You choose this test because you know that echocardiography enhances sensitivity and specificity of CAD detection.) Enhances sensitivity while reducing specificity of CAD detection Enhances specificity while not changing sensitivity of detection for CAD You like pretty pictures of wall motion Question 27. Your patient underwent an exercise stress test for CAD. There is significant elevation of the ST-segment. What do you need to know about these changes to manage your patient’s care? These changes have minimal predictive value for CAD (Significant elevation of the ST-segment has minimal predictive value for CAD. ) This patient needs to see someone more experienced in treatment of CAD These changes are predictive of myocardial infarction These changes predict dire outcomes Question 28. The sensitivity of a routine ETT is effort dependent. What physiological changes occur during effort in the routine ETT? Rapid heart rates and coronary artery narrowing Increased coronary flow and increased systolic blood pressure (The physiological changes that occur during effort in the routine ETT are increased coronary flow and increased systolic blood pressure.) Decrease in coronary blood flow Decreased heart rate and increased systolic blood pressure Question 29. What purpose does the principle of fidelity serve in the provider/patient relationship? Ensures that providers honor their commitments to the patient (The principle of fidelity mandate assures that providers honor their commitments to the patient. ) Obligates the provider to a one-on-one relationship with the individual Ensures that patients receive whatever they want Maintains costs in the healthcare arena Question 30. A 55-year old man is referred to your clinic. He has been sedentary all of his life, is gaining weight and wishes to get into better physical shape. He has never had any chest pain or shortness of breath when walking or climbing a flight of stairs. Before recommending a vigorous exercise routine for this patient, you order what test? ETT (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended that the patient obtains an ETT to rule out underlying CAD.) Stool samples Thyroid levels [Show Less]
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NSG 6001 Midterm Exam – Question and Answers
NSG 6001 Midterm Exam – Question and Answers NSG 6001 Midterm Exam – Question and Answers 1. Question : Your patient is morbidly obese and cannot ... [Show More] sit on a bicycle or walk a treadmill. She also has marked and severe emphysema. You need to make an assessment of the risk of significant CAD and your patient’s family says that their relative had their diagnosis based on an ultrasound echocardiography. What facts would influence your decision regarding the family request for echo assessment? Student Answer: Specificity would be increased because of obesity Sensitivity would be reduced because of obesity and lung disease (Sensitivity would be reduced because of obesity and lung disease.) Sensitivity would be increased because of lung disease Specificity would be reduced because of obesity and lung disease 2. Question : Medicaid is mandated to be provided by each state through federal codes. Each state must offer Medicaid exactly as the federal government prescribes. True or false? Student Answer: False (Medicaid is mandated to be provided by each state, however, Mediciad is not required to be delivered by any certain formula. Each state has autonomy to deliver Mediciad services under its own guidelines, provided that each state meets the federal guidelines for Medicaid coverage. ) True 3. Question : By standard criteria, how is a positive stress test defined? Student Answer: Development of a horizontal or down sloping ST-segment depression of 10mm Development of a horizontal or down sloping ST-segment depression of 1mm (A positive stress test is defined as the development of a horizontal or down sloping ST-segment depression of 1mm. ) Upward sloping ST-segment measured at the J point of the QRS Down sloping of the ST-segment at the J point of the QRS 4. Question : Population disease management is a term used to describe: Student Answer: Low prevalence specific diseases High prevalence specific diseases (Population disease management is a term used to describe the high prevalence of specific diseases. ) Low specificity diseases states High specificity disease states 5. Question : What are two of the most common forms of Exercise Stress Tests used today? Student Answer: Bicycle and treadmill (Bicycle and treadmill are the two most common forms of exercise stress tests used today. ) Unicycle and Running in pace Thallium and Dobutamine Bicycle and rowing machine 6. Question : You are counseling a patient diagnosed with stress-induced ischemia. You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by what phenomena? Student Answer: Too many carbonated drinks Diet and exercise Endothelial dysfunction of the microvascular (You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by endothelial dysfunction of the microvascular.) Heart muscle dysfunction 7. Question : Narrowed coronary arteries or plague rupture within the arteries of the coronary system may directly cause which condition? Student Answer: Venous Statis Diabetes Hypertension Coronary artery disease (Narrowed coronary arteries, plague rupture, and sometimes even spasms of the coronary arteries are the three most common direct causes for the diagnosis of coronary artery disease. ) 8. Question : Of the following, which is the best answer when asked for an advantage of echocardiogram exercise testing over thallium stress testing? Student Answer: Results are available more quickly (Echocardiogram exercise test results are available more quickly.) Does not depend on operator experience Doesn’t matter because there are no advantages Costs are the same 9. Question : A 55-year old man is referred to your clinic. He has been sedentary all of his life, is gaining weight and wishes to get into better physical shape. He has never had any chest pain or shortness of breath when walking or climbing a flight of stairs. Before recommending a vigorous exercise routine for this patient, you order what test? Student Answer: Stool samples CBC ETT (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended that the patient obtains an ETT to rule out underlying CAD.) Thyroid levels 10. Question : What ECG changes can reduce the specificity of the ETT? Student Answer: Paced rhythm and resting bundle branch block (The ECG changes that can reduce the specificity of the ETT are paced rhythm and resting bundle branch block. ) Low voltage up sloping of the ST-segment Exercise induced bundle branch blocks Paced rhythm and exercise induced bundle branch blocks 11. Question : In women, you need to know the limitations of certain tests for CAD. For example, single-photon emissions CT imaging, while an acceptable test for most men and some women, is technically limited in women for two reasons. From the following, choose the best possible answer. Student Answer: Breasts and fat deposits in abdomen Smoking rates and lack of uptake of photons Breasts and smaller coronary arteries (Single-photon emissions CT imaging is technically limited in women due to breasts and smaller coronary arteries.) Multiple vessel disease and fat deposits 12. Question : Improvements in the delivery and management of healthcare are necessary if we are to improve the overall health of this nation’s population. Which of the following are identified in your readings as strategic in the movement to improve the healthcare system? Student Answer: Monetary savings and limited disruption in healthcare delivery Population management and healthcare practice (Population management and healthcare practice are strategic in the movement to improve the nation’s healthcare system. ) Socialized medicine and governmental controls President and Congress 13. Question : The sensitivity of a routine ETT is effort dependent. What physiological changes occur during effort in the routine ETT? Student Answer: Decrease in coronary blood flow Increased coronary flow and increased systolic blood pressure (The physiological changes that occur during effort in the routine ETT are increased coronary flow and increased systolic blood pressure.) Rapid heart rates and coronary artery narrowing Decreased heart rate and increased systolic blood pressure 14. Question : Your mentor says that you should be prepared to know how to determine the maximum heart rate for your patient during the ETT. How is the age-predicted maximum heart rate during an ETT determined? Student Answer: 220+age 120-age 220-age (The age-predicted maximum heart rate during an ETT determined by subtracting the patient’s age from 220 (220 – age). ) 65+age 15. Question : Medicare hospital insurance (Part A) is funded through what system? Student Answer: Interest from investments State income taxes Federal income taxes Federal payroll taxes (Medicare Part A is funded through federal payroll taxes. ) 16. Question : We all know that collaboration is integral to becoming a successful nurse practitioner. Among collaborations, however, only one can be considered as the most important. While each example below is important, which is the most important collaboration? The one that occurs: Student Answer: Between the patient and their family Between the patient and the nurse practitioner (The collaboration that is most important is the one that occurs between the patient and the nurse practitioner. ) Between the nurse practitioner and their physician mentor Between two healthcare providers about a single patient 17. Question : The leads on the ECG showing ischemic changes during or immediately after an ETT can correlate roughly to the culprit artery or arteries with significant CAD. Is this true or false? Student Answer: False True (This statement is true: the leads on the ECG showing ischemic changes during or immediately after an ETT can correlate roughly to the culprit artery or arteries with significant CAD. ) 18. Question : Ischemic changes on ECG during ETT is highly predictive of CAD. What is another important strong predictor of CAD that you might see during an ETT? Student Answer: Slow heart rate Exercise-induced hypotension (Another important strong predictor of CAD that you might see during an ETT is exercise-induced hypotension. ) Exercise-induced hypertension Rapid heart rate 19. Question : In CAD, after both systolic and diastolic dysfunction have occurred, the typical pattern of chest pain and related EKG changes occur. During an EKG, you should expect to see ST-segment and T-wave changes that are central to demonstration of ischemia occurring relatively late in the ischemic cascade. Is this true or false? Student Answer: False True (This is a true statement. During an EKG, you should expect to see ST-segment and T-wave changes that are central to demonstration of ischemia occurring relatively late in the ischemic cascade. ) 20. Question : Chronic, non-communicable diseases account for disproportionate costs to the healthcare system. According to the World Health Organization, what percent of preventable deaths and disabilities occur in the Americas related to chronic non-communicable diseases? Student Answer: 10%-15% 80%-90% 35%-45% 60%-70% (According to the World Health Organization, 60%--7 0% of preventable deaths and disabilities occur in the Americas related to chronic non-communicable diseases. ) 21. Question : Your patient has a maximum age-predicted heart rate of 180. During the exercise, he reaches a heart rate of 140 and then states he can no longer exercise. You see no evidence of ischemia on the ECG. This would be diagnostic for what condition? Student Answer: Has no diagnostic value to rule out CAD (This scenario has no diagnostic value to rule out CAD.) Predictive of no CAD Diagnostic of laziness Diagnostic for impending Myocardial Infarction 22. Question : What happens to coronary flow related to CAD? Student Answer: Functional systolic pressures Hyper profusion of the myocardium Cerebral vascular infarction Hypo profusion of the myocardium (Because of the restrictive flow of blook through the coronary ateries,hypo profusion of the myocardium results from coronary flow related to CAD which causes the presenting symptoms. ) 23. Question : Your patient cannot sit on a bicycle and has difficulties walking a treadmill with limited capacity for exercising. Still, you know that the ETT is the preferred test for CAD. You consider adding a pharmacological agent to get to maximum heart rate. What agent would be the most commonly used agent to assist in an ETT? Student Answer: Epinephrine Dobutamine (The pharmacological agent most commonly used to assist in an ETT is dobutamine.) Dopamine Aspirin 24. Question : A 47-year old female with general complaints of fatigue and shortness of breath shows up in your clinic as a referral from another nurse practitioner. Several blood tests and chest x-rays have been completed without any diagnosis or outstanding abnormalities. You decide to order an ETT despite the fact that the recent ECG does not show any abnormalities. From the answers below, which would be the best answer to support your decision? Student Answer: To please the patient CAD in women is under diagnosed (You make this choice because you are aware that CAD in women is under diagnosed.) Women present with the same pattern of CAD as do males You are out of other options 25. Question : Why would inability to exercise reduce the specificity of the routine ETT? Student Answer: Produces persistent ST-segmental changes and T-wave abnormalities (The inability to exercise reduces the specificity of the routine ETT because it produces persistent ST-segmental changes and T-wave abnormalities. ) Will not produce any changes in ECG Produces QRS changes that cannot be interpreted Causes ST-segment changes and P-wave abnormalities 26. Question : On the echocardiography during the ETT you notice the following change: abnormal left ventricular ejection fraction. What do these changes suggest related to this patient? Student Answer: Ischemia of the myocardium (Abnormal left ventricular ejection fraction suggests ischemia of the myocardium.) Weak ventricular muscles Rise in heart rate without evidence of ischemia Non-ischemic changes of the baseline ECG 27. Question : Specifically, when is an ETT considered to be negative? Student Answer: Patient exercises to 20% maximum age-predicted heart rate without induced ischemia Patient exercises to 85% of age predicted maximum heart rate without evidence of induced ischemia (An ETT is considered to be negative when the patient exercises to 85% of age predicted maximum heart rate without evidence of induced ischemia. ) Patient exercises until tired without evidence of induced ischemia Patient has ST-segmental changes with down sloping of greater than 1 mm at 50% of age-predicted maximum heart rate 28. Question : Eligibility for Medicaid includes the following: Student Answer: Elderly, children and women living in poverty (Eligibility for Medicaid includes the elderly as well as children and women living in poverty. ) Very young and elderly only Everyone unemployed Children and women regardless of income 29. Question : What is the leading cause of death for women in the United States? Student Answer: Complications of childbirth Lung cancer Breast cancer Heart disease (Heart disease is the leading cause of death for women in the United States.) 30. Question : What do you know regarding ischemia that is confined to only the posterior and or lateral segments of the left ventricle? Student Answer: Requires both for detection of changes by ETT Easier to detect by ETT Difficult to detect by ETT (Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. ) ETT cannot be used for detection [Show Less]
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NSG 6001 Final Exam Study Guide
NSG 6001 Final Exam Study Guide NSG 6001 NSG 6001 Final Exam Study Guide Areas Covered ABDOMINAL AORTIC ANEURYSM Know the causes of an abdominal aor... [Show More] tic aneurysm. P493 Understand risk factors for abdominal aortic aneurysm. P494 Development of AAA AAA expansion AAA rupture Know the symptoms of an abdominal aortic aneurysm. AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches). SYMPTOMS Symptom and sign of a ruptured AAA classic diagnostic triad of ruptured AAA is hypotension (42%), pulsatile abdominal mass (91%), and abdominal pain (58%) or back pain (70%). The triad is encountered in only 50% of patients with a ruptured AAA. Ruptured AAAs should be suspected in any patient who comes in with complaints of hypotension and atypical abdominal or back pain symptoms What is a Saccular Abdominal Aneurysm? What are the risks for abdominal aortic aneurysm? DIAGNOSTIC TESTING FOR CAD Why is CT imaging limited in women? P492 Can ischemic changes on an ECG during or after an ETT correlate to the effected artery or arteries? What diagnostic test is used for CAD? P488 Exercise Tolerance Test What defines a positive exercise echocardiogram? .Myocardial Perfusion Imaging Cardiac Magnetic Resonance Imaging (MRI) Exercise Echocardiography Understand the coronary flow related to CAD. What is the best reason to add a Doppler flow studies during an echocardiogram study? What changes would you see during an ETT that are highly predictive of CAD? P489 What is an Isometric ST-segment during exercise caused by? P488 Where would you measure the J point located on an ECG in relation to the QRS and ST-segment depression after an exercise stress test? P488 Why would you order an ETT in a symptomatic woman with a normal ECG? What predictive value does a significant ST-segment elevation have for CAD? p488 What physiological changes occur during effort in the routine ETT? nsg 6001 final exam What does an abnormal left ventricular ejection fraction on an echocardiogram mean for a patient during an ETT? P490 Know the reasons for using the risk stratification according to the Farmingham risk score to justify a ETT in an asymptomatic patient. HEART FAILURE Where could you find supporting data for guidelines for prevention of future heart disease? P456 What are the signs of heart failure? p541 Symptoms: Shortness of breath (dyspnea) Persistent coughing, bronchospasm, or wheezing- Edema SIGNS Jugular venous distention: Crackles, frothy or pink sputum, pleural effusions- Third heart sound: Fourth heart sound: Aortic stenosis: Mitral regurgitation: Tricuspid regurgitation: Hepatomegaly, right upper quadrant tenderness: Physical Exam: Ascites, anasarca, or edema: Physical Exam: Altered hemodynamics: Tachycardia: Displaced point of maximal impulse: Hypotension, cool extremities: Abdominal aortic aneurysm 1. Know the causes of an abdominal aortic aneurysm. P493 proposed causes of AAA include atherosclerosis, inflammation, mycotic infection, inheritable connective tissue disorders (Marfan syndrome, type IV Ehlers-Danlos syndrome), and trauma. atherosclerosis has been considered the most common cause of AAA and the known cause in 25% of all AAA. 2. Understand risk factors for abdominal aortic aneurysm. P494 Development of AAA: Atherosclerotic vascular disease, white race, male gender, advanced age, HTN, smoking, COPD, history of hernias, family history of AAA, and presence of other aneurysms. Hypercholesterolemia AAA expansion: Advanced age, Severe cardiac disease, Previous stroke, Tobacco use, Cardiac or renal transplant. AAA rupture: Female gender, Low FEV1, Larger initial AAA diameter, Higher mean blood pressure, Current tobacco use, Cardiac or renal transplant, Critical wall stress–wall strength relationship AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches). Evidence suggests that the high prevalence of AAA in patients with COPD may be related to medications (oral steroids) and coexisting diseases rather than to a common pathway of pathogenesis involving plasma elastase or α1-antitrypsin deficiency AAA and elevated homocysteine plasma levels. AAA represent 75% of aortic aneurysms 3. Know the symptoms of an abdominal aortic aneurysm. AAA may cause symptoms as a result of the pressure on surrounding structures, about 75% are asymptomatic at initial diagnosis. Symptoms: Symptomatic aneurysms increase in number after the age of 70years. In thin patients, a supine abdominal examination may readily show a pulsatile abdominal mass, Inflammatory AAAs may be manifested with chronic abdominal pain or back pain and, sometimes, ureteral obstruction Microembolic infarcts in the lower extremity of a patient with easily palpable pedal pulses may suggest either abdominal or popliteal aneurysm. Embolization of mural thrombus from an abdominal aneurysm may be seen with acute limb ischemia caused by femoral or popliteal occlusion. Symptom and sign of a ruptured AAA classic diagnostic triad of ruptured AAA is hypotension (42%), pulsatile abdominal mass (91%), and abdominal pain (58%) or back pain (70%). The triad is encountered in only 50% of patients with a ruptured AAA. Ruptured AAAs should be suspected in any patient who comes in with complaints of hypotension and atypical abdominal or back pain symptoms 4. What is a Saccular Abdominal Aneurysm? Saccular aneurysm is an asymmetric weakness or bleb on the side of the aorta; these defects result from trauma or an internal wall defect caused by an ulcer. Fusiform aneurysm is a symmetric weakness of the entire circumference of the aorta that produces a bulge. 5. What are the risks for abdominal aortic aneurysm? AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches) Diagnostic Testing for CAD 6. Why is CT imaging limited in women? P492 Single-photon emission CT imaging is technically limited in women because breast tissue and smaller coronary artery size 7. Can ischemic changes on an ECG during or after an ETT correlate to the effected artery or arteries? Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. 8. What diagnostic test is used for CAD? P488 Exercise Tolerance Test- standard first-line approach to initial testing for CAD is the ETT, during which the patient (attached to a 12-lead electrocardiogram) is continuously monitored during graded exercise. The bicycle and treadmill are the two most often used. The primary goal of the ETT is to increase workload incrementally to induce ischemia or until a predetermined workload is reached. Myocardial Perfusion Imaging- MPI offers a method of visualizing blood flow to the heart by injection of a radioactive cardiac-specific tracer. This improves the diagnostic accuracy of a stress test because it gives another method of detecting perfusion defects aside from measuring ST depression on the electrocardiogram. thallium chloride Tl 201 and technetium Tc 99m sestamibi are the radiopharmaceutical agents used for the detection of CAD in MPI. MPI such be used when baseline ECG abnormality that would interfere with measurement of stress-induced ST-segment changes, such as left ventricular hypertrophy, bundle branch blocks, and digoxin use. MPI is also a useful tool for use with high-risk diabetic patients Cardiac Magnetic Resonance Imaging (MRI): Cardiac MRI is, with further technologic refinement, anticipated to provide accurate data to distinguish between stable and unstable plaque and to assist with quantifying CAD, replacing the diagnostic cardiac catheterization Exercise Echocardiography- echocardiographic imaging enhances the sensitivity and specificity of CAD detection to an extent comparable to that provided by nuclear techniques.1 The 2DE evidence for ischemia includes an abnormal left ventricular ejection fraction (LVEF) response to exercise or the development of regional wall motion abnormalities. The exercise is performed with a bicycle or treadmill, and dobutamine is the most common pharmacologic agent used simultaneously with the echocardiography imaging. The image quality may be enhanced by the injection of echogenic microbubbles. 9. Understand the coronary flow related to CAD. CAD exists when coronary arteries are narrowed by atherosclerotic plaque formation, plaque rupture, or spasm. This narrowing impedes coronary blood flow, resulting in hypoperfusion of the myocardium. The hypoperfusion produces first diastolic, and then systolic dysfunction, with characteristic signs and symptoms, including chest pain. Typical ECG changes of ischemia result, although the ST-segment and T-wave changes that are central to demonstration of ischemia occur relatively late in the ischemic cascade. 10. What is the best reason to add a Doppler flow studies during an echocardiogram study? The Doppler portion of the examination is able to provide an assessment of the outflow gradient that closely approximates that obtained by cardiac catheterization. By combining Doppler ultrasonography and echocardiography, the examiner may make a reasonable calculation of the aortic valve area. Thickened, calcified, and immobile leaflets are readily noted by transthoracic two-dimensional echocardiography. Detect and evaluate blood shunting from a septal defect (Your best response for this specific case, however, would be that Doppler Flow studies would detect and evaluate blood shunting from a septal defect.) 