Acute Coronary Syndrome: Identification and Management, Exams of Nursing

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Fisdap Cardiology EXAM 2024 AND PRACTICE

QUESTIONS |ACCURATE ANSWERS| VERIFIED

FOR GUARANTEED PASS |GRADED A |NEW

VERSION WITH 150 QUESTIONS

Which of the following is the MOST appropriate response when a patient with chest pain asks you if he or she is having a heart attack? A) Yes, so I recommend going to the hospital. B) I don't know, but we will take good care of you. C) Probably not, but we should transport you to be safe. D) I believe you are, but only a physician can tell for sure.

• ANSWERS-B) I don't know, but we will take good care of you. Patients experiencing chest pain often have a good idea about what is happening, so do not lie or offer false reassurance. Conversely, do not tell patients they are having a heart attack; EMTs are not trained to interpret the 12-lead ECG, and the 12-lead ECG is currently the only way a heart attack can be diagnosed in the prehospital setting. If asked, "Am I having a heart attack?", an appropriate response would be "I don't know for sure, but in case you are, we are going to take good care of you." When treating a patient with chest pain, pressure, or discomfort, you should FIRST: A) administer supplemental oxygen B) place the patient in a position of comfort. C) request an ALS ambulance response to the scene. D) assess the blood pressure and give nitroglycerin.
  • ANSWERS-B) place the patient in a position of comfort.

An important aspect of treating a patient with chest pain, pressure, or discomfort is to ensure that the patient is in a comfortable position. Most of the time, the patient will already be in this position upon your arrival. A comfortable position will help minimize anxiety, which in turn decreases cardiac oxygen consumption and demand. The decision to administer supplemental oxygen depends on the patient's oxygen saturation and/or whether or not respiratory distress is present. Following your assessment, if you feel that ALS support is needed, you should request it. If the patient has prescribed, unexpired nitroglycerin; the systolic blood pressure is greater than 100 mm Hg; and the patient has not taken the maximum of three doses, you should contact medical control to obtain permission to assist the patient in taking the nitroglycerin. The MOST important initial treatment for a patient whose cardiac arrest was witnessed is: A) defibrillation. B) cardiac drug therapy. C) rapid transport. D) high-quality CPR

. - ANSWERS-D) high-quality CPR. Regardless of whether a patient's cardiac arrest is witnessed or unwitnessed, the single most important initial treatment is high-quality CPR. Delays in performing CPR have been clearly linked to poor patient outcomes. After CPR has been initiated, apply the AED as soon as it is available. Cardiac drug therapy may enhance the patient's chance of survival. There is evidence suggesting that transport to the hospital with CPR in progress does not improve survival; resuscitation at the scene may be more beneficial for the patient; follow your local protocols and current research trends. Minimally interrupted, highquality CPR, however, is clearly linked to good patient outcomes.

In addition to chest pain or discomfort, a patient experiencing an acute coronary syndrome would MOST likely present with: A) ashen skin color, diaphoresis, and anxiety. B) severe projectile vomiting and flush ed skin. C) irregular breathing and low blood pressure. D) profound cyanosis, dry skin, and a headache.

• ANSWERS-A) ashen skin color, diaphoresis, and anxiety. Chest pain, pressure, or discomfort is the most common symptom of acute coronary syndrome (ACS; eg, unstable angina, acute myocardial infarction); it occurs in approximately 80% of cases. Patients with ACS are usually anxious and may have a feeling of impending doom. Nausea and vomiting are common complaints; however, projectile vomiting, which is typically associated with increased intracranial pressure, is uncommon. The skin is often ashen gray and clammy (diaphoretic) because of poor cardiac output and decreased perfusion. Less commonly, the patient's skin is cyanotic. Respirations are usually unlabored unless the patient has congestive heart fai lure, in which case respirations are rapid and labored; irregular breathing, however, is not common. Blood pressure may fall as a resu lt of decreased cardiac output; however, most patients will have a normal or elevated blood pressure. If the patient complains of a headache, it is usually a side effect of the nitroglycerin he or she took before your arrival; ACS itself usually does not cause a headache. A 49-year-old woman presents with a headache, nausea, and ringing in her ears. She is conscious and alert and states that she has hypertension and type 2 diabetes. Her BP is 202/114 mm Hg, her pulse is 60 beats/min, and her respirations are 16 breaths/min. What should you do? A) Place her in a supine position. B) Give her one tube of oral glucose.

C) Prepare for immediate transport. D) Summon an ALS unit to the scene.

