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Chapter 17:
Patient Assessment:
Cardiovascular System
Extra Activity
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Case 1
While caring for a 42-year-old male patient, the patient
complains of fluttering in the chest and feeling dizzy. The
BP is 88/50 with the client lying supine. The respirations
are 20/minute. The temperature is 100 degrees F. The
ECG strip shows:
See Figure 17-29.
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Case 1 Question
The appropriate first action the nurse should take is?
A. Defibrillate according to ACLS guidelines.
B. Provide acetaminophen as ordered.
C. Ask the client to hold his breath and bear down as if he
was having a bowel movement.
D. Assess the client’s lungs because the problem is related
to COPD.
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Answer
C. Ask the client to hold his breath and bear down as if he
was having a bowel movement.
Rationale: The client’s strip is PSVT. The valsalva
manuever may help the dysrhythmia to stop or slow
down to see what the underlying mechanism is- either
atrial or junctional in nature. Although the client has a
fever and can receive acetaminophen, this dysrhythmia is
unrelated to fever. A client with COPD would display
multifocal atrial tachycardia, which would have p waves
with several different shapes. Defibrillation is used to
treat pulseless VT or VF. The doctor needs to be called
for further orders.
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Case 2
The nurse enters the room of a 48-year-old male client
who is admitted with a MI. The client is unresponsive, no
pulse is present, and the ECG monitor shows:
See Figure 17-37.
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Case 2 Question
The nurse should immediately call a code and
A. Take the BP.
B. Perform CPR until the crash cart arrives.
C. Wait until the defibrillator arrives and defibrillate the
client.
D. Provide amiodarone per ACLS guidelines.
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Answer
B. Perform CPR until the crash cart arrives.
Rationale: The client has pulseless VT and is unresponsive.
Until the crash cart arrives complete with a defibrillator,
the nurse must call a code and provide CPR. Once the
cart arrives defibrillate according to ACLS guidelines, and
then go to drugs with CPR according to ACLS guidelines.
If there is no pulse, a BP will not be present either.
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Case 3
A 55-year-old female client is admitted with an anterior
wall MI. The client complains of feeling light-headed. The
BP is 88/50 and the pulse is 60. The patient has no chest
pain. The monitor in the room shows:
See Figure 17-41D.
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Case 3 Question
The nurse decides the client is in
A. Mobitz I Second degree heart block and needs atropine.
B. Mobitz II Second degree heart block and needs atropine.
C. Third-degree heart block and needs a pacemaker.
D. Sinus rhythm with blocked PACs and needs fluids.
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Answer
C. Third-degree heart block and needs a pacemaker.
Rationale: There is no relationship between atrial and
ventricular activity. The atrial activity is regular and the
ventricular activity is regular. This defines this rhythm as
third degree heart block, which is treated by a
pacemaker. The nurse needs to call the physician for
orders, and be prepared in case the patient becomes
more symptomatic- by following ACLS guidelines.
Atropine could be given, but the external pacemaker is a
better choice when a client has third degree heart block.
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Case 4
A client receives a thrombolytic after an anterior wall MI.
The client’s BP is 80/44, and pulse is weak and thready
at 50. The following ECG rhythm is present.
See Figure 17-40.
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Case 4 Question
The nurse recognizes the rhythm as ___ and the treatment
is _____.
A. Ventricular tachycardia; defibrillation
B. Sinus bradycardia with bundle branch block; atropine
C. Atrial fibrillation; cardioversion
D. Accelerated idioventricular rhythm; pacing
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Answer
D. Accelerated idioventricular rhythm; pacing
Rationale: The rhythm has no p waves or fibrillation waves
present. The QRS complexes are wide. There are a
couple of sinus beats present. It is not uncommon that
after tPA is provided that a client will exhibit reperfusion
rhythms, such as episodes of accelerated idioventricular
rhythm. If the client is symptomatic with this rhythm,
then the client will need pacing to increase cardiac
output. The reperfusion rhythms usually are short-lived.
This rhythm is mistaken by some as VT- but tachycardia
is a rhythm > 100.
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Case 5
A 33-year-old client is admitted for surgery and has the
following rhythm on the ECG monitor. The vitals are
stable and the client has no complaints of dizziness, pain,
or discomfort.
See Figure 17-33A.
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Case 5 Question
The rhythm is _____ and the treatment is _______.
A. Sinus rhythm; none
B. Junctional rhythm; search for underlying cause and
treat.
C. Atrial flutter 2:1; ibutilide
D. Junctional rhythm; none
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Answer
B. Junctional rhythm; search for underlying cause and
treat.
Rationale: The p waves are inverted and before the QRS.
The PR < 0.12 sec. The client is going for surgery. The
nurse needs to look for a cause for the junctional
rhythm, such as hypokalemia, or cardiac meds and
correct the situation. Atrial flutter has saw tooth waves
and the PR interval closes to the QRS is normal.
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Case 6
A client presents in the emergency department with a
complaint of a fluttering feeling in her chest. The client
has mitral valve insufficiency. The client’s apical pulse is
60 and her radial pulse is 110. The BP is 110/78. The
monitor shows:
See Figure 17-31.
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Case 6 Question
The nurse recognizes this as _____ and asks three
questions, including how long the client has been in this
rhythm, is there a potential for thromboembolism, and _
A. Sinus rhythm with PACs; what grade is the murmur
B. Sinus rhythm with PJCs; what grade is the mumur
C. Atrial fibrillation; what is the ventricular response
D. Multifocal atrial tachycardia; what is the ventricular
response
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Answer
C. Atrial fibrillation; what is the ventricular response
Rationale: The rhythm is irregular-irregular; QRS WNL;
fibrillatory waves present and ventricular response is
below 100 and client is experiencing palpitations. The
nurse needs to ask how long the client has experienced
the symptoms, and the client will most likely need an
echocardiogram to evaluate for risk for
thromboembolism, and will need anticoagulation to
prevent the risk of thromboembolism. These
considerations need to be met before the possibiliy of
cardioversion by meds or by elective cardioversion is
undertaken.
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Identify the Following ECG Strip
See Figure 17-34.
A. Sinus with PJC
B. Sinus with PAC
C. Sinus with PVC
D. Sinus arrhythmia
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Answer
A. Sinus with PJC
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Question
True or False: This rhythm is VT.
See Figure 17-38.
A. True
B. False
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Answer
B. False
The rhythm is Torsades de Pointe, which is a form of VF. It
is characterized by a twisting of the points, the polarity
changes from positive to negative. The VT is a regular
rhythm.
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Identify the following ECG strip
See Figure 17-36.
A. Sinus with PVC
B. Sinus with R-on-T phenomenon
C. Sinus with biphasic PVC
D. Sinus with PVC couplet
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Answer
B. Sinus with R-on-T phenomenon
Rationale: The PVC is too close to the T wave- ventricular
repolarization (vulnerable period)- could cause V-fib. The
underlying cause needs to be investigated and treated.
This can be caused by certain cardiac meds that have the
potential to lengthen the T wave.
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