Valvular ****
Which type of murmur is observed in patients with chronic aortic valve regurgitation? 1 Diastolic murmur 2 Austin Flint murmur 3 Holosystolic murmur 4 Loud midsystolic murmur
2 Rationale: An Austin Flint murmur occurs in patients with chronic aortic valve regurgitation. Mitral valve stenosis involves diastolic murmur. Holosystolic murmur occurs in patients with mitral valve prolapse. Loud midsystolic murmur occurs in patients with tricuspid and pulmonic stenosis.
A patient with a transplanted heart has developed heart valve disease. What should the nurse include in the patient teaching? Select all that apply. 1 Avoid pregnancy. 2 Avoid strenuous physical exercise. 3 Notify the health care provider for planned dental work. 4 If the valve disease was caused by rheumatic fever, prophylactic antibiotics will be prescribed. 5 If on anticoagulation therapy, the international normalized ratio (INR) will need to be checked annually.
2, 3, 4 Raitonale: Patients should avoid strenuous physical exercise because damaged valve may not handle the increased cardiac output (CO) demand. Any planned invasive or dental work requires the patient to notify the health care provider. If the valve disease was caused by rheumatic fever, prophylactic antibiotics will be prescribed. Pregnancy is not contraindicated; however, prophylactic antibiotic therapy may be administered to prevent endocarditis. If on anticoagulation therapy, the international normalized ratio (INR) will need to be checked regularly (more frequently than just annually).
The nurse assesses a patient and suspects acute mitral valve regurgitation (MR). Which symptoms support the nurse's suspicion? Select all that apply. 1 Palpitations 2 Cool extremities 3 Peripheral edema 4 Thready, peripheral pulses 5 Audible third heart sound (S3)
2, 4 Rationale: Mitral regurgitation is a valvular heart disease that causes backward flow of blood from the left ventricle to the left atrium due to incomplete valve closure during systole. Acute mitral regurgitation is characterized by thready peripheral pulses and cool extremities. Palpitations, peripheral edema, and an audible third heart sound (S3) are symptoms of chronic mitral regurgitation.
A patient is admitted to the hospital with a diagnosis of acute mitral valve regurgitation. What is the priority nursing intervention? 1 Auscultate the lung sounds. 2 Observe for bloody sputum. 3 Assess for water-hammer pulse. 4 Palpate lower extremities for edema.
1 Rationale: Auscultation of the lung sounds is the priority nursing intervention in acute mitral valve regurgitation. In acute mitral valve regurgitation there is a rapid increase in left atrial pressure and volume, which leads to pulmonary congestion, resulting in pulmonary edema and possible cardiogenic shock. Hemoptysis can occur with mitral valve stenosis, not acute mitral valve regurgitation. Lower extremity edema is a manifestation of tricuspid stenosis. Water-hammer pulse is a manifestation of chronic, severe aortic valve regurgitation.
The nurse finds diastolic murmurs in a patient who says, "I'm finding it hard to breathe, and sometimes I cough up blood." What condition does the nurse suspect? 1 Mitral valve stenosis 2 Aortic valve stenosis 3 Mitral valve prolapse 4 Aortic valve regurgitation
1 Rationale: Coughing up of blood from the bronchi, larynx, or lungs is known as hemoptysis, and difficulty breathing is dyspnea. Hemoptysis, dyspnea, and diastolic murmurs indicate mitral valve stenosis. Aortic valve stenosis is characterized by angina, dyspnea, syncope, and left ventricular failure. Mitral valve prolapse is an abnormality of the mitral valve leaflets and the papillary muscles that involves dysrhythmias, ventricular tachycardia, palpitations, light-headedness, and dizziness. Aortic valve regurgitation is associated with abrupt dyspnea, chest pain, left ventricular failure, and cardiogenic shock.
A patient seeks information about the advantages of minimally invasive valvuloplasty surgery. What should the nurse say to explain the procedure to the patient? Select all that apply. 1 "It is associated with less pain." 2 "It can lead to postoperative atrial fibrillation." 3 "It involves a shorter length of stay in the hospital." 4 "It is associated with a higher risk of sternal infection." 5 "It is more likely that a postoperative blood transfusion will be needed."