11. What defines a positive exercise echocardiogram? A positive exercise echocardiogram is defined by stress- induced decrease in regional wall motion, decreased wall thickening, or regional compensatory hyperkinesis Induced decrease in regional wall motion (Induced decrease in regional wall motion would be included in defining a positive exercise echocardiogram. Wall thickening would not traditionally occur in a positive test and hyperkinesis, not hypokinesis, generally occurs in a positive test.) 12. What changes would you see during an ETT that are highly predictive of CAD? P489 On the other hand, if there is evidence of ischemia (typical angina, ischemic ST changes) before the patient's target heart rate is reached, the test is considered strongly predictive of significant CAD. A second important predictor of more advanced CAD is exercise-induced hypotension (i.e., a fall in systolic blood pressure of at least 20mm Hg at any point during exercise). 13. What is an Isometric ST-segment during exercise caused by? P488 result in positive chronotropic (rate) and inotropic (strength of contraction) response of the cardiovascular system, increasing myocardial oxygen demand. The normal hemodynamic response to these stimuli is an increase in absolute coronary blood flow. ECG response of normal hearts is maintenance of an “isoelectric” ST segment during exercise and recovery 14. Where would you measure the J point located on an ECG in relation to the QRS and ST-segment depression after an exercise stress test? P488 Junction between QRS and ST segment (The J point is located at the junction between QRS and ST-segment.) J point of the QRS complex (the junction between the QRS complex and the ST segment). 15. Why would you order an ETT in a symptomatic woman with a normal ECG? Diagnostic testing is not always accurate in women and need more specialized test to detect CAD. 16. What predictive value does a significant ST-segment elevation have for CAD? p488 ECG changes such as upsloping ST segment (elevation) or isolated T-wave downsloping (depression) have not demonstrated significant predictive value. These changes have minimal predictive value for CAD (Significant elevation of the ST-segment has minimal predictive value for CAD.) 17. What physiological changes occur during effort in the routine ETT? In a stress test or ETT, patients are asked to perform incremental exercises that result in positive chronotropic (rate) and inotropic (strength of contraction) stimulation of the cardiovascular system, which in turn increases myocardial oxygen demand. Increases in oxygen demand obligate an increase in myocardial blood flow. The healthy coronary circulation can increase flow approximately five times above the baseline level. The fundamental pathophysiologic change in CAD is a limitation of the ability of the coronary arterial circulation to vasodilate appropriately. As a result, the ability to increase coronary blood flow in the face of increased myocardial oxygen demand is limited, leading to an imbalance between oxygen supply and demand and resulting in myocardial ischemia. 18. What does an abnormal left ventricular ejection fraction on an echocardiogram mean for a patient during an ETT? P490 The 2DE evidence for ischemia includes an abnormal left ventricular ejection fraction (LVEF) response to exercise or the development of regional wall motion abnormalities. 19. Know the reasons for using the risk stratification according to the Farmingham risk score to justify a ETT in an asymptomatic patient. High Farmingham risk score has a high accuracy of predicting a patient risk for CAD within the next 10 years. All patients, even if asymptomatic, require risk stratification according to the Framingham risk score (low, intermediate, or high) to identify CAD risk equivalents he ACC/AHA guidelines do not recommend stress tests for asymptomatic patients, unless the patient (men 45years or older, women 55years or older) is sedentary and wishes to begin exercising aggressively exception is asymptomatic women with diabetes and peripheral arterial disease. These women are classified as high risk; diabetes and peripheral arterial disease are CAD risk equivalents. The recommendation for asymptomatic women with diabetes, peripheral vascular disease, and possible kidney disease is for secondary prevention strategies to prevent future cardiac events. Heart Failure 20. Where could you find supporting data for guidelines for prevention of future heart disease? P456 The American College of Cardiology (ACC) and the American Heart Association (AHA) have devised a classification system that grades heart failure by stage (Box 120-3) to include patients at risk for the development of heart failure (stage A) and those with end-stage, advanced disease (stage D). And guidelines to prevent heart failure and treatment New York Heart Association Functional Classification Prevention of heart failure is linked to prevention of ischemic heart disease as well as to control of hypertension in the primary care setting. all patients should be screened for heart disease risk and encouraged to reduce their risk by adopting a healthy lifestyle, including normalization of weight, low-fat diet, smoke exposure avoidance, and exercise. Interventions to screen for heart disease risk include a family history, blood pressure measurement, lipid screen, and blood glucose concentration or hemoglobin A1c level to screen for diabetes. RISK FACTORS: Most individuals with heart failure have antecedent hypertension or myocardial infarction. Other risk factors include coronary artery disease, diabetes, renal disease, and increasing age. African Americans have a higher prevalence of heart failure than other ethnicities and with a greater 5-year fatality than for whites. Causes: Coronary artery disease is the most common cause of systolic heart failure Hypertension, atrial fibrillation, and diabetes are common antecedents of diastolic dysfunction Hypertension and valvular heart disease were considered the most common causes of heart failure 30 to 50 years ago. 21. What are the signs of heart failure? p541 Symptoms: Shortness of breath (dyspnea)- Pressure is increased in the pulmonary veins because the heart), which leads to left ventricular overload and worsening symptoms of failure cannot keep up with the supply. This can cause pulmonary congestion or pulmonary edema (interstitial and alveolar congestion Patients Describe: Breathlessness during activity, at rest, or while sleeping (called paroxysmal nocturnal dyspnea); these symptoms worsen with severity of heart failure Difficulty breathing while lying flat (orthopnea) or complaints of waking up tired or feeling anxious and restless Persistent coughing, bronchospasm, or wheezing- Persistent pulmonary interstitial or alveolar edema (sometimes called cardiac asthma), worse when recumbent Patients Describe: edema (sometimes called cardiac asthma), worse when recumbent. Coughing that produces white or pink blood-tinged mucus may not always be present. Edema- As blood flow out of the heart is impeded, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention. This is evidence of right-sided heart failure. Patient Describe: Swelling in the feet, ankles, legs, or abdomen or weight gain Patients may find that their pants or shoes feel tight. Signs Jugular venous distention: An index of right atrial pressure; when elevated, it is an indicator of volume overload. (Tricuspid regurgitation may alter the examination findings.) With normal pressure, the upper level of visible jugular vein is approximately 4cm above the sternal notch. Physical Examination: With the patient at a 45-degree angle, note the upper limit of visible pulse in the internal jugular. In some patients, this pressure may be normal at rest, but it rises to abnormal levels with compression of the right upper quadrant. This sign is known as the hepatojugular or abdominal jugular reflex. The internal or external jugular vein is compressed in the supraclavicular fossa, and as the examiner's finger strips the vein cephalad, blood rises in the more proximal portion of the vein; the height of this blood volume above the patient's clavicles reflects the central venous pressure. The height of the venous column normally falls during inspiration as a result of the accompanying decrease in intrathoracic pressure. Crackles, frothy or pink sputum, pleural effusions- Pulmonary fluids transudate to interstitial spaces and alveoli, usually in lung bases because of gravity. Pulmonary edema. Occur with volume overload—transudative Physical exam: Lung examination, Dull or absent breath sounds Third heart sound: Early diastolic rapid ventricular filling associated with left ventricular systolic dysfunction Physical Exam: S3 is best heard with patient in left lateral position Fourth heart sound: Overdistention of ventricles during late diastole as the stiff ventricles expand further to accommodate final diastolic filling by atrial contraction (atrial “kick”) Physical Exam: Best heard with patient in left lateral position; absence of S3 suggests early failure or the presence of diastolic dysfunction Aortic stenosis: Small volume, high velocity Physical Exam: Harsh murmur, usually loud Mitral regurgitation: Large volume, low turbulent flow Physical Exam: Soft holosystolic murmur Tricuspid regurgitation: Large volume in right ventricle Physical Exam: Hepatic congestion, edema, ascites Hepatomegaly, right upper quadrant tenderness: Liver enlargement or stretching of the hepatic capsule Physical Exam: Right upper quadrant tenderness indicates enlarged or tender liver Ascites, anasarca, or edema: Due to volume overload Physical Exam: Edema of subcutaneous tissue may be found in abdomen, chest, buttocks. Ascites may be suggested by protuberant abdomen, but the examination is not reliable. Pitting or firm edema of lower extremities is common in heart failure. Altered hemodynamics: Changes in cardiac output by stroke volume and heart rate Physical Exam: May appear with symptoms and signs of low output, such as lightheadedness, impaired cognition, tachycardia, cool extremities, hypotension Tachycardia: Changes in heart rate due to arrhythmia or activation of baroreceptors, which in turn activate sympathetic nervous system These compensatory mechanisms along with the renin-angiotensin-aldosterone and vasopressin release help modulate heart rate early on with a drop in pressure. Ultimately, a tachycardia will ensue, unless it is masked by medication (such as beta blockers, digoxin, calcium channel blockers). Physical Exam: Heart rate measurement; evaluation of rhythm is important Displaced point of maximal impulse: Displacement of the palpable apical impulse away from the midclavicular line toward the anterior axillary line indicates left ventricular enlargement. The palpable apical impulse should be a quick tap, narrow in distribution, not more than 1 to 2cm (0.4 to 0.8 inch) in diameter. An impulse that is palpable with the palm of the hand, lasts longer, or is forceful indicates increased cardiac output or ventricular hypertrophy. Physical Exam: Palpable impulse may be elicited with the palm placed on the sternum. This finding is a right ventricular tap or heave, indicating right ventricular enlargement and volume overload. Hypotension, cool extremities: Due to low cardiac output; sometimes medication related Physical Exam: Blood pressure measurement [Show Less]
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NSG 6001 Midterm Exam 2 – Question with Answers and Explanations