• ANSWERS-C) Prepare for immediate transport. The patient's presentation is indicative of acute hypertensive crisis. Her blood pressure is severely elevated and she is experiencing other symptoms one might expect with such a high blood pressure (ie, headache, nausea, ringing in the ears). You should place her in a position of comfort, which is usually a semisitting position; lying her supine would likely only make her headache worse. Prompt transport to the hospital is essential so her blood pressure can be lowered in a controlled setting. Without knowing her blood glucose level, proceeding with oral glucose would not be appropriate. If it does not delay transport, you could consider summoning an ALS ambulance to the scene. It is far more important, however, to get her to a definitive care facility. You should suspect that your patient has pulmonary edema if he or she: A) has swollen feet and ankles B) cannot breathe while lying down. C) is hypertensive and tachycardic. D) has a dry, nonproductive cough.
• ANSWERS-B) cannot breathe while lying down. Pulmonary edema is often caused by failure of the left side of the heart. When the patient is lying down, he or she experiences worsened difficulty breathing (orthopnea) because more blood backs up in the lungs. Patients with severe pulmonary edema often produce pink, frothy sputum when they cough; this is another sign of blood backing up in the lungs. A dry, nonproductive cough is not common. Hypertension and tachycardia are common in patients with pulmonary edema; however, many other conditions can cause these findings. Swelling of the feet and ankles is commonly seen in patients with right heart

failure, and occurs when blood backs up beyond the right atrium; it is not a common sign of left hear-t failure and pulmonary edema. Use of the automated external defibrillator is contraindicated in patients who: A) are between 1 and 8 years of age. B) experienced a witnessed cardiac arrest. C) are apneic and have a weak carotid pulse. D) have a nitroglycerin patch applied to the skin.

• ANSWERS-D) have a nitroglycerin patch applied to the skin. The AED is applied only to patients in cardiac arrest (eg, pulseless and apneic), whether the arrest was witnessed or unwitnessed. According to the 2015 guidelines for CPR and Emergency Cardiac Care (ECC), AED can safely be u ed in infants and children less than 8 years of age in conjunction with a doseattenuating system (energy reducer) and pediatric pads. However, if pediatric pads and an energy reducer are unavailable, adult AED pads should be used. A nitroglycerin patch is not a contraindication to the use of an AED; simply remove the patch (with gloved hands) and apply the AED as usual. The pain associated with acute aortic dissection: A) typically comes on gradually and progressively worsens. B) is typically described as a stabbing or tearing sensation. C) is usually preceded by nausea, sweating, and weakness. D) originates in the epigastrium and radiates down both legs.
• ANSWERS-B) is typically described as a stabbing or tearing sensation. Aortic dissection occurs when the inner layers of the aorta become separated, allowing blood to flow between the layers at high pressure. This separation of

layers significantly weakens the aortic wall, making it prone to rupture. Signs and symptoms of acute aortic dissection include a sudden onset of a ripping, tearing, or stabbing pain in the anterior part of the chest or in the back between the scapulae. It may be difficult to differentiate the pain of acute aortic dissection from that of an acute myocardial infarction (AMI), but a number of distinctive features may help. The pain from an AMI is often preceded by other signs and symptoms (ie, nausea, indigestion, weakness, sweating [diaphoresis]). It tends to come on gradually and becomes more severe as time progresses, and is usually described as a crushing pain or as a feeling of heaviness or pressure. By contrast, the pain associated with aortic dissection is acute and is often of maximum intensity from the onset; it is typically described as a ripping, tearing, or stabbing sensation. Which of the following structures is the primary pacemaker, which sets the normal rate for the heart? A) Bundle of His B) Purkinje fibers C) Sinoatrial node D) Atrioventricular node - ANSWERS-C) Sinoatrial node Cardiac pacemakers are bundles of nerves that generate electrical impulses and conduct them to the cardiac cells, resulting in contraction of the myocardium (heart muscle). In a normal healthy heart, the sinoatrial (SA) node is the primary pacemaker that sets the inherent rate for the heart. The SA node generates electricity at a rate of 60 to 100 electrical discharges per minute; hence the normal adult heart rate is 60 to 100 beats/min. The atrioventricular (AV) node serves as the heart's secondary pacemaker; if the SA node fails , the AV node resumes the pacing function of the heart, although at a slower rate (40 to 60 beats/min). The bundle of His and Purkinjie fibers, located within the ventricles, may serve as tertiary pacemakers if the SA and AV nodes fail; their inherent pacing rate is 20 to 40 beats/min.

