Proctored Cardiac and Respiratory

Correct Answers

B. Shortness of breath

F. Exertional fatigue

Explanation

Atrial fibrillation is an irregular heart rhythm that can lead to ineffective cardiac output and poor perfusion. Symptoms result from reduced blood flow and oxygenation to vital organs.

B. Shortness of Breath 

This occurs because atrial fibrillation can lead to decreased cardiac output, causing pulmonary congestion and difficulty breathing. Blood can back up into the lungs, resulting in shortness of breath, especially with exertion or at rest in more severe cases.

F. Exertional Fatigue

Atrial fibrillation reduces the heart’s efficiency in pumping oxygen-rich blood to the body. This leads to fatigue, particularly during physical activity, because muscles and tissues are not receiving adequate oxygenation.

Why the Other Options Are Incorrect

A. Hiccups

Hiccups are not a common symptom of atrial fibrillation. They are more commonly linked to gastrointestinal issues, phrenic nerve irritation, or electrolyte imbalances.

C. Difficulty Swallowing 

Difficulty swallowing is not directly related to atrial fibrillation. This symptom is more commonly associated with stroke, which can be a complication of atrial fibrillation, esophageal disorders, or neurological conditions.

D. Increased Urination 

Atrial fibrillation does not directly cause increased urination. Increased urination may occur in heart failure, which can develop due to long-term atrial fibrillation, but it is not a primary symptom.

E. Weight Gain

Weight gain is not a direct symptom of atrial fibrillation. However, fluid retention or edema can occur if atrial fibrillation progresses to heart failure, but this is a secondary complication rather than a primary symptom.

Summary

A nurse teaching a client about symptomatic atrial fibrillation should include shortness of breath and exertional fatigue as key manifestations. These symptoms occur due to poor cardiac output and decreased oxygenation. Other options such as hiccups, difficulty swallowing, increased urination, and weight gain are not primary symptoms of atrial fibrillation.

Correct Answer: A. Pulmonary embolism

Rationale:

A pulmonary embolism (PE) occurs when a blood clot (thrombus), usually from a deep vein thrombosis (DVT) in the leg, travels to the lungs and blocks a pulmonary artery. This can lead to:

Sudden shortness of breath (dyspnea)

Chest pain that worsens with breathing (pleuritic pain)

Tachycardia and hypoxia

Coughing, sometimes with blood (hemoptysis)

PE is a medical emergency because it can cause respiratory distress, heart strain, and death if untreated.

Why the Other Options Are Incorrect:

B. Chronic bronchitis: A form of chronic obstructive pulmonary disease (COPD) caused by long-term inflammation and mucus production, not a sudden blockage of a pulmonary artery.

C. Asthma: A chronic inflammatory disease of the airways causing bronchoconstriction, wheezing, and shortness of breath, but it does not involve a blood clot.

D. Tuberculosis (TB): A bacterial infection caused by Mycobacterium tuberculosis, leading to chronic cough, night sweats, and weight loss, but not a sudden blockage of an artery.

Key Takeaway:

A pulmonary embolism (PE) is a life-threatening emergency caused by a blood clot blocking a pulmonary artery, leading to sudden respiratory distress and chest pain.

Correct Answer: A. Control fluid balance

Explanation:

Heart failure exacerbations in older adults are most commonly triggered by fluid overload, leading to symptoms such as shortness of breath, swelling in the legs, and weight gain. Controlling fluid balance is the primary goal to prevent hospital readmissions. This includes adhering to prescribed diuretics, monitoring daily weight, restricting sodium intake, and educating patients on early warning signs of fluid retention. Proper fluid management reduces congestion in the lungs and prevents worsening heart failure symptoms, which significantly decreases the frequency of hospitalizations.

Why the Other Options Are Incorrect:

B. Control blood pressure

While managing hypertension is important in preventing heart failure progression, it is not the most immediate concern in reducing hospitalizations due to acute exacerbations. Many patients with heart failure already experience low or fluctuating blood pressure, making fluid balance a higher priority in acute management. Blood pressure control is a long-term strategy for heart failure management, but it does not directly prevent acute decompensations that lead to hospitalization.

C. Prevent deconditioning

Deconditioning, or muscle weakening due to inactivity, is a concern in chronic heart failure management, but it is not the primary cause of hospital admissions. Encouraging activity is important for overall well-being, but patients experiencing acute heart failure symptoms often need to prioritize fluid balance before engaging in physical activity. Fluid overload causes breathlessness and fatigue, making exercise difficult; thus, addressing fluid retention first is essential before focusing on physical activity.

D. Maintain patient safety

Ensuring patient safety is always a priority, but it does not directly reduce hospitalizations for heart failure exacerbations. Safety concerns, such as fall prevention and medication adherence, are important in general care but do not target the primary issue causing acute exacerbations, which is fluid overload. Managing fluid balance has a more direct impact on hospital admission rates than general safety measures.