NSG 6001 Midterm Exam 2 – Question with Answers and Explanations N.B (Explanations are in brackets) NSG 6001 Midterm Exam 2 – Question with Answers... [Show More] and Explanations N.B (Explanations are in brackets) Question 1. A 35 year old female arrives at your clinic. She has had diabetes and peripheral artery disease for the past 5 years. You decide to obtain an ETT. The insurance company argues that this is inappropriate. You justify the ETT because you are planning secondary strategies to prevent future heart disease. Where could one find the supporting data for these guidelines? Medicare guidelines Framingham risk score (These guidelines come from the Framingham risk score.) Medicaid guidelines Do not exist Question 2. You are counseling a patient diagnosed with stress-induced ischemia. You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by what phenomena? Diet and exercise Heart muscle dysfunction Too many carbonated drinks Endothelial dysfunction of the microvascular (You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by endothelial dysfunction of the microvascular.) Question 3. What happens to coronary flow related to CAD? Hyper profusion of the myocardium Cerebral vascular infarction Hypo profusion of the myocardium (Because of the restrictive flow of blook through the coronary arteries, hypo profusion of the myocardium results from coronary flow related to CAD which causes the presenting symptoms) Functional systolic pressures Question 4: A 47-year old female with general complaints of fatigue and shortness of breath shows up in your clinic as a referral from another nurse practitioner. Several blood tests and chest x-rays have been completed without any diagnosis or outstanding abnormalities. You decide to order an ETT despite the fact that the recent ECG does not show any abnormalities. From the answers below, which would be the best answer to support your decision? You are out of other options Women present with the same pattern of CAD as do males CAD in women is under diagnosed (You make this choice because you are aware that CAD in women is under diagnosed.) To please the patient Question 5: You are in the clinic with your mentor observing the Echocardiogram exercise test of a 45-year old male that has been experiencing slight chest pressure almost daily during exercise. While observing your patient, your mentor points out that the left ventricle wall is thinning and there is some hyperkinesias of the ventricular wall. From your time in the clinic, you know that this test will be considered to be what type of result? Impossible Negative Positive (From your time in the clinic, you know because of wall thinning and hyperkinesis that this test will be considered to be positive.) Non-readable Question 6: On the echocardiography during the ETT you notice the following change: abnormal left ventricular ejection fraction. What do these changes suggest related to this patient? Non-ischemic changes of the baseline ECG Ischemia of the myocardium (Abnormal left ventricular ejection fraction suggests ischemia of the myocardium.) Rise in heart rate without evidence of ischemia Weak ventricular muscles Question 7: Population disease management is a term used to describe: High specificity disease states Low specificity diseases states Low prevalence specific diseases High prevalence specific diseases (Population disease management is a term used to describe the high prevalence of specific diseases.) Question 8: Why would inability to exercise reduce the specificity of the routine ETT? Causes ST-segment changes and P-wave abnormalities Will not produce any changes in ECG Produces persistent ST-segmental changes and T-wave abnormalities (The inability to exercise reduces the specificity of the routine ETT because it produces persistent ST-segmental changes and T-wave abnormalities.) Produces QRS changes that cannot be interpreted Question 9: All patients, even if asymptomatic, require risk stratification according to the Farmingham risk score. At present, ACC/AHA guidelines, however, do not normally support stress tests for asymptomatic patients without additional justification. From the list below, what could be used to justify an ETT in an asymptomatic patient? Sedentary and wishes to begin aggressive exercise (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended to obtain an ETT to rule out underlying CAD.) A smoker of 3 weeks A member of congress Developmentally challenged Question 10: What is the leading cause of death for women in the United States? Heart disease (Heart disease is the leading cause of death for women in the United States.) Breast cancer Lung cancer Complications of childbirth Question 11: In women, you need to know the limitations of certain tests for CAD. For example, single-photon emissions CT imaging, while an acceptable test for most men and some women, is technically limited in women for two reasons. From the following, choose the best possible answer. Smoking rates and lack of uptake of photons Multiple vessel disease and fat deposits Breasts and fat deposits in abdomen Breasts and smaller coronary arteries (Single-photon emissions CT imaging is technically limited in women due to breasts and smaller coronary arteries.) Question 12. What are two of the most common forms of Exercise Stress Tests used today? Unicycle and Running in pace Thallium and Dobutamine Bicycle and rowing machine Bicycle and treadmill (Bicycle and treadmill are the two most common forms of exercise stress tests used today. ) Question 13. Improvements in the delivery and management of healthcare are necessary if we are to improve the overall health of this nation’s population. Which of the following are identified in your readings as strategic in the movement to improve the healthcare system? Socialized medicine and governmental controls Population management and healthcare practice (Population management and healthcare practice are strategic in the movement to improve the nation’s healthcare system. ) Monetary savings and limited disruption in healthcare delivery President and Congress Question 14. For women with known CAD and diabetes, which is most appropriate to assess CAD risk? ETT ETT with imaging (ETT with imaging is most appropriate to assess CAD risk.) Coronary catheterization Coronary bypass surgery Question 15. What is considered the first-line initial approach to test for CAD? EKG Exercise Stress Test (Exercise stress test is considered the first-line initial approach to test for CAD. ) Cardiac Catheterization Echocardiogram Question 16: Encouragement of patients to take effective actions in their own healthcare refers to the concept of: Interprofessional support Family care givers Physician or provider-driven care Self-management support (Encouragement of patients to take effective actions in their own healthcare refers to the concept of self-management support. ) Question 17. Ischemic changes on ECG during ETT is highly predictive of CAD. What is another important strong predictor of CAD that you might see during an ETT? Exercise-induced hypertension Rapid heart rate Exercise-induced hypotension (Another important strong predictor of CAD that you might see during an ETT is exercise-induced hypotension. ) Slow heart rate Question 18. Maintenance of an Isoelectric ST-segment during exercise is the response of? Hypo profusion CAD An abnormal heart A normal heart (Maintenance of an Isoelectric ST-segment during exercise is the response of a normal heart. ) Question 19. What ECG changes can reduce the specificity of the ETT? Paced rhythm and exercise induced bundle branch blocks Exercise induced bundle branch blocks Low voltage up sloping of the ST-segment Paced rhythm and resting bundle branch block (The ECG changes that can reduce the specificity of the ETT are paced rhythm and resting bundle branch block. ) Question 20. Your patient has a maximum age-predicted heart rate of 180. During the exercise, he reaches a heart rate of 140 and then states he can no longer exercise. You see no evidence of ischemia on the ECG. This would be diagnostic for what condition? Predictive of no CAD Diagnostic of laziness Has no diagnostic value to rule out CAD (This scenario has no diagnostic value to rule out CAD.) Diagnostic for impending Myocardial Infarction Question 21. We all know that collaboration is integral to becoming a successful nurse practitioner. Among collaborations, however, only one can be considered as the most important. While each example below is important, which is the most important collaboration? The one that occurs: Between the nurse practitioner and their physician mentor Between two healthcare providers about a single patient Between the patient and their family Between the patient and the nurse practitioner (The collaboration that is most important is the one that occurs between the patient and the nurse practitioner. ) Question 22. As patients that entrust our care to another individual, we always expect honesty to avoid leading us down a deceptive pathway in our healthcare decisions. Adherence to which principle compels providers to be truthful? Fidelity Self-reflection Finance Veracity (Adherence to veracity compels providers to be truthful with patients). Question 23. What do you know regarding ischemia that is confined to only the posterior and or lateral segments of the left ventricle? Easier to detect by ETT Requires both for detection of changes by ETT Difficult to detect by ETT (Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. ) ETT cannot be used for detection Question 24. Your patient is morbidly obese and cannot sit on a bicycle or walk a treadmill. She also has marked and severe emphysema. You need to make an assessment of the risk of significant CAD and your patient’s family says that their relative had their diagnosis based on an ultrasound echocardiography. What facts would influence your decision regarding the family request for echo assessment? Specificity would be reduced because of obesity and lung disease Specificity would be increased because of obesity Sensitivity would be increased because of lung disease Sensitivity would be reduced because of obesity and lung disease (Sensitivity would be reduced because of obesity and lung disease.) Question 25. Your mentor says that you should be prepared to know how to determine the maximum heart rate for your patient during the ETT. How is the age-predicted maximum heart rate during an ETT determined? 220-age (The age-predicted maximum heart rate during an ETT determined by subtracting the patient’s age from 220 (220 – age). ) 65+age 120-age 220+age Question 26. You are considering adding an adjunctive form of testing to detect wall motion abnormalities during the ETT. You select Echocardiography as the added testing. You choose this test because you know that echocardiography does what when added to a standard ETT? Enhances sensitivity and specificity of CAD detection (You choose this test because you know that echocardiography enhances sensitivity and specificity of CAD detection.) Enhances sensitivity while reducing specificity of CAD detection Enhances specificity while not changing sensitivity of detection for CAD You like pretty pictures of wall motion Question 27. Your patient underwent an exercise stress test for CAD. There is significant elevation of the ST-segment. What do you need to know about these changes to manage your patient’s care? These changes have minimal predictive value for CAD (Significant elevation of the ST-segment has minimal predictive value for CAD. ) This patient needs to see someone more experienced in treatment of CAD These changes are predictive of myocardial infarction These changes predict dire outcomes Question 28. The sensitivity of a routine ETT is effort dependent. What physiological changes occur during effort in the routine ETT? Rapid heart rates and coronary artery narrowing Increased coronary flow and increased systolic blood pressure (The physiological changes that occur during effort in the routine ETT are increased coronary flow and increased systolic blood pressure.) Decrease in coronary blood flow Decreased heart rate and increased systolic blood pressure Question 29. What purpose does the principle of fidelity serve in the provider/patient relationship? Ensures that providers honor their commitments to the patient (The principle of fidelity mandate assures that providers honor their commitments to the patient. ) Obligates the provider to a one-on-one relationship with the individual Ensures that patients receive whatever they want Maintains costs in the healthcare arena Question 30. A 55-year old man is referred to your clinic. He has been sedentary all of his life, is gaining weight and wishes to get into better physical shape. He has never had any chest pain or shortness of breath when walking or climbing a flight of stairs. Before recommending a vigorous exercise routine for this patient, you order what test? ETT (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended that the patient obtains an ETT to rule out underlying CAD.) Stool samples Thyroid levels [Show Less]
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NSG 6001 Midterm Exam – Question and Answers