A 50-year-old man's implanted defibrillator has fired twice within the last hour. He is conscious and alert and reports a "sore chest." Further assessment reveals that his chest pain is reproducible to palpation and is localized to the area of his implanted defibrillator. Treatment for him should include: A) application of the AED and transport to the hospital. B) prompt transport with continuous monitoring en route. C) deactivating his defibrillator by running a magnet over it. D) up to three doses of nitroglycerin and prompt transport. - ANSWERS-B) prompt transport with continuous monitoring en route. Palients who are at high risk for lethal cardiac dysrhythmias (ie, VF, VT) may have an automated implantable cardioverter/defibrillator (AICD). This small device is usually implanted in the upper left chest.just below the left clavicle. The AJCD detects cardiac dysrhythmias and rapidly delivers a shock. When treating a patient whose AJCD has fired, you should determine the number of limes the device fired, assess vital signs, and transport to the hospital with continuous monitoring en route. Administer supplemental oxygen if the patient is experiencing respiratory distress and/or the oxygen saturation is less than 94%. Application of the AED is not indicated; however, if the patient develops cardiac arrest, you should use the AED as you normally would (remember to apply the pads at least 1 inch away from the implanted device). The pain that the patient is experiencing, which is reproducible and localized near his AICD, is likely musculoskeletal pain as the result of his AICD shocking him; therefore, nitroglycerin is not indicated. Because the AICD works so quickly (much faster than you can apply an AED), you should not make any attempt to deactivate it. Following return of spontaneous circulation, the patient remains apneic. The EMT should: A) ventilae at 10 breaths/min and maintain an oxygen saturation of 92% to 98% B) ventilate at 15 to 18 breaths/min and maintain an oxygen saturation of 100%. C) elevate the patient's lower extremities and ventilate at a rate of 20 breaths/min.

D) remove the AED pads and vent ilate the patient at a rate of 24 breaths/min. - ANSWERS-A) ventilae at 10 breaths/min and maintain an oxygen saturation of 92% to 98% Following return of spontaneous circulation (ROSC) in a patient who remains apneic, you should ventilate at a rate of 10 breaths/min and maintain an oxygen saturation of 92% to 98%. An oxygen saturation of 100% should not be achieved; there is evidence that such a high oxygen saturation post-ROSC can have a negative impact on neurologic recovery. Keep the patient supine, leave the AED pads in place, and transport without delay. A 60-year-old woman presents with chest discomfort, confusion, and weakness. The patient's husband t ells you that she vomited once before EMS arrival. The patient's BP is 70/40 mm Hg, her pulse is 45 beats/min and weak, and her respirat ions are 14 breaths/min and unlabored. Which of the following is the MOST likely cause of her hypotension? A) Bradycardia B) Hypovolemia C) Myocardial isch emia D) Respiratory compromise - ANSWERS-A) Bradycardia Given the patient's presentation, her slow heart rate (bradycardia) is the most likely cause of her hypo tension. When the heart rate is too slow or too fast, cardiac output can fall, resulting in hypotension. Hypovolemia would be expected to cause tachycardia, not bradycardia. There is no evidence of respiratory compromise in this patient; her breathing is unlabored and at a normal rate. Myocardial ischemia, which would explain her chest discomfort, may be caused by her bradycardia, but would not explain her blood pressure. Which of the following statements regarding the automated external defibrillator (AED) is correct?

A) The AED should be applied to patients at risk for cardiac arrest. B) AEDs will analyze the patient's rhythm while CPR is in progress. C) The AED should not be used in patients with an implanted defibrilator. D) AEDs can safely be used in infants and children less than 8 years of age. - ANSWERS-D) AEDs can safely be used in infants and children less than 8 years of age. According to the 2020 guidelines for CPR and Emergency Cardiac Care (ECC), the AED can safely be used in infants and children less than 8 years of age. Although a manual defibrillator is preferred in infants, an AED can be used. When using the AED in infants and children, you should use pediatric pads and a dose-attenuating system (energy reducer); however, if these are not available, adult AED pads should be used. The AED should be applied only to patients in cardiac arrest; if a patient is at risk for cardiac arrest, have the AED ready but not applied. The AED will not analyze the cardiac rhythm if the patient is moving (ie, CPR is in progress). AEDs can be used in patients with an automated implanted cardioverter/defibrillator (AICD) or implanted pacemaker; ensure that the pads are at least 1 inch away from the implanted device. In patients with heart disease, acute coronary syndrome is MOST often the result of: A) atrial damage. B) atherosclerosis. C) coronary artery spasm. D) coronary artery rupture. - ANSWERS-B) atherosclerosis. In most patients with acute coronary syndrome {ACS; eg, unstable angina, acute myocardial infarction), atherosclerosis is the underlying problem that causes heart disease. Athero clerosis is a disorder in which calcium and a fatty material called cholesterol build up and form a plaque inside the walls of blood vessels, obstructing blood flow. ACS due to atherosclerosis usually occurs when a fragment of plaque ruptures and occludes a coronary artery; further

