SAS 7

1. In a severely anemic patient, you expect to find

 Patients with severe anemia (hemoglobin level, less than 6 g/dL) exhibit the following
cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic
murmurs, intermittent claudication, angina, heart failure, myocardial infarction, tachypnea,
orthopnea, and dyspnea at rest.

2. You are caring for a patient with a diagnosis of iron-deficiency anemia. Which clinical
manifestations are you most likely to observe when assessing this patient?

 Specific clinical manifestations may be related to iron-deficiency anemia. Pallor is the most
common finding, and glossitis (inflammation of the tongue) is the second most common;
another finding is cheilitis (inflammation of the lips). The patient may report headache,
paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in
the tissues. A sore tongue is a sign of cobalamin deficiency. Tenting skin is a sign of
dehydration that often accompanies diarrhea. Blue mucous membranes are associated with
cyanosis.

3. When providing teaching for the patient with iron-deficiency anemia who has been prescribed
iron supplements, you should include taking the iron with which beverage?

 Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also
enhances iron absorption. Milk may interfere with iron absorption. Ginger ale and water do
not facilitate iron absorption.

4. The primary pathophysiology underlying thalassemia is

 Thalassemia is a group of autosomal recessive diseases that involve inadequate production

of normal hemoglobin. Hemolysis also occurs in thalassemia, but insufficient production of
normal hemoglobin is the predominant problem. Erythropoietin deficiency is associated with
a renal disorder, and S-shaped hemoglobin is associated with sickle cell disease.

5. Which individual is at high risk for a cobalamin (vitamin B12) deficiency anemia?

 There are many causes of cobalamin deficiency. The most common cause is pernicious
anemia, a disease in which the gastric mucosa is not secreting intrinsic factor (IF) because of
antibodies being directed against the gastric parietal cells or IF itself. Other causes of
cobalamin deficiency include gastrectomy, gastritis, nutritional deficiency, chronic
alcoholism, and hereditary enzymatic defects of cobalamin use.

6. You encourage the patient with cobalamin deficiency to seek treatment because untreated
pernicious anemia may result in

 Regardless of how much cobalamin is ingested, the patient is not able to absorb it if intrinsic
factor is lacking or if there is impaired absorption in the ileum. For this reason, increasing
dietary cobalamin does not correct the anemia. However, the patient should be instructed
about adequate dietary intake to maintain good nutrition (see Table 31-5). Parenteral
(cyanocobalamin or hydroxocobalamin) or intranasal (Nascobal, CaloMist) administration of
cobalamin is the treatment of choice. Without cobalamin administration, these individuals
will die in 1 to 3 years.
7. The Schilling test for pernicious anemia involves

 Parietal cell function can be assssed with a Schilling test. After radioactive cobalamin is
administered to the patient, the amount of cobalamin excreted in the urine is measured. An
individual who cannot absorb cobalamin excretes only a small amount of this radioactive
form.

8. Which finding allows you to identify the patient's anemia as folic acid deficiency rather than
cobalamin deficiency?

 The absence of neurologic problems is an important diagnostic finding and differentiates

folic acid deficiency from cobalamin deficiency.

9. Which foods should you encourage patients with folic acid deficiency to include in their daily
food intake (select all that apply)?

 Whole-grain foods and beans are high in folic acid.

10. You are evaluating the laboratory data of the patient with suspected aplastic anemia. Which
findings support this diagnosis?

 Because all marrow elements are affected, hemoglobin, WBC, and platelet values are
decreased in aplastic anemia. Other RBC indices usually are normal.

SAS 8

DISCUSSION QUESTION

1. What contributing factors to the development of ISH are present in K.J.?

 Increasing age, which leads to loss of elasticity in large arteries from atherosclerosis, and
more prevalent in women (and in African Americans).

2. What additional risk factors are present?

 High sodium intake from canned foods, sedentary lifestyle, and weight gain.

3. What specific dietary changes would the nurse recommend for K.J.?
 The Dietary Approaches to Stop Hypertension (DASH) eating plan is rich in fresh or frozen
fruits and vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and
nuts. In this eating plan there are less salt and sodium, less sweets, less fat, and less red
meat than in the typical American diet. Increasing activity and losing weight (if necessary) is
encouraged. Increasing calcium, magnesium, potassium, and fiber occurs with the increased
fruits and vegetables.