NSG 6001 Midterm Exam – Question and Answers NSG 6001 Midterm Exam – Question and Answers 1. Question : Your patient is morbidly obese and cannot ... [Show More] sit on a bicycle or walk a treadmill. She also has marked and severe emphysema. You need to make an assessment of the risk of significant CAD and your patient’s family says that their relative had their diagnosis based on an ultrasound echocardiography. What facts would influence your decision regarding the family request for echo assessment? Student Answer: Specificity would be increased because of obesity Sensitivity would be reduced because of obesity and lung disease (Sensitivity would be reduced because of obesity and lung disease.) Sensitivity would be increased because of lung disease Specificity would be reduced because of obesity and lung disease 2. Question : Medicaid is mandated to be provided by each state through federal codes. Each state must offer Medicaid exactly as the federal government prescribes. True or false? Student Answer: False (Medicaid is mandated to be provided by each state, however, Mediciad is not required to be delivered by any certain formula. Each state has autonomy to deliver Mediciad services under its own guidelines, provided that each state meets the federal guidelines for Medicaid coverage. ) True 3. Question : By standard criteria, how is a positive stress test defined? Student Answer: Development of a horizontal or down sloping ST-segment depression of 10mm Development of a horizontal or down sloping ST-segment depression of 1mm (A positive stress test is defined as the development of a horizontal or down sloping ST-segment depression of 1mm. ) Upward sloping ST-segment measured at the J point of the QRS Down sloping of the ST-segment at the J point of the QRS 4. Question : Population disease management is a term used to describe: Student Answer: Low prevalence specific diseases High prevalence specific diseases (Population disease management is a term used to describe the high prevalence of specific diseases. ) Low specificity diseases states High specificity disease states 5. Question : What are two of the most common forms of Exercise Stress Tests used today? Student Answer: Bicycle and treadmill (Bicycle and treadmill are the two most common forms of exercise stress tests used today. ) Unicycle and Running in pace Thallium and Dobutamine Bicycle and rowing machine 6. Question : You are counseling a patient diagnosed with stress-induced ischemia. You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by what phenomena? Student Answer: Too many carbonated drinks Diet and exercise Endothelial dysfunction of the microvascular (You base your discussion on your knowledge that stress-induced ischemia is thought to be caused by endothelial dysfunction of the microvascular.) Heart muscle dysfunction 7. Question : Narrowed coronary arteries or plague rupture within the arteries of the coronary system may directly cause which condition? Student Answer: Venous Statis Diabetes Hypertension Coronary artery disease (Narrowed coronary arteries, plague rupture, and sometimes even spasms of the coronary arteries are the three most common direct causes for the diagnosis of coronary artery disease. ) 8. Question : Of the following, which is the best answer when asked for an advantage of echocardiogram exercise testing over thallium stress testing? Student Answer: Results are available more quickly (Echocardiogram exercise test results are available more quickly.) Does not depend on operator experience Doesn’t matter because there are no advantages Costs are the same 9. Question : A 55-year old man is referred to your clinic. He has been sedentary all of his life, is gaining weight and wishes to get into better physical shape. He has never had any chest pain or shortness of breath when walking or climbing a flight of stairs. Before recommending a vigorous exercise routine for this patient, you order what test? Student Answer: Stool samples CBC ETT (Many patients have underlying CAD but remain asymptomatic. Before beginning any new vigorous activities after years of sedentary lifestyle, it is recommended that the patient obtains an ETT to rule out underlying CAD.) Thyroid levels 10. Question : What ECG changes can reduce the specificity of the ETT? Student Answer: Paced rhythm and resting bundle branch block (The ECG changes that can reduce the specificity of the ETT are paced rhythm and resting bundle branch block. ) Low voltage up sloping of the ST-segment Exercise induced bundle branch blocks Paced rhythm and exercise induced bundle branch blocks 11. Question : In women, you need to know the limitations of certain tests for CAD. For example, single-photon emissions CT imaging, while an acceptable test for most men and some women, is technically limited in women for two reasons. From the following, choose the best possible answer. Student Answer: Breasts and fat deposits in abdomen Smoking rates and lack of uptake of photons Breasts and smaller coronary arteries (Single-photon emissions CT imaging is technically limited in women due to breasts and smaller coronary arteries.) Multiple vessel disease and fat deposits 12. Question : Improvements in the delivery and management of healthcare are necessary if we are to improve the overall health of this nation’s population. Which of the following are identified in your readings as strategic in the movement to improve the healthcare system? Student Answer: Monetary savings and limited disruption in healthcare delivery Population management and healthcare practice (Population management and healthcare practice are strategic in the movement to improve the nation’s healthcare system. ) Socialized medicine and governmental controls President and Congress 13. Question : The sensitivity of a routine ETT is effort dependent. What physiological changes occur during effort in the routine ETT? Student Answer: Decrease in coronary blood flow Increased coronary flow and increased systolic blood pressure (The physiological changes that occur during effort in the routine ETT are increased coronary flow and increased systolic blood pressure.) Rapid heart rates and coronary artery narrowing Decreased heart rate and increased systolic blood pressure 14. Question : Your mentor says that you should be prepared to know how to determine the maximum heart rate for your patient during the ETT. How is the age-predicted maximum heart rate during an ETT determined? Student Answer: 220+age 120-age 220-age (The age-predicted maximum heart rate during an ETT determined by subtracting the patient’s age from 220 (220 – age). ) 65+age 15. Question : Medicare hospital insurance (Part A) is funded through what system? Student Answer: Interest from investments State income taxes Federal income taxes Federal payroll taxes (Medicare Part A is funded through federal payroll taxes. ) 16. Question : We all know that collaboration is integral to becoming a successful nurse practitioner. Among collaborations, however, only one can be considered as the most important. While each example below is important, which is the most important collaboration? The one that occurs: Student Answer: Between the patient and their family Between the patient and the nurse practitioner (The collaboration that is most important is the one that occurs between the patient and the nurse practitioner. ) Between the nurse practitioner and their physician mentor Between two healthcare providers about a single patient 17. Question : The leads on the ECG showing ischemic changes during or immediately after an ETT can correlate roughly to the culprit artery or arteries with significant CAD. Is this true or false? Student Answer: False True (This statement is true: the leads on the ECG showing ischemic changes during or immediately after an ETT can correlate roughly to the culprit artery or arteries with significant CAD. ) 18. Question : Ischemic changes on ECG during ETT is highly predictive of CAD. What is another important strong predictor of CAD that you might see during an ETT? Student Answer: Slow heart rate Exercise-induced hypotension (Another important strong predictor of CAD that you might see during an ETT is exercise-induced hypotension. ) Exercise-induced hypertension Rapid heart rate 19. Question : In CAD, after both systolic and diastolic dysfunction have occurred, the typical pattern of chest pain and related EKG changes occur. During an EKG, you should expect to see ST-segment and T-wave changes that are central to demonstration of ischemia occurring relatively late in the ischemic cascade. Is this true or false? Student Answer: False True (This is a true statement. During an EKG, you should expect to see ST-segment and T-wave changes that are central to demonstration of ischemia occurring relatively late in the ischemic cascade. ) 20. Question : Chronic, non-communicable diseases account for disproportionate costs to the healthcare system. According to the World Health Organization, what percent of preventable deaths and disabilities occur in the Americas related to chronic non-communicable diseases? Student Answer: 10%-15% 80%-90% 35%-45% 60%-70% (According to the World Health Organization, 60%--7 0% of preventable deaths and disabilities occur in the Americas related to chronic non-communicable diseases. ) 21. Question : Your patient has a maximum age-predicted heart rate of 180. During the exercise, he reaches a heart rate of 140 and then states he can no longer exercise. You see no evidence of ischemia on the ECG. This would be diagnostic for what condition? Student Answer: Has no diagnostic value to rule out CAD (This scenario has no diagnostic value to rule out CAD.) Predictive of no CAD Diagnostic of laziness Diagnostic for impending Myocardial Infarction 22. Question : What happens to coronary flow related to CAD? Student Answer: Functional systolic pressures Hyper profusion of the myocardium Cerebral vascular infarction Hypo profusion of the myocardium (Because of the restrictive flow of blook through the coronary ateries,hypo profusion of the myocardium results from coronary flow related to CAD which causes the presenting symptoms. ) 23. Question : Your patient cannot sit on a bicycle and has difficulties walking a treadmill with limited capacity for exercising. Still, you know that the ETT is the preferred test for CAD. You consider adding a pharmacological agent to get to maximum heart rate. What agent would be the most commonly used agent to assist in an ETT? Student Answer: Epinephrine Dobutamine (The pharmacological agent most commonly used to assist in an ETT is dobutamine.) Dopamine Aspirin 24. Question : A 47-year old female with general complaints of fatigue and shortness of breath shows up in your clinic as a referral from another nurse practitioner. Several blood tests and chest x-rays have been completed without any diagnosis or outstanding abnormalities. You decide to order an ETT despite the fact that the recent ECG does not show any abnormalities. From the answers below, which would be the best answer to support your decision? Student Answer: To please the patient CAD in women is under diagnosed (You make this choice because you are aware that CAD in women is under diagnosed.) Women present with the same pattern of CAD as do males You are out of other options 25. Question : Why would inability to exercise reduce the specificity of the routine ETT? Student Answer: Produces persistent ST-segmental changes and T-wave abnormalities (The inability to exercise reduces the specificity of the routine ETT because it produces persistent ST-segmental changes and T-wave abnormalities. ) Will not produce any changes in ECG Produces QRS changes that cannot be interpreted Causes ST-segment changes and P-wave abnormalities 26. Question : On the echocardiography during the ETT you notice the following change: abnormal left ventricular ejection fraction. What do these changes suggest related to this patient? Student Answer: Ischemia of the myocardium (Abnormal left ventricular ejection fraction suggests ischemia of the myocardium.) Weak ventricular muscles Rise in heart rate without evidence of ischemia Non-ischemic changes of the baseline ECG 27. Question : Specifically, when is an ETT considered to be negative? Student Answer: Patient exercises to 20% maximum age-predicted heart rate without induced ischemia Patient exercises to 85% of age predicted maximum heart rate without evidence of induced ischemia (An ETT is considered to be negative when the patient exercises to 85% of age predicted maximum heart rate without evidence of induced ischemia. ) Patient exercises until tired without evidence of induced ischemia Patient has ST-segmental changes with down sloping of greater than 1 mm at 50% of age-predicted maximum heart rate 28. Question : Eligibility for Medicaid includes the following: Student Answer: Elderly, children and women living in poverty (Eligibility for Medicaid includes the elderly as well as children and women living in poverty. ) Very young and elderly only Everyone unemployed Children and women regardless of income 29. Question : What is the leading cause of death for women in the United States? Student Answer: Complications of childbirth Lung cancer Breast cancer Heart disease (Heart disease is the leading cause of death for women in the United States.) 30. Question : What do you know regarding ischemia that is confined to only the posterior and or lateral segments of the left ventricle? Student Answer: Requires both for detection of changes by ETT Easier to detect by ETT Difficult to detect by ETT (Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. ) ETT cannot be used for detection [Show Less]
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NSG 6001 Final Exam Study Guide