occlusion occurs when platelets aggregate in the area and clump together. Less commonly, acute coronary artery spasm may result in ACS. The cause of acute coronary vasospasm is largely unknown. Rupture of a coronary artery is a rare cause of ACS. Atrial or ventricular damage is usually caused by, rather than the cause of, ACS. Aspirin is beneficial to patients experiencing an acute coronary syndrome because it: A) prevents a clot from getting larger. B) effectively relieves their chest pain. C) decreases cardiac workload by lowering the BP. D) destroys the clot that is blocking a coronary artery. - ANSWERS-A) prevents a clot from getting larger. Early administration of baby aspirin (160 to 325 mg) to patients with acute coronary syndrome (ACS) has clearly been shown to reduce mortality and morbidity. Aspirin (acetylsalicylic acid [ASA]) prevents the clot in a coronary artery from getting larger by inhibiting platelet aggregation; in other words, it makes the platelets less sticky, which means that they will be less likely to clump together. Aspirin does not relieve the chest pain or discomfort associated with ACS, nor does it reduce blood pressure. Furthermore, aspirin does not remove the clot that is blocking a coronary artery; cardiac catheterization or fibrinolytic (clot-buster) drugs are required to do this. At the end of ventricular relaxation, the left ventricle contains 110 mL of blood. This is referred to as the: A) preload. B) afterload. C) stroke volume. D) cardiac output. - ANSWERS-A) preload.

Preload is the amount of pressure on the ventricular wall at the end of ventricular relaxation (diastole) and is influenced by the volume of blood in the ventricle just before it contracts. Afterload refers to the resistance that the ventricles must contract against. A patient with hypertension, for example, would have an increased afterload due to systemic vasoconstriction; the smaller the arteries, the greater the resistance the heart must contract against. Stroke volume is the volume of blood ejected from the ventricles in a single beat. Cardiac output is the volume of blood pumped by the heart each minute; it is calculated by multiplying the stroke volume and heart rate. You are assessing a 70-year-old man who reports pain in both of his legs. He is conscious and alert, has a blood pressure of 160/90 mm Hg, a pulse rate of 110 beats/min, and respirations of 14 breaths/min and unlabored. Further assessment reveals edema to both of his feet and legs and jugular venous distention. What should you suspect? A) Left heart fa ilure B) Right heart failure C) Pulmonary edema D) Chronic hypertension - ANSWERS-B) Right heart failure If the right side of the heart is damaged, fluid collects in the body (edema), often showing in the feet and legs. The collection of fluid in the part of the body that is closest to the ground is called dependent edema. The swelling causes relatively few symptoms other than discomfort. Another feature of right heart failure is jugular venous distention, which is an indication of blood backing up into the systemic circulation. Left heart failure typically presents with shortness of breath due to fluid in the lungs (pulmonary edema), which indicates blood backing up from the left side of the heart into the lungs. In severe pulmonary edema, the patient may cough up pink, frothy sputum. Right heart failure and/or left heart failw·e are also referred to as congestive heart failure (CHF). Chronic hypertension cannot be established on the basis of a single blood pressure reading.

In which of the fo llowing patients is nitroglycerin contraindicated? HIDE THIS MENU A) 41-year-old man with crushing substernal chest pressure, a blood pressure of160/90 mm Hg, and severe nausea B) 53-year-old man with chest discomfort, diaphoresis, a blood pressure of 146/66 mm Hg, and regular use of Levitra C) 58-year-old man with chest pain radiating to the left arm, a blood pressure of 130/64 mm Hg, and prescribed Tegretol D) 66-year-old woman with chest pressure of 6 hours' du ration, lightheadedness, and a blood pressure of 110/58 mm Hg - ANSWERS-B) 53-year-old man with chest discomfort, diaphoresis, a blood pressure of 146/66 mm Hg, and regular use of Levitra Nitroglycerin is contraindicated in patients who do not have a prescription for nitroglycerin, in those with a systolic BP less than 100 mm Hg, and in patients who have taken medications for erectile dysfunction (ED) within the previous 24 to 48 hours. Such medications include sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). Because bothED drugs and nitroglycerin cause vasodilation, concomitant use of these drugs may result in significant hypotension. Carbamazepine (Tegretol) is an anticonvulsant medication; there are no known interactions between Tegretol and nitroglycerin. Which of the following statements regarding one-rescuer CPR is correct? A) You should assess the patient for a pulse after 3 cycles of CPR. B) A compression to ventilation ratio of 15:2 should be delivered. C) Ventilations should be delivered over a period of 2 to 3 seconds. D) The chest should be allowed to fully recoil after each compression. - ANSWERS-D) The chest should be allowed to fully recoil after each compression. When performing CPR on any patient, you should allow the chest to fully recoil after each compression; do not lean on the chest between compressions.

