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Simulation          Scenario Identify the Top 3 client areas...

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Simulation          Scenario Identify the Top 3 client areas...






ScenarioIdentify the Top 3 client areas for the nurse to assess.

It is midmorning on the cardiac unit where you work, and you are getting a new patient.  G.P. is a 60-year-old retired businessman who is married and has 3 grown children.  As you take his health history, he tells you that he began feeling changes in his chest about 10 days ago.  He has hypertension (HTN) and a 3-year history of angina pectoris.  During the past week, he has had frequent episodes of mid-chest discomfort.  The chest pain responds to nitroglycerin (NTG), which he has taken sublingually about 8 to 10 times over the past week.  During the week, he has also experienced increased fatigue. He states, "I just feel crappy all the time." 

A cardiac catheterization done several years ago revealed 50% stenosis of the right coronary artery and 50% stenosis of the left anterior descending coronary artery. 

He tells you that both his mother and his father had coronary artery disease (CAD). 

He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. 

He is retired and says that he spends his days watching television, with some occasional yard work. He has gained 25 lb. (11.3 kg) since retiring and admits that he is overweight.

















Next GEN NCLEX: What matters most?  Noticing, Tanner's Clinical Judgement model


1. What other information are you going to obtain about his episodes of chest pain? This client has so much gone on, he has history of cardia problem for the past 10years, and he went through cardiac catheterization because of his artery stenosis. He also has past history of angina and hypertension which all if these can lead to cardiac issues and will link with his current condition.  I will ask this client some question such as if he has any uncomfortable pressure in his chest or have squeezing in chest lasting more time. I will also ask if he feel any worsen pain with activity such exercise. This question will help analysis what type of angina his face with. The duration and frequency of each chest pain if very vital. Since there are two type of angina, stable and unable angina, unstable show impending cardiac arrest while stable happen when exertion and will relief with rest or sublingual nitro. We the above information this client can receive appropriate care. 


2. What are common sites for radiation of ischemic cardiac pain? This pain can radiate to upper arm, shoulder, back, neck and jaw along with chest pain. 



3. There are several risk factors for coronary artery disease. For each risk factor listed, mark whether it is "M" modifiable or "N" non-modifiable.  

4. Based on the history you have so far, circle the modifiable and non-modifiable risk factors in Question 3 that apply to G.P.

a. ___ Age - N

b. ___ Stress - M

c. ___ Gender -N

d. ___ Obesity  -M

e. ___ Smoking 

f. ___ Hypertension - N

g. ___ Hyperlipidemia 

h. ___ Diabetes mellitus 

i. ___ Physical inactivity - M

j. ___ Ethnic background 

k. ___ Excessive alcohol use 

l. ___ Family history of CAD -N

5. Although the client has had a prescription for sublingual nitroglycerin (SL NTG) for a long time, the nurse wants to be certain he is using the medication correctly.  Which actions are correct when taking SL NTG for chest pain? Select all that apply.   What is the rationale for each answer- add comment in for each correct action?


a. Call 911 immediately.  He can be transported to the hospital for further evaluation 

b. Stop the activity and lie or sit down. When activity stop will allow the chest to relax and reduce the pain or discomfort of heaviness, tightness in the heart.

c. Chew the tablet slowly then swallow.  Nitro should not be chewed, crushed, or swallowed.  

d. Place the NTG tablet under the tongue. place under tongue and work faster when is absorbed through the lining of the mouth. 

e. Call 911 if the pain is not relieved after taking 1 SL tablet. This indicate that it may not work to treat chest pain further evaluation is needed

f. Call 911 if the pain is not relieved after taking 3 SL tablets, 5 minutes apart.   For the Doc to further evaluate and probably unstable angina is pending which can lead to heart attack.


6. The nurse reviews the use and storage of SL NTG with G.P.  Which statement by G.P. indicates a need for further education? Explain your answer next to your answer selection.


a. "I carry the tablets with me at all times." Nitro is to be store at a room temperature, carrying it with you at all times could expose this med to light and cause it to lose his potency when come intact with substance that is not made for it.

b. "I will keep the pills in their original brown bottle." 

c. "I will not store other pills in the nitroglycerin bottle."

d. "I will discard any open bottle of nitroglycerin after a year." 



Case Study Progress

When you first admit G.P., the nurse places the client on telemetry and observes his cardiac rhythm. The rhythm has periods of faster rates than below.


8. Identify the rhythm: (6 second strip) after answering the questions below to analyze the rhythm.

  • Rate: What is the rate?  Rate count the number of QRS complexes in a 6-second strip, then               multiply that number by 10


  • Regularity: Is the rate regular or irregular? Measure regularity using R waves.
  • P-Wave examination: Is there a P wave before each QRS? No there is P-wave in the below strip
  • P to R interval: Measure P to R interval, is it within normal limits? Is it consistent?
  • QRS width: Is the QRS narrow or wide? Measure the duration of the QRS complex.


