The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Anxiety

Sleep

Fever

Hyperglycemia

Blood loss

Answer and Explanation

Correct Answer : A,C,E

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

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Correct Answer is D

Explanation

A. This result indicates muscle injury but does not specify the source.

This statement is partly correct. An elevated troponin I level does indicate muscle injury, specifically damage to the heart muscle. However, troponin I is highly specific to cardiac muscle, so an elevated level would indeed specify the source as cardiac or myocardial injury.

B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury.

This statement is incorrect. A history of unstable angina does not diminish the significance of an elevated troponin I level. In fact, unstable angina is itself a serious condition that can lead to myocardial injury or heart attack, and an elevated troponin I level in this context indicates ongoing or recent myocardial damage.

C. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours.

This statement is not entirely accurate. While it is true that troponin I levels may continue to rise and peak within 12-24 hours after the onset of myocardial injury, an elevated troponin I level at any point is still a significant indicator of myocardial damage. It's essential to recognize elevated troponin I levels promptly to initiate appropriate interventions and monitor the client's cardiac status closely.

D. This is an accurate indicator of myocardial injury.

This statement is correct. An elevated troponin I level is a highly sensitive and specific marker of myocardial injury. It indicates damage to the heart muscle, which can occur due to conditions like unstable angina, heart attack (myocardial infarction), myocarditis, or other cardiac issues. Therefore, recognizing an elevated troponin I level in a client with unstable angina is crucial for proper management and further evaluation.

A. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." B. "These tests help determine the degree of damage to the heart tissues." C. "These tests will enable the provider to determine the heart structure." D. "Cardiac enzymes will identify the location of the MI."

Correct Answer is B

Explanation

A. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion.": Cardiac enzymes are not used to diagnose pulmonary congestion. They are specific markers used to assess damage to the heart muscle, particularly after a myocardial infarction (MI).

B. "These tests help determine the degree of damage to the heart tissues.": This statement is correct. Cardiac enzyme studies, such as troponin levels, CK-MB (creatine kinase-MB), and LDH (lactate dehydrogenase), are used to evaluate the extent of myocardial damage during and after an MI. Elevated levels of these enzymes indicate myocardial injury.

C. "These tests will enable the provider to determine the heart structure.": While cardiac imaging studies like echocardiograms or angiograms are used to assess heart structure, cardiac enzymes are primarily used to evaluate myocardial damage and not heart structure.

D. "Cardiac enzymes will identify the location of the MI.": Cardiac enzymes can indicate the presence of an MI and the extent of myocardial damage, but they do not specifically identify the location of the MI within the heart. Additional diagnostic tests, such as electrocardiograms (ECGs) and imaging studies, are often used to determine the location of the MI.

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The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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