Incomplete chest recoil causes increased intrathoracic pressure, which may impair blood return to the heart. Assess the patient's pulse after every 5 cycles (about 2 minutes) of CPR; take no longer than 5 to 10 seconds to do this. A compression to ventilation ratio of 30:2 should be used during all adult and onerescuer CPR (adult, child, and infant), except for newborns. A compression to ventilation ratio of 15:2 is used during two-rescuer infant and child CPR. Ventilations should be delivered over a period of 1 second each, just enough to produce visible chest rise. While assessing a patient with chest pain, you note that his pulse is irregular. This indicates: A) acute myocardial infarction or angina pectoris. B) a dysfunction in the left side of the patient's heart C) high blood pressure that is increasing cardiac workload. D) abnormalities in the heart's electrical conduction system. - ANSWERS-D) abnormalities in the heart's electrical conduction system. An irregular pulse indicates abnormalities in the electrical conduction system of the heart. The electrical conduction system, beginning with the sinoatrial node as the primary pacemaker, is responsible for initiating the electrical impulses that stimulate the myocardium to contra t. An irregular pulse could indicate a potentially lethal dysrhythmia that could result in cardiac arrest. You should document an irregular pulse and report this important finding to the emergency department. Which of the following is an expected finding in patients who have a left ventricular assist device (LVAD) with a continuous flow pump? A) cyanotic skin. B) hypertension. C) peripheral edema. D) absence of pulses. - ANSWERS-D) absence of pulses.

A left ventricular assist device (LVAD) is used to enhance left ventricular pumping. LVADs are commonly implanted in patients with severe heart failure, those who are awaiting a heart transplant, or those who need a temporary boost following acute myocardial infarction. Several types of LVADs exist; the most common ones have an internal pump unit and an external battery pack. These pumps may be pulsatile, meaning they pump in pulsations just like the natural heart, or they may be continuous, in which case the patient will not have any palpable pulses. If pulses are not palpable, then a blood pressure will not be obtainable. You would not expect to encounter cyanosis in any patient with an LVAD, whether the pump is pulsatile or continuous; if you do, an oxygenation problem exists. Peripheral edema is also not expected in patients with an LVAD. A middle-aged woman took three of her prescribed nitroglycerin tablets after she began experiencing chest pain. She complains of a bad headache and is still experiencing chest pain. You should assume that: A) her blood pressure is elevated. B) she has ongoing cardiac ischemia. C) her nitroglycerin is no longer potent. D) her chest pain is not cardiac related. - ANSWERS-B) she has ongoing cardiac ischemia. A headache and/or a bitter taste under the tongue are common side effects of nitroglycerin ( TG) that many patients experience. If the patient does not experience these side effects, the NTG may have lost its potency. However, if a patient with chest pain takes NTG and experiences these side effects, but still has chest pain, you should assume that his or her pain is the resu lt of cardiac ischemia, a relative deprivation of oxygen to the heart. NTG is a vasodilator drug; therefore, it would lower her blood pressure, not raise it. Any patient with nontraumatic chest pain or pressure should be assumed to be experiencing cardiac ischemia, especially if the pain or pressure is not rel ieved with NTG.

A middle-aged man was fo und unresponsive by his wife. When you arrive at the scene, you assess the patient and determine that he is apneic and pulseless. You should: A) immediately begin CPR, reassess for a carotid pulse after 60 seconds, and then apply the AED. B) immediately apply the AED, analyze his cardiac rhythm, deliver a shock if indicated, and begin CPR. C) begin CPR starting with chest compressions, apply the AED as soon as possible, and request backup. D) perform CPR with a compression to ventilation ratio of 15:2, apply the AED, and request backup. - ANSWERS-C) begin CPR starting with chest compressions, apply the AED as soon as possible, and request backup. As soon as you determine that a patient is unresponsive, pulseless, and apneic, you should begin CPR (starting with chest compressions), apply the AED as soon as possible, and deliver a shock (if indicated). The appropriate compression to ventilation ratio for adult CPR (one- or two-rescuer) is 30:2. A compression to ventilation ratio of 15:2 is used for two-rescuer infant and child CPR. Request a backup ambulance as soon as possible; however, do not interrupt CPR to do so. One EMT should perform CPR while the other radios for assistance. Continue CPR and reanalyze the patient's cardiac rhythm every 2 minutes. If indicated, deliver a single shock and immediately resume CPR, starting with chest compressions. If the AED gives a no shock message, resume CPR, starting with chest compressions. Continue CPR, rhythm analysis every 2 minutes, and defibrillation (if indicated), until backup arrives or the patient starts to move. Switching compressors during two-rescuer CPR: A) should take no more than 15 seconds to accomplish. B) should occur every 2 minutes throughout the arrest.