1, 2, 3 Rationale: Minimally invasive valvuloplasty surgery involves a mini-sternotomy. Hence, there is a shorter hospital stay because a small surgical wound takes less time to heal. Postoperative atrial fibrillation is reported in this procedure due to the surgery on the valves but is less common than with open surgical valvuloplasty. Because the procedure is minimally invasive, there is less postoperative pain. The procedure carries a lesser risk of sternal infection due to the small incision. Also, fewer blood transfusions are needed compared to open valvuloplasty because the blood loss is typically minimal.
A patient with aortic valve stenosis is receiving nitroglycerin. What should the nurse include in the medication teaching? Select all that apply. 1 It can worsen chest pain. 2 It is given to treat angina. 3 It can cause hypotension. 4 It is given to control heart palpitations. 5 It is a drug of choice in mitral valve prolapse.
1, 2, 3 Rationale: Nitroglycerin is used with caution in patients with aortic valve stenosis to treat angina. This is because it can significantly reduce blood pressure and worsen chest pain due to a decrease in preload and a drop in blood pressure. The drug causes hypotension through dilation of blood vessels. It is not recommended in mitral valve prolapse because the chest pain in mitral valve prolapse does not respond to antianginal treatment. Also, nitroglycerin is not administered for controlling palpitations.
The nurse assesses a 70-year-old patient during a follow-up visit. The patient has progressive valvular disease caused by rheumatic fever. Which interventions are appropriate for the nurse to perform? Select all that apply. 1 Encourage planned rest periods. 2 Ensure ongoing prophylactic therapy. 3 Encourage persistent physical exercise. 4 Evaluate the effectiveness of medication. 5 Discuss the recommendation for a mechanical valve replacement.
1, 2, 4 Rationale: 5 Discuss the recommendation for a mechanical valve replacement. When assessing a patient with progressive valvular disease caused by rheumatic fever, the nurse should ensure ongoing prophylaxis to prevent recurrence. The nurse should encourage the patient to plan rest periods and should evaluate the effectiveness of medication. The patient should avoid persistent physical exercise to prevent fatigue and dyspnea; instead, the patient should have an appropriate exercise plan to increase cardiac tolerance. It is preferable for patients over 65 years of age to undergo biologic valve replacement rather than mechanical valve replacement because the latter involves higher risk of bleeding from anticoagulants.
A patient has undergone surgery for a valve replacement. Which statements indicate that the patient understands the instructions from the nurse? Select all that apply. 1 "I should wear a Medic Alert device." 2 "I will start a vigorous aerobic exercise program." 3 "Valve surgery has completely cured my disease." 4 "I will need to take antibiotics when I have my teeth extracted." 5 "I should contact my health care provider if I have a respiratory infection."
1, 4, 5 Rationale: It is advisable for this patient to wear a Medic Alert device to provide information in case of an emergency. Antibiotic prophylaxis prior to invasive dental procedures (such as extraction) is necessary to prevent endocarditis. Respiratory infections should be treated with antibiotics because some microorganisms may damage the valves of the heart. Also, valve surgery only relieves the symptoms and does not cure the disease; therefore, regular follow-up is important to monitor the disease progression. Strenuous physical exercise should be avoided because the valve may be unable to accommodate the associated increase in cardiac output. The extent of physical exercise should be prescribed by the health care provider.
The nurse conducts a complete physical assessment on a patient admitted with suspected infective endocarditis (IE). Which diagnostic finding is indicative of the disorder? 1 Heart rate of 50 2 Retinal hemorrhages 3 Respiratory rate of 10 4 Feeling of impending doom
2 Rationale: Retinal hemorrhages are associated with IE. A feeling of impending doom is not a clinical manifestation. Tachycardia and tachypnea are also clinical manifestations.
The nurse should include which instructions when teaching a patient with mitral valve prolapse about self-care? Select all that apply. 1 Avoid caffeine. 2 Avoid all exercise. 3 Avoid heavy lifting or isometric exercises. 4 Avoid ephedrine in over-the-counter medications. 5 Use antibiotics prophylactically prior to a procedure. 6 Immediately report shortness of breath, fatigue, and palpitations.
1, 4, 6 Rationale: The nurse will teach a patient with mitral valve prolapse to immediately report shortness of breath, fatigue, palpitations, or other symptoms such as anxiety to the healthcare provider, or if necessary, activate the emergency response system. Avoiding caffeine and ephedrine will prevent heart palpitations. The patient is encouraged to begin or maintain an exercise program to maintain optimal health. The use of antibiotics prior to a procedure is not necessary with mitral valve prolapse. Instructing a patient to avoid heavy lifting or isometric exercises is reserved for patients with a symptomatic or a pathologic cardiac condition such as cardiomyopathy.