NSG 6001 Final Exam Study Guide NSG 6001 Final Exam Study Guide Areas Covered ABDOMINAL AORTIC ANEURYSM Know the causes of an abdominal aortic aneury... [Show More] sm. P493 Understand risk factors for abdominal aortic aneurysm. P494 Development of AAA AAA expansion AAA rupture Know the symptoms of an abdominal aortic aneurysm. AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches). SYMPTOMS Symptom and sign of a ruptured AAA classic diagnostic triad of ruptured AAA is hypotension (42%), pulsatile abdominal mass (91%), and abdominal pain (58%) or back pain (70%). The triad is encountered in only 50% of patients with a ruptured AAA. Ruptured AAAs should be suspected in any patient who comes in with complaints of hypotension and atypical abdominal or back pain symptoms What is a Saccular Abdominal Aneurysm? What are the risks for abdominal aortic aneurysm? DIAGNOSTIC TESTING FOR CAD Why is CT imaging limited in women? P492 Can ischemic changes on an ECG during or after an ETT correlate to the effected artery or arteries? What diagnostic test is used for CAD? P488 Exercise Tolerance Test What defines a positive exercise echocardiogram? .Myocardial Perfusion Imaging Cardiac Magnetic Resonance Imaging (MRI) Exercise Echocardiography Understand the coronary flow related to CAD. What is the best reason to add a Doppler flow studies during an echocardiogram study? What changes would you see during an ETT that are highly predictive of CAD? P489 What is an Isometric ST-segment during exercise caused by? P488 Where would you measure the J point located on an ECG in relation to the QRS and ST-segment depression after an exercise stress test? P488 Why would you order an ETT in a symptomatic woman with a normal ECG? What predictive value does a significant ST-segment elevation have for CAD? p488 What physiological changes occur during effort in the routine ETT? nsg 6001 final exam What does an abnormal left ventricular ejection fraction on an echocardiogram mean for a patient during an ETT? P490 Know the reasons for using the risk stratification according to the Farmingham risk score to justify a ETT in an asymptomatic patient. HEART FAILURE Where could you find supporting data for guidelines for prevention of future heart disease? P456 What are the signs of heart failure? p541 Symptoms: Shortness of breath (dyspnea) Persistent coughing, bronchospasm, or wheezing- Edema SIGNS Jugular venous distention: Crackles, frothy or pink sputum, pleural effusions- Third heart sound: Fourth heart sound: Aortic stenosis: Mitral regurgitation: Tricuspid regurgitation: Hepatomegaly, right upper quadrant tenderness: Physical Exam: Ascites, anasarca, or edema: Physical Exam: Altered hemodynamics: Tachycardia: Displaced point of maximal impulse: Hypotension, cool extremities: Abdominal aortic aneurysm 1. Know the causes of an abdominal aortic aneurysm. P493 proposed causes of AAA include atherosclerosis, inflammation, mycotic infection, inheritable connective tissue disorders (Marfan syndrome, type IV Ehlers-Danlos syndrome), and trauma. atherosclerosis has been considered the most common cause of AAA and the known cause in 25% of all AAA. 2. Understand risk factors for abdominal aortic aneurysm. P494 Development of AAA: Atherosclerotic vascular disease, white race, male gender, advanced age, HTN, smoking, COPD, history of hernias, family history of AAA, and presence of other aneurysms. Hypercholesterolemia AAA expansion: Advanced age, Severe cardiac disease, Previous stroke, Tobacco use, Cardiac or renal transplant. AAA rupture: Female gender, Low FEV1, Larger initial AAA diameter, Higher mean blood pressure, Current tobacco use, Cardiac or renal transplant, Critical wall stress–wall strength relationship AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches). Evidence suggests that the high prevalence of AAA in patients with COPD may be related to medications (oral steroids) and coexisting diseases rather than to a common pathway of pathogenesis involving plasma elastase or α1-antitrypsin deficiency AAA and elevated homocysteine plasma levels. AAA represent 75% of aortic aneurysms 3. Know the symptoms of an abdominal aortic aneurysm. AAA may cause symptoms as a result of the pressure on surrounding structures, about 75% are asymptomatic at initial diagnosis. Symptoms: Symptomatic aneurysms increase in number after the age of 70years. In thin patients, a supine abdominal examination may readily show a pulsatile abdominal mass, Inflammatory AAAs may be manifested with chronic abdominal pain or back pain and, sometimes, ureteral obstruction Microembolic infarcts in the lower extremity of a patient with easily palpable pedal pulses may suggest either abdominal or popliteal aneurysm. Embolization of mural thrombus from an abdominal aneurysm may be seen with acute limb ischemia caused by femoral or popliteal occlusion. Symptom and sign of a ruptured AAA classic diagnostic triad of ruptured AAA is hypotension (42%), pulsatile abdominal mass (91%), and abdominal pain (58%) or back pain (70%). The triad is encountered in only 50% of patients with a ruptured AAA. Ruptured AAAs should be suspected in any patient who comes in with complaints of hypotension and atypical abdominal or back pain symptoms 4. What is a Saccular Abdominal Aneurysm? Saccular aneurysm is an asymmetric weakness or bleb on the side of the aorta; these defects result from trauma or an internal wall defect caused by an ulcer. Fusiform aneurysm is a symmetric weakness of the entire circumference of the aorta that produces a bulge. 5. What are the risks for abdominal aortic aneurysm? AAA is an important clinical diagnosis because it is associated with considerable risk of rupture and death as the aneurysm enlarges to a diameter of more than 5.0cm (1.96 inches) Diagnostic Testing for CAD 6. Why is CT imaging limited in women? P492 Single-photon emission CT imaging is technically limited in women because breast tissue and smaller coronary artery size 7. Can ischemic changes on an ECG during or after an ETT correlate to the effected artery or arteries? Ischemia that is confined to only the posterior and or lateral segments of the left ventricle is difficult to detect by ETT, but that does not mean that ETT cannot detect ischemia limited to these functional areas of the heart. 8. What diagnostic test is used for CAD? P488 Exercise Tolerance Test- standard first-line approach to initial testing for CAD is the ETT, during which the patient (attached to a 12-lead electrocardiogram) is continuously monitored during graded exercise. The bicycle and treadmill are the two most often used. The primary goal of the ETT is to increase workload incrementally to induce ischemia or until a predetermined workload is reached. Myocardial Perfusion Imaging- MPI offers a method of visualizing blood flow to the heart by injection of a radioactive cardiac-specific tracer. This improves the diagnostic accuracy of a stress test because it gives another method of detecting perfusion defects aside from measuring ST depression on the electrocardiogram. thallium chloride Tl 201 and technetium Tc 99m sestamibi are the radiopharmaceutical agents used for the detection of CAD in MPI. MPI such be used when baseline ECG abnormality that would interfere with measurement of stress-induced ST-segment changes, such as left ventricular hypertrophy, bundle branch blocks, and digoxin use. MPI is also a useful tool for use with high-risk diabetic patients Cardiac Magnetic Resonance Imaging (MRI): Cardiac MRI is, with further technologic refinement, anticipated to provide accurate data to distinguish between stable and unstable plaque and to assist with quantifying CAD, replacing the diagnostic cardiac catheterization Exercise Echocardiography- echocardiographic imaging enhances the sensitivity and specificity of CAD detection to an extent comparable to that provided by nuclear techniques.1 The 2DE evidence for ischemia includes an abnormal left ventricular ejection fraction (LVEF) response to exercise or the development of regional wall motion abnormalities. The exercise is performed with a bicycle or treadmill, and dobutamine is the most common pharmacologic agent used simultaneously with the echocardiography imaging. The image quality may be enhanced by the injection of echogenic microbubbles. 9. Understand the coronary flow related to CAD. CAD exists when coronary arteries are narrowed by atherosclerotic plaque formation, plaque rupture, or spasm. This narrowing impedes coronary blood flow, resulting in hypoperfusion of the myocardium. The hypoperfusion produces first diastolic, and then systolic dysfunction, with characteristic signs and symptoms, including chest pain. Typical ECG changes of ischemia result, although the ST-segment and T-wave changes that are central to demonstration of ischemia occur relatively late in the ischemic cascade. 10. What is the best reason to add a Doppler flow studies during an echocardiogram study? The Doppler portion of the examination is able to provide an assessment of the outflow gradient that closely approximates that obtained by cardiac catheterization. By combining Doppler ultrasonography and echocardiography, the examiner may make a reasonable calculation of the aortic valve area. Thickened, calcified, and immobile leaflets are readily noted by transthoracic two-dimensional echocardiography. Detect and evaluate blood shunting from a septal defect (Your best response for this specific case, however, would be that Doppler Flow studies would detect and evaluate blood shunting from a septal defect.) 11. What defines a positive exercise echocardiogram? A positive exercise echocardiogram is defined by stress- induced decrease in regional wall motion, decreased wall thickening, or regional compensatory hyperkinesis Induced decrease in regional wall motion (Induced decrease in regional wall motion would be included in defining a positive exercise echocardiogram. Wall thickening would not traditionally occur in a positive test and hyperkinesis, not hypokinesis, generally occurs in a positive test.) 12. What changes would you see during an ETT that are highly predictive of CAD? P489 On the other hand, if there is evidence of ischemia (typical angina, ischemic ST changes) before the patient's target heart rate is reached, the test is considered strongly predictive of significant CAD. A second important predictor of more advanced CAD is exercise-induced hypotension (i.e., a fall in systolic blood pressure of at least 20mm Hg at any point during exercise). 13. What is an Isometric ST-segment during exercise caused by? P488 result in positive chronotropic (rate) and inotropic (strength of contraction) response of the cardiovascular system, increasing myocardial oxygen demand. The normal hemodynamic response to these stimuli is an increase in absolute coronary blood flow. ECG response of normal hearts is maintenance of an “isoelectric” ST segment during exercise and recovery 14. Where would you measure the J point located on an ECG in relation to the QRS and ST-segment depression after an exercise stress test? P488 Junction between QRS and ST segment (The J point is located at the junction between QRS and ST-segment.) J point of the QRS complex (the junction between the QRS complex and the ST segment). 15. Why would you order an ETT in a symptomatic woman with a normal ECG? Diagnostic testing is not always accurate in women and need more specialized test to detect CAD. 16. What predictive value does a significant ST-segment elevation have for CAD? p488 ECG changes such as upsloping ST segment (elevation) or isolated T-wave downsloping (depression) have not demonstrated significant predictive value. These changes have minimal predictive value for CAD (Significant elevation of the ST-segment has minimal predictive value for CAD.) 17. What physiological changes occur during effort in the routine ETT? In a stress test or ETT, patients are asked to perform incremental exercises that result in positive chronotropic (rate) and inotropic (strength of contraction) stimulation of the cardiovascular system, which in turn increases myocardial oxygen demand. Increases in oxygen demand obligate an increase in myocardial blood flow. The healthy coronary circulation can increase flow approximately five times above the baseline level. The fundamental pathophysiologic change in CAD is a limitation of the ability of the coronary arterial circulation to vasodilate appropriately. As a result, the ability to increase coronary blood flow in the face of increased myocardial oxygen demand is limited, leading to an imbalance between oxygen supply and demand and resulting in myocardial ischemia. 18. What does an abnormal left ventricular ejection fraction on an echocardiogram mean for a patient during an ETT? P490 The 2DE evidence for ischemia includes an abnormal left ventricular ejection fraction (LVEF) response to exercise or the development of regional wall motion abnormalities. 