C) is necessary only if the compressor becomes fatigued. D) is performed after every 10 to 20 cycles of adult CPR. - ANSWERS-B) should occur every 2 minutes throughout the arrest. Rescuer fatigue leads to inadequate chest compression rate and/or depth. Fatigue is common after 1 minute of CPR, although the rescuer may not recognize it for 5 minutes or longer. Therefore, compressor should be changed every 2 minutes (after 5 cycles of CPR at a 30:2 ratio) throughout the resuscitation attempt. If the compressor is not switched until he or she recognizes the fatigue, the patient has likely been without effective chest compressions for at least 4 or 5 minutes. In general, interruptions in CPR should be infrequent and should not exceed 10 seconds. However, every effort should be made to switch compressors in less than 5 seconds. After administering nitroglycerin to a patient with chest discomfort, it is MOST important for you to: A) ask the patient if the discomfort has improved. B) find out how long the discomfort has been present. C) position the patient supine and transport immediately. D) reassess the patient's blood pressure within 5 minutes. - ANSWERS-D) reassess the patient's blood pressure within 5 minutes. Nitroglycerin (NTG) relaxes the muscle of blood vessel walls, dilates the coronary arteries, increases blood flow and the supply of oxygen to the heart muscle (myocardium), and decreases the workload of the heart. NTG also dilates blood vessels in other parts of the body, potentially resulting in hypotension. For this reason, you should reassess the patient's blood pressure within 5 minutes after each dose of NTG. If the systolic blood pressure is less than 100 mm Hg, do not give anymore NTG. If significant hypotension occurs, position the patient supine and transport without delay. Asking the patient if his or her chest

pain or discomfort has improved following NTG helps you determine if the drug is working and whether additional dosing is needed; however, detecting hypotension is clearly more important. You should determine when the chest pain or discomfort began during the focused history, which is typically performed before assisting a patient with his or her prescribed NTG. Which of the following is an abnormal finding when using the Cincinnati Stroke Scale to assess a patient who presents with signs of a stroke? A) One arm drifts down compared with the other side. B) One of the pupils is dilated and does not react to light. C) The patient's face is symmetrical when he or she smiles. D) Both arms drift slowly and equally down to the patient's side. - ANSWERS-A) One arm drifts down compared with the other side. The Cincinnati Stroke Scale is used to assess patients suspected of experiencing a stroke. It consists of three tests: speech, facial droop, and arm drift. Abnormality in any one of these areas indicates a high probability of stroke. To test arm drift, ask the patient to hold both arms in front of his or her body, palms facing upward, with eyes closed and without moving. Over the next 10 seconds, observe the patient's arms. If one a1·m drifts down toward the ground, you know that side is weak; this is an abnormal finding. To test for facial droop, have the patient smile, showing his or her teeth. The face should be symmetrical (both sides of the face should move equally). If only one side of the face moves well, you know that something is wrong with the part of the brain that controls the facial muscles. You should assess the pupils of a patient with a suspected stroke; however, this is not a component of the Cincinnati Stroke Scale. After delivering one shock with the AED and performing 2 minutes of CPR on a woman in cardiac arrest, you reanalyze her cardiac rhythm and receive a no shock advised message. This means that:

A) she is not in a shockable rhythm. B) she has electrical activity but no pulse. C) her rhythm has deteriorated to asystole. D) the first shock restored a rhythm and pulse. - ANSWERS-A) she is not in a shockable rhythm. If the AED gives a no shock advised message, it has determined that the patient i not in a shockable rhythm (eg, V-Fib, pulseless V-Tach). It does not indicate that the patient has a pulse, nor does it indicate that a normal cardiac rhythm has been restored. The AED does not distinguish pulseless electrical activity (PEA) from asystole; it only recognizes them as nonshockable. PEA is a condition in which organized cardiac electrical activity is present despite the absence of a pulse. Asystole is the absence of all cardiac electrical and mechanical activity. If the AED gives a no shock advised message, immediately resume CPR, starting with chest compressions, until ALS arrives or the patient starts to move. Aspirin may be contraindicated in patients with: A) glaucoma. B) diabetes. C) stomach ulcers. D) ibuprofen allergy. - ANSWERS-C) stomach ulcers. Aspirin (acetylsalicylic acid [ASA]) inhibits platelet aggregation, thus preventing clots from forming or preventing an existing clot from getting bigger. Aspirin, in a dose of 160 to 325 mg, should be admini tered to patients experiencing acute coronary syndrome (ie, unstable angina, acute myocardial infarction) as soon as possible. Aspirin is absolutely contraindicated for patients who are allergic to salicylates. Because aspirin prolongs bleeding time, it may be contraindicated for patients with stomach ulcers; therefore, you should contact medical control before giving aspirin to such patients. Aspirin is not