  • What is the rhythm?  Is irregular
  • What are the nurse's top 3 responses once the rhythm is confirmed? Medication,




9. Explain the primary complication that could occur if this heart rhythm were not treated. 





10. Review G.P.'s history. What conditions may have contributed to the development of this dysrhythmia?




11. The nurse reviews G.P.'s lab test results and notes that all of them are within normal range, including troponin and creatinine phosphokinase levels.  His potassium level is 4.9 mEq/L.  Given this and his current dysrhythmia, what is the likely cause of the symptoms he has been experiencing this past week? 





Case Study Progress

Within the hour, G.P. converts with intravenous diltiazem (Cardizem) to sick sinus syndrome with long sinus pauses that cause lightheadedness and hypotension.  Sick sinus syndrome is the inability of the heart's natural pacemaker (sinus node) to create a heart rate that's appropriate for the body's needs. It causes irregular heart rhythms (dysthymias).



12. What risks does the new rhythm pose for G.P.? Explain the reasons for your answers





Case Study Progress

Because G.P.'s dysrhythmia is causing unacceptable symptoms, he is taken to surgery and a permanent DDDR pacemaker is placed and set at a rate of 70beats per minute (BPM). 


13. What does the code DDDR mean?




14. What is the purpose of DDDR pacing? 




15. The pacemaker insertion surgery places G.P. at risk for several serious complications.  List 3 potential problems you would monitor when caring for him.




16. G.P. will need some education regarding his new pacemaker.  What information will you give him before he leaves the hospital? 



18. Describe the teach-back process and the top 3 priorities on living with a pacemaker?



19. G.P. and his wife tell the nurse they have heard that people with pacemakers can have their hearts stop because of microwave ovens and cell phones. Where can you help them find more information?  Name 3 resources.



Case Study Progress

After discharge, G.P. is referred to a cardiac rehabilitation center to start an exercise program.  He will be exercise tested, and an individualized exercise prescription will be developed for him, based on the results of the exercise test.  (NG NCLEX What outcomes demonstrate interventions are working(Reflecting)



20. What information will be obtained from a graded exercise (stress) test?  




21. What is included in an exercise prescription? 



Case Study Outcome

G.P. returns in 1 month for a pacemaker check.  He reports that he and his wife go for a walk at least 3 times a week at the mall, and he is hoping to start volunteering soon. He has lost 8 lbs. (3.6 kg).


Harding and Snyder: Perfusion CS 5 ACS, Dysrhythmia and pacemaker

Reflecting/Analysis Compare and contrast the assessment and care among the dysrhythmias.

Using the information including this case, compare and contrast the findings, treatment and care among the dysrhythmias. (NG NCLEX What could it mean? (Noticing/Analyzing).

Example: Under sinus bradycardia, you would check off bradycardia because bradycardia is an assessment finding for this dysrhythmia. 


 Client Assessment Findings (above)Sinus bradycardiaAtrial fibrillation (AF)Ventricular Tachycardia


Chest Pain

Clammy skin

Consciousness change



Pulse +1 


What else would you assess for each rhythm?

 Best treatment (medications)1.1.




Name Top 2 nursing interventions for each






















ScenarioIdentify the Top 3 client areas for the nurse to assess.

An 89-year-old female client is admitted to a telemetry unit with a diagnosis of heart failure exacerbation.  She reports a medical history of osteoarthritis, chronic renal insufficiency, and coronary artery disease including a myocardial infarction and coronary artery bypass surgery 22 years ago.  She is alert and her daughter is at her bedside.  The nurse's initial client assessment findings include:

  • Oriented to person only, follows simple commands
  • Clear speech
  • Sinus tachycardia
  • Respirations of 26 breaths/min
  • Oxygen saturation of 90% on room air
  • Breathing labored with use of accessory muscles
  • Productive cough with pink frothy sputum
  • Crepitus in bilateral knee joints
  • Enlarged body nodes on hands
  • Hemoglobin = 12.4 g/dL
  • Hematocrit = 39%
  • White blood cell count = 12, 000 mm3

















Next GEN NCLEX: What matters most?  Noticing, Tanner's Clinical Judgement model


  1. Indicate which nursing action listed on the far-left column is appropriate for each potential heart failure complication.  Note that not all actions will be used, but there is only one appropriate action for each complication, and they can be used only once.




Case Study Progress

The 80-year-old client will be discharged today and will move in with her daughter until she feels well enough to go home alone.  Which of the following discharge instructions will the nurse provide the client and her daughter? Select all that apply

  1. "Weight yourself each day at the same time on the same scale to monitor for fluid retention"
  2. Contact your primary health care provider if you experience cold symptoms lasting more than 3 days."
  3. Exertion can cause another episode of heart failure, so help your mother by assisting her with daily activities."
  4. Notify your primary health care provider if you experience shortness of breath or chest pain while resting."
  5. "Do not use table salt, avoid salty foods, and read labels on all food items to ensure your diet is low in sodium."
  6. "Do not take metoprolol if your heart rate is less than 60 beats per minute."
  7. "Heart failure is a chronic condition, so you don't need to be alarmed when you experience heart palpitations."