A patient is scheduled for a percutaneous transluminal balloon valvuloplasty. What information should the nurse provide to the patient before the procedure? Select all that apply. 1 It has few complications. 2 It requires a surgical incision. 3 It is performed in an operating room. 4 The procedure is difficult but has good results. 5 Long-term results are similar to surgical commissurotomy.
1, 5 Rationale: Percutaneous transluminal balloon valvuloplasty is an alternative treatment for patients with valvular disease. It is an easy procedure with few complications, because the approach for the procedure is transcutaneous; therefore, it is a minimally invasive procedure. The long-term results are similar to those of surgical commissurotomy with regard to the function of the repaired valve. The surgery is performed in a cardiac catheterization laboratory and not in an operating room. The procedure is not difficult and does not require a surgical incision.
Which questions are appropriate for the nurse to ask to assess the cognitive-perceptual patterns of a patient diagnosed with valvular heart disease? Select all that apply. 1 "Do you experience angina?" 2 "Do you experience fainting?" 3 "Do you experience dizziness?" 4 "Do you experience orthopnea?" 5 "Do you experience atypical chest pain?"
1, 5 Rationale: While assessing the effect of valvular heart disease on a patient's cognitive-perceptual pattern, it is appropriate to ask if the patient has angina and atypical chest pain. Cognitive perceptual pattern understands how a patient perceives and responds to sensory input. Angina and chest pain indicates the presence of an effect on nociceptors that send signals to the brain and spinal cord. The sensation is known by the sensation-generating mechanism defined by the modality of receptors. Asking the patient about fainting, dizziness, and orthopnea helps in assessing the activity-exercise functional health pattern.
The nurse is assessing a patient with chronic aortic regurgitation in the emergency unit of a health care facility. The nurse expects to find which heart sound? 1 S3 gallop 2 Water-hammer pulse 3 Loud accentuated S1 4 Low-pitched diastolic murmur
2 Rationale: The nurse assessing a patient with chronic aortic regurgitation would find a strong, quick beat that collapses immediately, known as water-hammer pulse. Heart sounds may include a soft or absent S1, S3, or S4 and a soft, high-pitched diastolic murmur. Low-pitched diastolic murmur and loud accentuated S1 are observed in mitral valve stenosis. An S3 gallop is found in patients with chronic mitral valve regurgitation.
The nurse reviews a list of potential candidates for valve replacement surgery. When considering the two types of prosthetic valves available, the nurse identifies that which patients are more likely to receive a biologic valve? Select all that apply. 1 A 20-year-old man 2 A 67-year-old man 3 A 35-year-old man 4 A 12-year-old boy 5 A 32-year-old woman
2, 5 Rationale: The 32-year-old woman is of childbearing age and cannot take anticoagulant therapy, which is required after mechanical valve replacement. Taking long-term anticoagulant therapy may increase the risk of bleeding during future pregnancies; therefore, she would be considered for a biologic valve. Biologic valves are less durable than mechanical valves. In a 67-year-old man, durability is less important than the side effects of anticoagulant therapy, such as the risk of bleeding from anticoagulants. Hence, a biologic valve is preferred. A 20-year-old boy, 35-year-old man, and 12-year-old boy are all younger patients; hence, a mechanical valve is best for them because of its durability.
The nurse assesses a patient with valvular heart disease. The nurse recalls that the absence of what heart sound is indicative of aortic valve stenosis? 1 Absence of S1 2 Absence of S2 3 Absence of S3 4 Absence of S4
2 Rationale: Aortic stenosis occurs as the result of rheumatic fever and is characterized by a diminished or absent S2. A diminished or absent S1, S3, or S4 is associated with aortic valve regurgitation.