contraindicated for patients with glaucoma or diabetes. Ibuprofen, the active ingredient in Motrin and Advil, is a nonsteroidal anti-inflammatory drug ( SAID), not a salycilate. Common signs and symptoms of a hypertensive emergency include: A) unequal pupils, irregular pulse, and pallor B) ringing in the ears, headache, and epistaxis. C) chest discomfort, weak pulses, and cool skin. D) vomiting without nausea and hemiparesis. - ANSWERS-B) ringing in the ears, headache, and epistaxis. Although different sources cite various values, most agree that a hypertensive emergency exists when the systolic blood pressure exceeds 180 mm Hg and the diastolic blood pressure exceeds 110 mm Hg. A hypertensive emergency also exists when the systolic BP suddenly rises and produces signs and symptoms. One of the most common symptoms of a hypertensive emergency is a severe heada he. Other signs and symptoms include ringing in the ears (tinnitus), epistaxis (nosebleed), bounding pulses, flushed skin (dry or moist), nausea and vomiting, and dizziness. In severe cases, mental status changes may occur and the patient may experience a sudden onset of pulmonary edema. Untreated hypertension can cause a stroke, heart failure, or aortic dissection, to name a few. By itself, a hypertensive emergency does not usual ly cause unequal pupils or weakness to one side of the body (hemiparesis); if these signs are present in a hypertensive patient, the EMT should suspect a stroke. The EMT is treating a man with chest pain and has assisted him with his nitroglycerin. Which of the fo llowing should the EMT anticipate during reassessment of this patient? A) Decreased blood pressure B) Increased level of anxiety

C) Increased oxygen saturation D) Burning sensation in the chest - ANSWERS-A) Decreased blood pressure Because nitroglycerin is a vasodilator, you should expect that the patient's blood pressure will be lower when you reassess it. Some patients experience only a minor decrease in blood pressure; other patients may experience a more significant decrease (one of the many reasons to reassess your patient). Nitroglycerin typically does not increase anxiety; the fact that it relieves their chest pain, however, may actually decrease their anxiety. Nitroglycerin has no effect on oxygen saturation. Some patients may experience a burning sensation under their tongue; a burning sensation in the chest is not typical following nitroglycerin administration. Freshly oxygenated blood returns to the heart via the: A) aorta. B) venae cavae. C) pulmonary veins. D) pulmonary arteries. - ANSWERS-C) pulmonary veins. The pulmonary veins are the only veins that carries oxygen-rich blood. They carry blood from the lungs back to the left atrium. All other veins in the human body, including the venae cavae, carry deoxygenated blood back to the heart. The aorta is the largest artery in the body and branches immediately from the left ventricle, carrying fresh ly oxygenated blood to the rest of the body. The pulmonary arteries carry deoxygenated blood from the right ventricle to the lungs for reoxygenation. In which of the following situations would nitroglycerin MOST likely be administered? A) Recent use of Cialis

B) Systolic BP of 90 mm Hg C) The presence of a head injury D) History of cardiac bypass surgery - ANSWERS-D) History of cardiac bypass surgery Nitroglycerin (NTG) is a vasodilator drug used to relieve chest pain in patients with cardiac compromise by dilating the coronary arteries and improving blood flow to the heart. Because of its vasodilator effects, it should not be given to patients who have a systolic BP less than 100 mm Hg or to patients who have recently (within the past 24 to 48 hours) taken erectile dysfunction (ED) drugs (eg, sildenafil [Viagra], vardenafil [Levitra], tadalafil [Cialis]). ED drugs also cause vasodilation and may cause significant hypotension if given together with NTG. You should also avoid NTG in patients with a head injury; dilation of the cerebral blood vessels may worsen intracranial pressure caused by the head injury. By itself, a history of cardiac bypass surgery does not contraindicate the use of NTG. A patient who is experiencing an acute myocardial infarction: A) most often describes his or her chest pain as being sharp or tearing. B) has chest pain or discomfort that does not change with each breath. C) often experiences relief of his or her chest pain after taking nitroglycerin. D) often complains of a different type of pain than a patient with angina. - ANSWERS-B) has chest pain or discomfort that does not change with each breath. The type of chest pain or discomfort associated with acute myocardial infarction (AMI) is the same that is experienced by patients with angina pectoris (eg, dull, crushing, pressure, heaviness); thus, you cannot distinguish AMI from angina pectoris based solely on the type or quality of pain. Furthermore, the pain associated with AMI, like that of angina, often radiates to the arm, jaw, back, or epigastrium. Relative to other causes of chest pain or discomfort (eg, pleurisy, pneumothorax), the pain associated with AMI and angina does not worsen or improve when the patient takes a breath. Rest and nitroglycerin often relieve