Case Study Progress

The client was discharged 2 weeks ago and is with her daughter for her follow up primary health care provider visit.  For each assessment finding, use an X to indicate whether the interventions are Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).


Assessment findingEffectiveIneffectiveUnrelated
States that she has had no shortness of breath since hospital discharge   
Has 2+ pitting edema in both ankles and feet   
Blood pressure of 134.76 mm Hg   
Has had no chest pain since hospital discharge   
Reports feeling like she has more energy now when compared with before her hospital stay   
Has new onset fungal skin infection    






ScenarioIdentify the Top 3 client areas for the nurse to assess.
A 72-year-old male client is admitted to a telemetry unit after a fall at home.  The clients is experiencing severe weakness in his lower extremities and states, "I got out of bed at 0430 this morning, my legs gave out on my way to the bathroom, and I was unable to get up."  Emergency medical services transported the client to the hospital.  Past medical history provided by the client includes high cholesterol, aortic valve stenosis, and residual lower extremity muscle pain and weakness secondary to poliomyelitis as a child.  He saw his cardiologist and had an echocardiogram completed 3 weeks ago.   He also received his influenza and pneumococcal vaccines this year.  The client is married and has two adult children.  He lives in a single-story home, ambulates with a cane, and completes ADLs independently.  His echocardiogram reports moderate heart failure with an ejection fraction (EF) of 38%.  The client's wife provides a list of his current medications, but the list is not complete.  Choose the most likely options for the information missing from the paragraph by selecting from the lists of options provided.














Next GEN NCLEX: What matters most?  Noticing, Tanner's Clinical Judgement model



MedicationDose, Route, FrequencyDrug ClassIndication
aspirin1SalicylatePrevention of platelet aggregation
Atorvastatin20 mg orally once a dayStatin2
312.5 mg orally twice a dayBeta-adrenergic blockerManagement of hypertension and heart failure
Ibuprofen400 mg orally every 6-8 hr as neededNonsteroidal anti-inflammatory drug4
50.125 mg orally once a dayCardiac glycosideIncrease myocardial contractile force
lisinopril2.5 mg orally once a day6Management of heart failure


Options for 1Options for 2Options for 3
0.25 mg orally twice a dayManagement of anginacarvedilol
81 mg orally every 4-5 hr as needed for painTreatment of bronchospasmhydrochlorothiazide
200 mg subcutaneously every 8 hoursManagement of heart failurefurosemide
325 mg orally once a dayManagement of hyperlipidemianesiritide
1000 mg transdermal patch every 2 daysPrevention of pulmonary hypertensionverapamil
Options for 4                   Option for 5Option for 6
Treatment for decreased cardiac outputenalaprilAldosterone antagonist
Prevention of dyspneaspironolactoneAngiotensin-converting enzyme inhibitor
Management of extremity paindigoxinCalcium channel blocker
Treatment of pyrexialosartanHistamine blocker
Prevention of tachycardiametroprololThiazide diuretic

Case Study Progress

After the medication reconciliation with the patient's wife, the nurse perform the initial assessment.  The nurse's findings include:

  • Alert and oriented
  • Blurred vision
  • Reports lower extremity stiffness; Ambulates with crutches
  • Sinus rhythm with preventricular contractions (PVCs); Cardiac murmur
  • Reports dyspnea on exertion; Bilateral basilar crackles
  • Blood urea nitrogen (BUN) = 11 mg/dL and Creatinine kinases 1200 U/L
  • Potassium 5.3 mg/dL


Circle or place a check mark next to the assessment findings that require follow-up by the nurse.


Case Study Progress

The provider arrives to the telemetry unit to discuss the diagnosis and plan with the patient and wife. The client is diagnosed with rhabdomyolysis.  Prescriptions to place a large-bore intravenous catheter and administer normal saline 0.9% at 125 mL/hr are received.  Choose the most likely options for the information missing from the paragraph by selecting from the lists of options provided.


When caring for a client who has left ventricular dysfunction, the nurse assesses for _____1_____ related to inadequate cerebral perfusion, _____2______ related to inadequate myocardium perfusion, and _____3______

related to inadequate renal perfusion.  The nurse monitors a client who has heart failure closely for complications of pulmonary congestion when administering intravenous fluids.  Manifestations of pulmonary congestion include _____4_____, _____5_____, and _____6_____.  If the client experiences acute pulmonary edema, the nurse would place the client in a sitting position and administer _____7_____ and _____8_____. 


Options for 1, 2, and 3Options for 4, 5, and 6Options for 7 and 8
ConfusionCracklesAlbuterol nebulizer
Chest painDyspneachest percussion
nauseaFatigueLorazepam orally
oliguriaJugular vein distentionMorphine intravenous push
orthopneaStridorNitroglycerin sublingual
pallorTachypneaSupplemental oxygen
polyuriaWeight gainFurosemide intravenous push

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