4. If drug therapy became necessary to treat K.J.’s hypertension, what diuretic would be
indicated based on her laboratory results?
 Because of K.J.'s low potassium level, a potassium-sparing diuretic, such as spironolactone,
amiloride, or triamterine, could be used. If a stronger diuretic were needed, potassium
supplementation would be indicated. If an ACE inhibitor were also needed, the diuretic
would need to be changed related to additional potassium sparing.
 5. Priority Decision: What other priority teaching measures should be instituted by the
nurse?
 The nurse should teach K.J. about regular daily aerobic exercise and weight reduction;
avoiding canned food and reading labels for sodium content; the need for stress
management indicated by weight gain in response to her husband's death and availability of
counseling; the pathology, complications, and management of hypertension; and
medications and the potential of orthostatic hypotension.

6. Priority Decision: Based on the assessment data presented, what are the priority nursing
diagnoses?
 Nursing diagnoses:
Ineffective health maintenance related to increased caloric intake and deficiency of
potassium sources
Ineffective coping related to use of food as coping mechanism
Deficient knowledge related to lack of knowledge of pathology, complications, and
management of hypertension and treatment

Collaborative problems: Potential complications: cerebrovascular accident, MI,

renal failure

MULTIPLE CHOICE

1. What are non-modifiable risk factors for primary hypertension (select all that apply)?
 Hypertension progresses with increasing age. It is more prevalent in men up to age
45 and above the age of 64 in women. African Americans have a higher incidence of
hypertension than do white Americans. Children and siblings of patients with
hypertension should be screened and taught about healthy lifestyles.
2. How is secondary hypertension differentiated from primary hypertension?
 Secondary hypertension has an underlying cause that can often be treated, in
contrast to primary or essential hypertension,which has no single known cause.
3. What is the patient with primary hypertension likely to report?
 Hypertension is often asymptomatic, especially if it is mild or moderate, and has
been called the "silent killer”.
4. A patient with stage 2 hypertension who is taking hydrochlorothiazide (Hydrodiuril) and
lisinopril (Prinivil) has prazosin (Minipress) added to the medication regimen. What is most
important for the nurse to teach the patient to do?
 Hydrochlorothiazide is a thiazide diuretic that causes sodium and potassium loss
through the kidneys. High-potassium foods should be included in the diet or
potassium supplements should be used to prevent hypokalemia. Enalapril and
spironolactone may cause hyperkalemia by inhibiting the action of aldosterone and
potassium supplements should not be used by patients taking these drugs.
5. A 38-year-old man is treated for hypertension with triamterene and hydrochlorothiazide
(Maxzide) and metoprolol (Lopressor). Four months after his last clinic visit, his BP returns
to pretreatment levels and he admits he has not been taking his medication regularly.
What is the nurse’s best response to this patient?
 Other heart medicines called beta-blockers have a small risk of ED. These include
popular drugs like metoprolol (Lopressor), atenolol (Tenormin), propranolol (Inderal)
and bisoprolol (Zebeta). If you're having ED and take one of these medications, it's
not all bad news. Thiazides at high doses (eg, ≥ 50 mg hydrochlorothiazide) can
 contribute to ED. Lower thiazide doses, more common in the treatment of
hypertension, are less likely to cause ED. However, reducing the hydrochlorothiazide
dose to 12.5 mg daily, or withdrawing the drug completely, could be tried.
6. A 78-year-old patient is admitted with a BP of 180/98 mm Hg. Which age-related physical
changes may contribute to this patient’s hypertension? (Select All That Apply)
 The age-related changes that contribute to hypertension include decreased renal
function, increased peripheral vascular resistance, increased collagen and stiffness
of the myocardium, and decreased elasticity in large arteries from arteriosclerosis.
7. What should the nurse emphasize when teaching a patient who is newly prescribed
clonidine (Catapres)?
 Do not stop taking clonidine without talking to your doctor. If you suddenly stop
taking clonidine, it can cause a rapid rise in your blood pressure and symptoms such
as nervousness, headache, and uncontrollable shaking of a part of the body.
8. What is included in the correct technique for BP measurements?
 When the BP is taken, the cuff should be inflated to a pressure approximately 30
mmHg greater than systolic, as estimated from the disappearance of the pulse in the
brachial artery by palpation. Initial estimation of the systolic pressure by palpation
avoids potential problems with an auscultatory gap.
9. Which manifestation is an indication that a patient is having a hypertensive emergency?
 Signs and symptoms of a hypertensive crisis that may be life-threatening may
include: Severe chest pain. Severe headache, accompanied by confusion and blurred
vision. Nausea and vomiting.
10. During treatment of a patient with a BP of 222/148 mm Hg and confusion, nausea, and
vomiting, the nurse initially titrates the medications to achieve which goal?
 Decrease the mean arterial pressure (MAP) to 129. In hypertensive emergencies
initial treatment is to reduce MAP by 20 to 25% in the first hour. Lowering the BP
too fast can cause stroke or MI or renal failure.