the pain associated with stable angina, but are less likely to relieve the pain associated with unstable angina or AMI. A 72-year-old woman reports dyspnea that woke her from her sleep. Her feet and ankles are swollen, and auscultation of her lungs reveals crackles to both lung bases. She has a history of hypertension, type 2 diabetes, and a heart attack 2 years ago. Her BP is 170/94 mm Hg, her pulse is 110 beats/min and irregular, her respirations are 24 breaths/min and labored, and her oxygen saturation is 85% on room air. What should you suspect? A) Acute asthma attack B) Congestive heart failure C) Acute hypertensive crisis D) Emphysema exacerbation - ANSWERS-B) Congestive heart failure The patient's clinical presentation is consistent with congestive heart failure (CHF) with acute pulmonary edema. Dyspnea that awakens a person from sleep is called paroxysmal nocturnal dyspnea (PND) and is classic for CHF. Crackles auscultated over her lungs further support the diagnosis of pulmonary edema, and her low oxygen saturation indicates hypoxemia. Swelling to the feet and ankles suggests an element of right heart failure as well. Emphysema is unlikely because there is no mention of it in her medical history. Furthermore, patients with emphysema typically have dyspnea all the time, not just when they lie down to sleep. Acute asthma is also unlikely; one would expect wheezing (not crackles) in the lungs. Although the patient's BP is elevated, she has no other signs of acute hypertensive crisis, such as a headache, nausea and vomiting, and ringing in the ears. Prior to administering nitroglycerin to a patient with chest pain, you should: A) elevate the patient's lower extremities.

B) obtain vital signs to detect hypotension. C) inquire about an allergy to salicylates. D) auscultate the patient's breath sounds. - ANSWERS-B) obtain vital signs to detect hypotension. Prior to assisting a patient with his or her prescribed nitroglycerin, there are two things that you must do: take the patient's vital signs and obtain authorization from medical control. Nitroglycerin is contraindicated for patients with a systolic blood pressure that is less than 100 mm Hg. If the patient develops hypotension after being given nitroglycerin, position him or her supine and transport without delay. Salicylates are a class of drugs that include aspirin, not nitroglycerin (nitroglycerin is a nitrate). Although you should inquire about medication allergies in general, it is not necessary to inquire specifically about an allergy to salicylates unless you are going to administer aspirin. Assessment of a patient with a possible cardiac or respiratory problem should include auscultation of breath sounds; however, this does not necessarily have to be done before assisting the patient with his or her nitroglycerin. Which of the following describes the MOST appropriate method of performing chest compressions on an adult patient in cardiac arrest? A) Compress the chest at least 2 inches, allow full recoil of the chest after each compression, minimize interruptions in chest compressions B) Allow full recoil of the chest after each compression, compress the chest to a depth of 2 inches, deliver compressions at a rate of at least 80/min C) Do not interrupt chest compressions for any reason, compress the chest no more than 1½ inches, allow partial recoil of the chest after each compression D) Minimize interruptions in chest compressions, provide 70% compression time and 30% relaxation time, deliver compressions at a

rate of 100/min - ANSWERS-A) Compress the chest at least 2 inches, allow full recoil of the chest after each compression, minimize interruptions in chest compressions Effective chest compressions are essential for providing forward blood flow during CPR. To perform adequate chest compressions, the EMT should compress the chest of an adult at a rate of 100 to 120/min to a depth of at least 2 inches. A compression depth that is greater than 2.4 inches should be avoided , although this is not possible to accomplish without a CPR device the provides immediate feedback. When performing chest compressions on an infant or child, compress the chest at least one-third the depth of the chest (about 1.5 inches for infants, about 2 inches for children). Allow the chest to fully recoil after each compression, avoid leaning on the chest, and allow equal time for compression and relaxation. Minimize interruptions in CPR to 10 seconds or less. Obviously, chest compressions must be paused when using the AED to analyze the patient's cardiac rhythm or defibril late and when assessing for a spontaneous pulse.