Summary:

The most important goal in reducing hospitalizations for heart failure exacerbations in older adults is controlling fluid balance. Fluid retention leads to worsening symptoms, pulmonary congestion, and hospital admissions. Managing fluid balance through diuretics, sodium restriction, daily weight monitoring, and patient education is the most effective strategy to prevent acute decompensations. While blood pressure control, physical activity, and patient safety are important, they do not directly address the main cause of frequent hospitalizations, which is fluid overload. Therefore, controlling fluid balance is the most critical nursing intervention for reducing hospital readmissions in older adults with heart failure.

Correct Answer: A. Bathe and eat slowly with periodic rest.

Rationale:

Patients with COPD experience dyspnea (shortness of breath) and fatigue, which can make self-care activities challenging. Pacing activities and incorporating rest periods helps conserve energy and prevents excessive oxygen demand. Eating slowly reduces the risk of breathlessness, and bathing at a relaxed pace prevents overexertion.

Why the Other Options Are Incorrect:

B. Walk short distances without oxygen.

If the patient requires supplemental oxygen, it should not be discontinued. Walking without oxygen could lead to hypoxia, causing dizziness, fatigue, or respiratory distress.

C. Perform all activities of daily living (ADLs) and then rest.

 Performing all ADLs in one go can cause excessive fatigue and breathlessness. It is better to spread activities throughout the day with rest periods to prevent exhaustion.

D. Bathe right after eating, and then rest.

 Bathing immediately after eating can increase oxygen demand, leading to breathlessness. Resting before and after activities is a better approach.

Key Takeaway:

Patients with COPD should pace activities, take rest breaks, and perform self-care slowly to conserve energy and avoid worsening symptoms. Option A is the best choice.

Correct Answer: C. Avoid sick people and wash hands

Explanation:

The most important patient teaching for preventing hospitalizations due to COPD exacerbations is infection prevention, which includes avoiding sick people and practicing good hand hygiene. Respiratory infections, particularly viral and bacterial infections, are the leading cause of COPD exacerbations, often leading to increased inflammation, mucus production, and airway obstruction. Hospitalizations for COPD exacerbations are most commonly triggered by respiratory infections such as the flu, pneumonia, or bronchitis. Encouraging patients to get vaccinated against influenza and pneumonia, maintain proper handwashing habits, and avoid crowded areas or sick individuals significantly reduces their risk of acquiring infections. Early recognition of symptoms, such as increased cough, shortness of breath, or sputum production, is also critical in preventing complications.

Why the Other Options Are Incorrect:

A. Ease breathing by sitting upright

Sitting upright can help ease breathing by improving lung expansion, but it does not directly prevent COPD exacerbations or hospitalizations. While positioning is useful for symptom management, it does not address the root cause of most exacerbations, which is infection or exposure to environmental triggers.

B. Use low-flow oxygen for dyspnea

Oxygen therapy is important for COPD patients with chronic hypoxemia, but it is not the primary measure for preventing hospitalizations. Not all COPD patients require oxygen therapy, and improper use can lead to CO₂ retention, which can worsen respiratory distress. While oxygen helps manage symptoms, it does not prevent the occurrence of exacerbations, which are mainly caused by infections and environmental factors.

D. Eat nutrient- and calorie-dense foods

Proper nutrition is essential for maintaining energy levels and preventing muscle wasting, but it does not directly prevent COPD exacerbations. Malnutrition can worsen COPD outcomes, but infection control remains the most critical factor in reducing hospitalizations. Encouraging a balanced diet supports overall health but does not replace the need for infection prevention strategies.

Summary:

The most important strategy to prevent COPD exacerbations and hospitalizations is infection prevention. Avoiding sick people, practicing good hand hygiene, and receiving vaccinations significantly reduce the risk of respiratory infections, which are the leading cause of COPD exacerbations. While upright positioning, oxygen therapy, and proper nutrition are all beneficial for managing COPD, they do not directly prevent hospitalizations caused by acute exacerbations. Therefore, the priority teaching for discharge is infection prevention through avoiding exposure to sick individuals and frequent handwashing.

Correct Answer: C. Baroreceptor function diminishes with age.

Rationale:

Baroreceptors are pressure-sensitive receptors located in the carotid arteries and aortic arch that help regulate blood pressure and heart rate by adjusting vascular tone. With aging, baroreceptor sensitivity declines, leading to impaired blood pressure regulation, especially during sudden postural changes or after exercise. Skipping the cool-down phase causes a rapid drop in heart rate and blood pressure, which can lead to post-exercise hypotension and syncope (fainting) due to poor baroreceptor response.

Why the Other Options Are Incorrect:

A. Cardiac output diminishes with age.

 While cardiac output may decrease with aging, it does not directly explain why skipping a cool-down causes fainting. Baroreceptor dysfunction is the primary cause of post-exercise syncope in older adults.