SAS 9

DISCUSSION QUESTION

1. What are H.C.’s risk factors for CAD?

 Diabetes, smoking history, physical inactivity, and stress response.
2. What symptoms should lead the nurse to suspect the pain may be angina?
 Unexplained fatigue; radiation of the burning from epigastric area into the sternum;
and prior episodes of chest pain with activity, relieved by rest; anxiety with fist
clenching.
3. What nursing actions should be taken for H.C.’s discomfort?
 Provide emotional support and explain all interventions and procedures. Position
her in an upright position, apply oxygen per nasal cannula, obtain vital signs, start
continuous ECG monitoring, auscultate heart and breath sounds, assess pain using
PQRST, medicate as ordered, and obtain baseline laboratory values and a chest x-
ray.
4. What kind of ECG changes would indicate myocardial ischemia?
 Depressed ST-segment and/or T wave inversion would show myocardial ischemia.
 5. What information should the nurse provide for H.C. before the treadmill testing?
 The nurse should inform H.C. that she will have continuous cardiac monitoring while
she walks on a treadmill with increasing speed and elevation to evaluate the effects
of exercise on the blood supply to her heart. Her pulse, respiration, BP, and heart
rhythm will be measured while she walks and after the test until they return to
normal, and the cardiac monitor will be used after the test until any changes return
to normal.
6. What is the priority nursing measures that should be instituted to help H.C. decrease her
risk factors?
 This patient does not seem motivated to assume responsibility for her health and, in
the absence of symptoms, has not had a desire to make lifestyle changes. First, the
nurse should assist her to clarify her personal values and goals. Then, by explaining
the symptoms related to her risk factors and having her identify her personal
vulnerability to various risks, the nurse may help her recognize her susceptibility to
CAD. Help the patient set realistic goals and allow her to choose which risk factor
(smoking, activity level, diabetes management, or stress response) to address first.
7. Based on the assessment data presented, what are the priority nursing diagnoses?
 Nursing diagnoses
• Acute pain; Etiology: imbalance between myocardial oxygen supply and demand
• Anxiety; Etiology: diagnosis and uncertain future
• Overweight; Etiology: lack of physical activity
• Difficulty coping; Etiology: lack of effective coping skills
• Hyperglycemia; Etiology: history of Type 2 diabetes, increased glucose level
• Substance abuse; Etiology: history of smoking 1 pack per day, 27 years
• Lack of knowledge: Etiology: management of coronary artery disease Collaborative
problems Potential complications: myocardial infarction, dysrhythmias