19. Know the reasons for using the risk stratification according to the Farmingham risk score to justify a ETT in an asymptomatic patient. High Farmingham risk score has a high accuracy of predicting a patient risk for CAD within the next 10 years. All patients, even if asymptomatic, require risk stratification according to the Framingham risk score (low, intermediate, or high) to identify CAD risk equivalents he ACC/AHA guidelines do not recommend stress tests for asymptomatic patients, unless the patient (men 45years or older, women 55years or older) is sedentary and wishes to begin exercising aggressively exception is asymptomatic women with diabetes and peripheral arterial disease. These women are classified as high risk; diabetes and peripheral arterial disease are CAD risk equivalents. The recommendation for asymptomatic women with diabetes, peripheral vascular disease, and possible kidney disease is for secondary prevention strategies to prevent future cardiac events. Heart Failure 20. Where could you find supporting data for guidelines for prevention of future heart disease? P456 The American College of Cardiology (ACC) and the American Heart Association (AHA) have devised a classification system that grades heart failure by stage (Box 120-3) to include patients at risk for the development of heart failure (stage A) and those with end-stage, advanced disease (stage D). And guidelines to prevent heart failure and treatment New York Heart Association Functional Classification Prevention of heart failure is linked to prevention of ischemic heart disease as well as to control of hypertension in the primary care setting. all patients should be screened for heart disease risk and encouraged to reduce their risk by adopting a healthy lifestyle, including normalization of weight, low-fat diet, smoke exposure avoidance, and exercise. Interventions to screen for heart disease risk include a family history, blood pressure measurement, lipid screen, and blood glucose concentration or hemoglobin A1c level to screen for diabetes. RISK FACTORS: Most individuals with heart failure have antecedent hypertension or myocardial infarction. Other risk factors include coronary artery disease, diabetes, renal disease, and increasing age. African Americans have a higher prevalence of heart failure than other ethnicities and with a greater 5-year fatality than for whites. Causes: Coronary artery disease is the most common cause of systolic heart failure Hypertension, atrial fibrillation, and diabetes are common antecedents of diastolic dysfunction Hypertension and valvular heart disease were considered the most common causes of heart failure 30 to 50 years ago. 21. What are the signs of heart failure? p541 Symptoms: Shortness of breath (dyspnea)- Pressure is increased in the pulmonary veins because the heart), which leads to left ventricular overload and worsening symptoms of failure cannot keep up with the supply. This can cause pulmonary congestion or pulmonary edema (interstitial and alveolar congestion Patients Describe: Breathlessness during activity, at rest, or while sleeping (called paroxysmal nocturnal dyspnea); these symptoms worsen with severity of heart failure Difficulty breathing while lying flat (orthopnea) or complaints of waking up tired or feeling anxious and restless Persistent coughing, bronchospasm, or wheezing- Persistent pulmonary interstitial or alveolar edema (sometimes called cardiac asthma), worse when recumbent Patients Describe: edema (sometimes called cardiac asthma), worse when recumbent. Coughing that produces white or pink blood-tinged mucus may not always be present. Edema- As blood flow out of the heart is impeded, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention. This is evidence of right-sided heart failure. Patient Describe: Swelling in the feet, ankles, legs, or abdomen or weight gain Patients may find that their pants or shoes feel tight. Signs Jugular venous distention: An index of right atrial pressure; when elevated, it is an indicator of volume overload. (Tricuspid regurgitation may alter the examination findings.) With normal pressure, the upper level of visible jugular vein is approximately 4cm above the sternal notch. Physical Examination: With the patient at a 45-degree angle, note the upper limit of visible pulse in the internal jugular. In some patients, this pressure may be normal at rest, but it rises to abnormal levels with compression of the right upper quadrant. This sign is known as the hepatojugular or abdominal jugular reflex. The internal or external jugular vein is compressed in the supraclavicular fossa, and as the examiner's finger strips the vein cephalad, blood rises in the more proximal portion of the vein; the height of this blood volume above the patient's clavicles reflects the central venous pressure. The height of the venous column normally falls during inspiration as a result of the accompanying decrease in intrathoracic pressure. Crackles, frothy or pink sputum, pleural effusions- Pulmonary fluids transudate to interstitial spaces and alveoli, usually in lung bases because of gravity. Pulmonary edema. Occur with volume overload—transudative Physical exam: Lung examination, Dull or absent breath sounds Third heart sound: Early diastolic rapid ventricular filling associated with left ventricular systolic dysfunction Physical Exam: S3 is best heard with patient in left lateral position Fourth heart sound: Overdistention of ventricles during late diastole as the stiff ventricles expand further to accommodate final diastolic filling by atrial contraction (atrial “kick”) Physical Exam: Best heard with patient in left lateral position; absence of S3 suggests early failure or the presence of diastolic dysfunction Aortic stenosis: Small volume, high velocity Physical Exam: Harsh murmur, usually loud Mitral regurgitation: Large volume, low turbulent flow Physical Exam: Soft holosystolic murmur Tricuspid regurgitation: Large volume in right ventricle Physical Exam: Hepatic congestion, edema, ascites Hepatomegaly, right upper quadrant tenderness: Liver enlargement or stretching of the hepatic capsule Physical Exam: Right upper quadrant tenderness indicates enlarged or tender liver Ascites, anasarca, or edema: Due to volume overload Physical Exam: Edema of subcutaneous tissue may be found in abdomen, chest, buttocks. Ascites may be suggested by protuberant abdomen, but the examination is not reliable. Pitting or firm edema of lower extremities is common in heart failure. Altered hemodynamics: Changes in cardiac output by stroke volume and heart rate Physical Exam: May appear with symptoms and signs of low output, such as lightheadedness, impaired cognition, tachycardia, cool extremities, hypotension Tachycardia: Changes in heart rate due to arrhythmia or activation of baroreceptors, which in turn activate sympathetic nervous system These compensatory mechanisms along with the renin-angiotensin-aldosterone and vasopressin release help modulate heart rate early on with a drop in pressure. Ultimately, a tachycardia will ensue, unless it is masked by medication (such as beta blockers, digoxin, calcium channel blockers). Physical Exam: Heart rate measurement; evaluation of rhythm is important Displaced point of maximal impulse: Displacement of the palpable apical impulse away from the midclavicular line toward the anterior axillary line indicates left ventricular enlargement. The palpable apical impulse should be a quick tap, narrow in distribution, not more than 1 to 2cm (0.4 to 0.8 inch) in diameter. An impulse that is palpable with the palm of the hand, lasts longer, or is forceful indicates increased cardiac output or ventricular hypertrophy. Physical Exam: Palpable impulse may be elicited with the palm placed on the sternum. This finding is a right ventricular tap or heave, indicating right ventricular enlargement and volume overload. Hypotension, cool extremities: Due to low cardiac output; sometimes medication related Physical Exam: Blood pressure measurement [Show Less]
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NSG 6001 Final Exam Questions and Answers (Graded A).
NSG 6001 Final Exam Questions and Answers (Graded A). 1. More than half of all cardiac arrhymias involve the atria - True 2. What are the most commo... [Show More] n symptoms caused by tachyarryhthmias - Palpitations 3. For women with known cad and diabetes, which is the most appropriate to assess CAD risk - ETT with imaging 4. Of the following, which is the best answer when asked about the advantage of echocardiogram exercise testing over thallium stress testing - Results are available more quickly 5. You patient has uncomplicated pyelonephritis. In deciding your recommended treatment, you consider the most common pathogenic reason for this diagnosis. What pathogen accounts for the majority of pyelonephritis? - E coli 6. What purpose does the principle of fidelity serve - Ensures that providers honor their committement to the patient 7. In CAD after both systolic and diastolic dysfunction have occurred. The typical pattern of chest pain and related EKG changes occur. During an ekg you should expect to see ST segment and T wave changes that are central to demonstration of ischemia occurring relatively late in the ischemic cascade is this true or false - True 8. The leads on the ECG showing ischemic changes during or immediately after an ETT can correlate roughly to the culprit artery or arteries with significant CAD. Is this true or false - True 9. Skin cancer is the most common malignant neoplasms in males in the us . What is the second leading cause of cancer deaths in men greater than 50 years of age - Prostate cancer 10. What ech changes can reduce the specificity of the ETT - Paced rhythm and resting bundle branch blocks. 11. You have confirmed that your patient does indeed have an abdominal aortic aneurysm. In teaching your patient about symptoms to report immediately to the vascular surgeon you instruct the patient to report which of the following - Back pain or flank pain 12. Which is one of the common causes of a saccular abdominal aneurysm - Trauma 13. The diagnostic accuracy of stress testing is decreased among women compared to men for what reasons - Women usually have single vessel or non-obstructive disease 14. Population disease management is a term used to describe - High prevalence specific diseases 15. You receive a report back on the suspected abdominal aortic aneurysm for your patient. It confirms your suspicion of AAA. The report describes the aneurysm as a symmetric weakness of the entire circumference of the aorta. You know that this form of aneurysm is referred to as what kind of aneurysm - Fusiform 16. You practice partner just ordered an exercise echocardiograph 2DE for a patient with suspected cardiovascular risk. This patient has known resting wall motion abnormalities. Why would this not be the best test to assess this patient’s cardiac risk - Sensitivity is decreased 17. Your 60-year-old male patient arrives for his appointment. He complains of general malaise and fever over the past several days with low back pain. He also states that he is getting up at night more often to urinate and never feels his bladder is completely empty. What differential diagnosis should you consider in this patient - Acute bacterial prostatitis 18. We all know that collaboration in integral to becoming a successful nurse practitioner. Among collaboration, however, only one can be considered the most important. While each example below is important, which is the most important collaboration. The one that occurs: - Between the patient and the nurse practitioner 19. The sensitivity of a routine ETT is effort dependent. What physiological changes occur during effort in the routine ETT? - Increased coronary blood flow and increased systolic blood pressure 20. A 47-year-old female with general complaints of fatigue and shortness of breath show up in your clinic as a referral from another nurse practitioner. Several blood tests and chest xrays have been completed without any diagnosis or outstanding abnormalities. You decide to order an ETT despite the fact that the recent ecg does not show any abnormalities. From the answers below which would be the best answer to support your decision - Cad in women is under diagnosed 21. Your patient underwent an exercise stress test for CAD. There is significant elevation of the ST segment. What do you need to know about these changes to manage your patients care? - These changes have minimal predictive value for CAD 22. When there is a consequential loss of structural integrity of the abdominal aorta, the resulting issue is what condition - AAA 23. You see a 60yr old AA male in your clinic with a recent diagnosis of htn. He asks you what he should restrict in his diet. And is particularly interested in limiting his sodium intake. What amount of sodium intake would you recommend on a daily basis for this patient? - 1.5g/day 24. Why would inability to exercise reduce the specificity of the routine ETT - Produces persistent ST segment changes and T wave abnormalities 25. By standard criteria, how is a positive stress test defined - Development of a horizontal or down sloping ST segment depression of 1mm 26. What are the two types of bradycardia recognized by the American heart association - Relative and absolute 27. You see a 75-year-old female in your clinic complaining of urinary incontinence. She is otherwise health based upon her last visit. She states that her mother told her this would happen someday because it happens to every woman at some age. What would you tell this patient? - This is not an expected condition related to aging. 