B. Mobility capacity decreases with age.

 Although mobility decreases with aging, it is not a direct cause of fainting after skipping the cool-down phase.

D. Sensory perception diminishes with age.

While aging can lead to decreased sensory perception, this does not cause post-exercise syncope. The primary issue is baroreceptor dysfunction, not sensory impairment.

Key Takeaway:

Older adults should gradually decrease their heart rate and blood pressure through a proper cool-down phase to prevent post-exercise hypotension and syncope caused by age-related baroreceptor dysfunction (Option C).

Correct Answer: C. Pericarditis

Rationale:

Pericarditis is the inflammation of the pericardium, the thin, double-layered membrane surrounding the heart. It can be caused by viral infections, bacterial infections, autoimmune disorders, myocardial infarction (Dressler’s syndrome), or chest trauma.

Common Symptoms of Pericarditis:

Sharp, pleuritic chest pain (worse with inspiration or lying flat, relieved by sitting up and leaning forward)

Pericardial friction rub (high-pitched, scratchy sound heard with a stethoscope)

ST-segment elevations in multiple ECG leads (without reciprocal changes)

Fever and tachycardia in infectious cases

Why the Other Options Are Incorrect:

A. Endocarditis

Inflammation of the endocardium (inner lining of the heart), usually due to bacterial infection (infective endocarditis). Symptoms: Fever, heart murmurs, Janeway lesions, Osler’s nodes, Roth spots.

B. Myocarditis

Inflammation of the myocardium (heart muscle), often due to viral infections. Symptoms: Fatigue, chest pain, arrhythmias, heart failure symptoms.

D. Cardiomyopathy

Disease of the heart muscle causing weakened cardiac function. Symptoms: Heart failure, dyspnea, arrhythmias, fluid retention.

Key Takeaway:

​​​​​​​Pericarditis is inflammation of the pericardial sac, typically causing pleuritic chest pain relieved by sitting up and a pericardial friction rub on auscultation. It requires NSAIDs, colchicine, or corticosteroids, and in severe cases, pericardiocentesis if there is a pericardial effusion leading to tamponade.

Correct Answer: B. Decrease heart rate

Rationale:

Beta-blockers work by blocking beta-adrenergic receptors, specifically beta-1 receptors in the heart. This leads to:

Decreased heart rate (negative chronotropic effect)

Reduced myocardial contractility (negative inotropic effect)

Lowered blood pressure due to decreased cardiac output

Beta-blockers are commonly used for hypertension, angina, heart failure, and arrhythmias. Examples include metoprolol, atenolol, and propranolol.

Why the Other Options Are Incorrect:

A. Increase heart rate: Beta-blockers do the opposite; they reduce heart rate by blocking sympathetic stimulation.

C. Increase blood pressure: Beta-blockers lower both heart rate and blood pressure, making this choice incorrect.

D. Increase cardiac output: Beta-blockers reduce cardiac output by decreasing heart rate and contractility, so this answer is incorrect.

Key Takeaway:

Beta-blockers slow the heart rate and lower blood pressure, making them effective for treating hypertension and heart-related conditions.

Correct Answer: D. Petechiae and ecchymosis

Rationale:

Aplastic anemia is a condition in which the bone marrow fails to produce enough red blood cells, white blood cells, and platelets, leading to pancytopenia (a deficiency of all three blood cell types). Due to low platelet counts (thrombocytopenia), clients often experience increased bleeding tendencies, including:

Petechiae (small, pinpoint hemorrhages)

Ecchymosis (bruising)

Prolonged bleeding from minor cuts or injuries

Additionally, low white blood cell counts (leukopenia) increase the risk of infections, and low red blood cell counts (anemia) can cause fatigue, pallor, and shortness of breath.

Why the Other Options Are Incorrect:

A. Plethoric appearance of facial skin

A plethoric (reddened or flushed) facial appearance is associated with polycythemia vera, a condition characterized by excessive red blood cell production, not aplastic anemia.

B. Glossitis and weight loss

Glossitis (inflamed, swollen tongue) and weight loss are symptoms of iron deficiency anemia or vitamin B12 deficiency anemia, rather than aplastic anemia.

C. Jaundice with an enlarged liver

Jaundice and hepatomegaly (enlarged liver) are more commonly seen in hemolytic anemias, where red blood cells are destroyed too quickly, leading to excess bilirubin production. Aplastic anemia results from bone marrow failure, not excessive RBC destruction.

Key Takeaways:

Aplastic anemia is characterized by pancytopenia, leading to:

Petechiae, ecchymosis, and increased bleeding tendencies (due to thrombocytopenia)

Fatigue and pallor (due to anemia)

Frequent infections (due to leukopenia). Thus, the correct answer is petechiae and ecchymosis.