MULTIPLE CHOICE

1. Which patient is most likely to be in the fibrous stage of development of coronary artery
disease (CAD)?
 The fibrous plaque stage has progressive changes that can be seen by age 30.
Collagen covers the fatty streak and forms a fibrous plaque in the artery. The
thrombus adheres to the arterial wall in the complicated lesion stage. Rapid onset of
coronary artery disease (CAD) with hypercholesterolemia may be related to familial
hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the
earliest stage of atherosclerosis and can be seen by age 15.
2. What accurately describes the pathophysiology of CAD?
 The etiology of CAD includes atherosclerosis as the major cause. The
pathophysiology of atherosclerosis development is related to endothelial chemical
injury and inflammation, which can be the result of tobacco use, hyperlipidemia,
hypertension, toxins, diabetes mellitus, hyperhomocysteinemia, and infection
causing a local inflammatory response in the inner lining of the vessel walls. Partial
or total occlusion occurs in the complicated lesion stage. Extra collateral circulation
occurs in the presence of chronic ischemia. Therefore it is more likely to occur in an
older patient
3. While obtaining patient histories, which patient does the nurse identify as having the
highest risk for CAD?
  This white woman has one unmodifiable risk factor (age) and two major modifiable
risk factors (hypertension and physical inactivity). Her gender risk is as high as a
man's because she is over 65 years of age. The white man has one unmodifiable risk
factor (gender), one major modifiable risk factor (smoking), and one minor
modifiable risk factor (stressful lifestyle). The Asian woman has only one major
modifiable risk factor (hyperlipidemia) and Asians in the United States have fewer
myocardial infarctions (MIs) than do whites. The African American man has an
unmodifiable risk factor related to age and one major modifiable risk factor
(obesity).
4. Priority Decision: While teaching women about the risks and incidence of CAD, what does
the nurse emphasize?
 CAD is the number-one killer of American women and women have a much higher
mortality rate within 1 year following MI than do men. Smoking carries specific
problems for women because smoking has been linked to a decrease in estrogen
levels and to early menopause and it has been identified as the most powerful
contributor to CAD in women under the age of 50. Fewer women than men present
with classic manifestations and women delay seeking care longer than men. Recent
research indicates that estrogen replacement does not reduce the risk for CAD, even
though estrogen lowers low-density lipoprotein (LDL) and raises high-density
lipoprotein (HDL) cholesterol.
5. Which characteristics are associated with LDLs (select all that apply)?
 LDLs contain more cholesterol than the other lipoproteins, have an attraction for
arterial walls, and correlate most closely with increased incidence of atherosclerosis
and CAD. HDLs increase with exercise and carry lipids away from arteries to the liver
for metabolism. A high HDL level is associated with a lower risk of CAD.
6. Which serum lipid elevation, along with elevated LDL, is strongly associated with CAD?
 Elevated fasting triglyceride levels are associated with cardiovascular disease and
diabetes. Apolipoproteins are found in varying amounts on the HDLs and activate
enzyme or receptor sites that promote removal of fat from plasma, which is
protective. The apolipoprotein A and apolipropotein B ratio must be done to predict
CAD. Elevated HDLs are associated with a lower risk of CAD. Elevated total serum
cholesterol must be calculated with HDL for a ratio over time to determine an
increased risk of CAD.
7. Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen
supply. What factors and disorders result in increased oxygen demand (select all that
apply)?
 Increased oxygen demand is caused by increasing the workload of the heart,
including left ventricular hypertrophy with hypertension, sympathetic nervous
stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed
coronary arteries contribute to decreased oxygen supply
8. What causes the pain that occurs with myocardial ischemia?
 When the coronary arteries are occluded, contractility ceases after several minutes,
depriving the myocardial cells of glucose and oxygen for aerobic metabolism.
Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial
nerve fibers that then transmit a pain F to the cardiac nerves and upper thoracic
posterior roots. The other factors may occur during vessel occlusion but are not the
source of pain.
9. What types of angina can occur in the absence of CAD (select all that apply)?
  Prinzmetal's angina and microvascular angina may occur in the absence of CAD but
with arterial spasm in Prinzmetal's angina or abnormalities of the coronary
microcirculation. Silent ischemia is prevalent in persons with diabetes mellitus and
contributes to asymptomatic myocardial ischemia. Nocturnal angina occurs only at
night. Chronic stable angina refers to chest pain that occurs with the same pattern of
onset, duration, and intensity intermittently over a long period of time
10. Which characteristics describe unstable angina (select all that apply)?
 Unstable angina is unpredictable and unrelieved by rest and has progressively
increasing severity. Chronic stable angina is usually precipitated by exertion. Angina
decubitus occurs when the person is recumbent. Prinzmetal's angina is frequently
caused by a coronary artery spasm.