28. What do you know regarding ischemia that is confined to only the posterior and or lateral segments of the left ventricle? - Difficult to detect by ETT 29. What 3 conditions definitely alter the results of echocardiography in determining CAD - Obesity, rapid heart rate, and lung disease 30. Specifically, when is an ETT considered to be negative - Patient exercises to 85% of age predicted maximum heart rate without evidence of induced ischemia 31. All patient even if asymptomatic require risk stratification according to the Framingham risk score. At present ACC/AHA guidelines however do not normally support stress tests for asymptomatic patients without additional justification. What could be used to justify ETT in an asymptomatic patient - Sedentary and wishes to begin aggressive exercise 32. BPH is not a risk factor for prostate cancer. Is this true to false - True 33. Spread of genital herpes only occurs during the time period with active lesions. Is the true or false - False 34. AAA are often asymptomatic, what percent of AAA are discovered in asymptomatic patient - 75% 35. Improvement in the delivery and management of the healthcare are necessary if we are to improve the overall health of this nation’s population. Which of the following are identified in your readings as strategic in the movement to improve healthcare system? - Population management and healthcare practice 36. Two main types of heart failure - Systolic and diastolic 37. The majority of all strokes are non-ischemic. Is this statement true or false? - False 38. When a murmur is first heard. It is important to determine if it is due to a pathological condition or benign. For an experienced practitioner, it is always easy to determine the cause of a murmur merely by listening to the sound. Is this true or false - False 39. Maintenance of an isometric ST segment during exercise is the response of - A normal heart 40. The goal of self-management is to specifically do what - Engage patients in own care 41. Your 56-year-old patient presents with bradycardia with a rate of 55 and first degree av block. The patient is hemodynamically stable and is not experiencing any syncope or chest pain. Hx includes: MI, home meds include BB, ASA, Lab work is non-significant for electrolyte imbalances. You decide to treat this patient for the arrhythmia to prevent future destabilizations. Which might be the appropriate first measure to consider - Discontinue BB and replace with another therapy if necessary 42. Your patient is morbidly obese and cannot sit on a bicycle or walk a treadmill. She also has marked and severe emphysema. You need to make an assessment of the risk of significant CAD and your patients family says that their relative had their diagnosis base don an ultrasound echo. What facts would influence your decisions regarding the family request for echo assmnt - Sensitivity would be reduced because of obesity and lung disease 43. Your are in a clinic with your mentor observing the echocardiogram exercise teset of a 45 year old male that had been experiencing slight chest pressure almost daily during exercise. While observing your patient, your mentor points out that the left ventricle wall is thinning and there is some hyperkinesia 44. Your patient is newly diagnosed with persistent atria fibrillation. You consider electro cardioversion. Before undergoing this procedure you should order the following examination to assess thrombus risk - Transesophageal echocardiopgrahy 45. Tachyarrhythmias cause a drop in commonly blood pressure, cardiac output syncope sob, cp. What phenomenon most often occurs during these arrhythmias to cause these s/s - Shortened diastole 46. At what age is afib most common - 60 or older 47. Automaticity is a property common to all cardiac cells - True 48. Your pt has a maximum age predicted HR of 180. During the exercise eh reaches a heart rate of 140 and then states he can no longer exercise. You see evidence of ischemic changes on the ecg. This would be predictive of what condition - Significant cad 49. You tell a patient he has a murmur. He says he has been told this before, but wonders what causes the unique sounds of a murmur. Which of the following would be your best option - Turbulent blood flow 50. What is the treatment of choice for uncomplicated community acquired cystitis - TMP-SMZ 51. Any pt presenting with symptomatic bradycardia should be referred to a cardiologist - True 52. Encouragement of pts to take effective action in their healthcare refers to the concept of - Self mgmt. support 53. You are considering adding an adjunctive form of testing to detect wall motion abnormalities during the ETT. You select echocardiography as the added testing. You choose this test because you known that echocardiography does what when added to a standard ETT - Enhances sensitivity and specificity of CAD detection 54. Medicaid is mandated to be provided by each state through federal codes. Each state must offer Medicaid exactly as the fed gvmt prescribes -False 55. What sexually transmitted disease is most widespread in the USA today - Chlamydia 56. Your preceptor decides to add doppler flow atudies to the echocardiogram exercise test for a patient with a recent history of a holistic murmur best auscultated at the left sternal border. The patient has no history of cardiac surgeries. He asks you what might be the main advantages of adding doppler flow for this particular patient. You know from your readings that there are several reasons to add doppler flow for this particular patient. Your best response for this specific case, however would be that doppler flow studies would be of what additive value during the echocardiogram study - Detect and evaluate blood shunting from a septal defect 57. Sexual partners of a patient with diagnosed STI should always be examined and treated. Is this true or false - True 58. Your patient presents with tachycardia. The QRS is measured at .10 seconds. Which of the following tachycardias would be an appropriate conclusion based on this information alone - Premature junctional contractions 59. A 65 year old white male arrives in your clinic with general complaints of slight abdominal discomfort. He has a known history of smoking two packs per day for 40 years and hypertension. He also has copd and has been treated numerous times with oral steroids. You consider optimal diagnoses. Of the ones listed below which should be included as a potential top suspect in our choice of diagnosis - Abdominal aortic aneurysm 60. What are the most common mechanisms to produce cardiac arrhythmias - Enhanced automaticity, triggered activity or reentry 61. Patient urinates then has incontinence right after what type of incontinence is this - Answers were overflow, 62. How long should you take TMP-SMZ for uncomplicated UTI - Answers were 3days, 2 days, 7-10 days (I put 7-10d) 63. If someone presents with atrial arrythmia and is stable hemodynamically what intervention will you plan - bb? CCB? 64. What signifies impending AAA rupture - boring pain radiating to legs, 65. Who is at the highest risk with AAA -Male 66. Most common cause of AAA rupture - Trauma, the tension exceeds collagen wall and few other answers (I put the one about tension exceeds ) 67. The two types of AAA are fusiform and saccular.. if you have a bleb on one side what type is this - saccular (pretty sure its saccular) 68. Gives definition and says what does this represent think the answer is veracity, the other didn’t make sense. Mentions about being truthful and honest with patients 69. 70. UTI in 35 year old denies homosexual activities what else will you ask you know this is uncommon is adults younger than 35. I picked heterosexual anal activities… but there were other option cant remember 71. Why is there more prevalence of chlamydia - Picked increase in sexual activities among all populations 72. Who is eligible under Medicaid? -Options were women and children regardless of income and children and women of low income and 2 others but I put the one about regardless of income 73. There is abnormal left ventricle EF without ischemia what does this mean? -I put no CAD the other answers were like impending MI, no diagnostic value for CAD 74. The next questions asks the same questions but says theres evidence of ischemia so I put it indicates CAD 75. Women and CT imaging is limited because of I selected small coronary arteries and breasts 76. 15. #1 leading cause of death in women - Answers heart disease 77. If AAA is 4cm in healthy adult what intervention would you do - Diet, meds, refer to vascular surgeon (I picked refer don’t know if this is correct) 78. What is relative bradycardi - Answer option were HR less than 60 or HR less than 60 with inability to meet body demands or something like that 79. What is the definition of CHF Inability to meet bodies demands 80. Question about pt wanting to start exercise and is obese what test will the provider order - I picked ETT because this was similar to the other question… that one by the way is on there too 81. Drug for ETT - I picked dobutamine 82. 2 common types of ETT - Bicycle and tread 83. Most common cause of systolic HF CAD 84. What indicates a positive Stress test Answers were like decrease in regional wall motion and hyperkinesis 85. You are in the clinic with your mentor observing the echo exercise test of a 45 year old who has been experiencing slight chest pressure almost daily during exercise. While observing your patient your mentor points out that the left ventricle wall is thinning and there is some hyperkinesias of the ventricular wall. From your time in the clinic you know that this test will be what type of result Positive 86. Medicare covers inpatient hospital services under which part of the medicare insurance - Part A 87. Of the answers below which would be included in defining a positive Exercise echocardiogram - Induced decrease in regional wall motion 88. A 35 year old female arrives at your clinic, she has had diabetes and peripheral artery disease for the past 5 years. You decide to obtain an ETT. The insurance company argues that this is appropriate. You justify the ETT because you are planning secondary strategies to prevent future heart disease. Where could one find the supporting data for these guidelines Framingham risk score 89. Medicare hospital insurance is funded through what system - Federal payroll taxes 90. Your patient underwent an exercise stress test for CAD. There is significant elevation of the ST segment. What do you need to know about these changes to manage your patients care -These changes have minimal predictive value for CAD 91. Population disease management is a term used to describe -High prevalence of specific diseases 92. You are counseling a patient diagnosed with stress induced ischemia. You base your discussion on your knowledge that stress induced ischemia is caused by - Endothelial dysfunction of microvascular 93. AAA are often asymptomatic, what percent of AAA are discovered in asymptomatic patient 75% 94. Improvement in the delivery and management of the healthcare are necessary if we are to improve the overall health of this nations population. Which of the following are identified in your readings as strategic in the movement to improve healthcare system - Population management and healthcare practice 95. Your patient is morbidly obese and cannot sit on a bicycle or walk a treadmill. She also has marked and severe emphysems. You need to make an assessment of the risk of significant CAD and your patients family says that their relative had their diagnosis base don an ultrasound echo. What facts would influence your decisions regarding the family request for echo assmnt - Sensitivity would be reduced because of obesity and lung disease 96. Question about where the J point? - Junction between QRS and ST [Show Less]
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