The nurse is caring for an older patient that is diagnosed with pulmonic stenosis. The nurse anticipates that which type of conservative therapy may be prescribed? 1 Annuloplasty 2 Balloon valvuloplasty 3 Mitral commissurotomy 4 Sapien Transcatheter Heart Valve (THV)
2 Rationale: Balloon valvuloplasty or percutaneous transluminal balloon valvuloplasty (PTBV) is generally indicated for older adults and for those who are poor surgery candidates. PTBV is used for mitral, tricuspid, and pulmonic stenosis. Annuloplasty is the reconstruction of annulus that is beneficial in patients with mitral or tricuspid regurgitation. Mitral commissurotomy or valvulotomy is used in patients with pure mitral stenosis. Sapien Transcatheter Heart Valve (THV) is beneficial in patients with atrial stenosis.
The nurse performs an international normalized ratio (INR) blood study for a patient two months after the patient underwent mitral valve replacement surgery. The patient has been receiving warfarin therapy since the surgery. The INR value is 3.1. The nurse should take what action? 1 Prepare to administer a vitamin K injection. 2 Maintain the patient at the same warfarin dose. 3 Request a prescription for a higher dose of warfarin. 4 Instruct the patient to stop taking the warfarin until the INR level decreases.
2 Rationale: International normalized ratio (INR) values of 2.5 to 3.5 are therapeutic for patients with mechanical valves, so it is not necessary to change the dose. The patient should not stop taking the warfarin or take a higher dose. Vitamin K is the antidote for warfarin, and it is not necessary to take because the INR is in a therapeutic range.
A patient that has undergone valve replacement takes warfarin. The patient asks the nurse why regular international normalized ratio (INR) tests are prescribed. What explanation should the nurse give to emphasize the importance of this test? Select all that apply. 1 To prevent endocarditis 2 To determine proper dosage 3 To prolong durability of valves 4 To determine patency of valves 5 To determine adequacy of therapy
2, 5 Rationale: The INR must be checked regularly if the patient is on anticoagulation therapy to determine the proper dosage. A high or low INR may require the dose to be adjusted. INR is also tested to determine the adequacy of anticoagulation. If the anticoagulant is not adequate, blood clots may form. If anticoagulation is more than adequate, there is an increased risk of bleeding. The test cannot indicate endocarditis or patency or durability of valves.
While auscultating a patient who underwent trauma, the nurse auscultates a quick, strong heartbeat that collapses immediately. The patient has severe dyspnea and describes the chest pain as 8 out of 10 on the pain scale. Which condition does the nurse suspect? 1 Aortic valve stenosis 2 Mitral valve stenosis 3 Aortic valve regurgitation 4 Mitral valve regurgitation
3 Rationale: A quick, strong beat that collapses immediately is known as water-hammer pulse. Water-hammer pulse, dyspnea, and chest pain due to trauma indicate aortic regurgitation (AR). Aortic stenosis (AS) is characterized by angina, exertional dyspnea, syncope, and left ventricular failure. Mitral valve stenosis involves exertional dyspnea, hoarseness, hemoptysis, chest pain, and seizures. Mitral valve regurgitation is associated with weakness, fatigue, palpitations, and dyspnea.
Which diagnostic study is used to assess congenital heart disease in a patient? 1 Chest x-ray 2 Doppler color-flow imaging 3 Real time 3-D echocardiography 4 Computerized tomography scan
3 Rationale: Real-time 3-D echocardiography is used to assess mitral valve defects and congenital heart disease. Chest x-ray reveals heart size, altered pulmonary circulation, and valve calcification. Doppler color-flow imaging and transesophageal echocardiography help diagnose and monitor valvular heart disease progression. Computerized tomography scan with contrast gold helps diagnose aortic disorders.
What assessment findings does the nurse expect when caring for a patient with mitral valve stenosis? Select all that apply. 1 Syncope 2 Orthopnea 3 Palpitations 4 Atrial fibrillation 5 Exertional dyspnea
3, 4, 5 Rationale: The overloaded left atrium places the patient at risk for atrial fibrillation. Dyspnea on exertion and palpitations may also occur. Orthopnea occurs with aortic valve regurgitation. Syncope occurs with mitral valve prolapse.
A patient with valvular heart disease is hospitalized. The nurse anticipates a prescription for which diagnostic tests that monitor heart disease progression? Select all that apply. 1 Chest x-ray 2 Electrocardiogram (ECG) 3 Doppler color-flow imaging 4 Real-time 3-D echocardiography 5 Transesophageal echocardiography
3, 5 Rationale: Transesophageal echocardiography and Doppler color-flow imaging help to diagnose and monitor progression of valvular disease. A chest x-ray reveals heart size, altered pulmonary circulation, and valve calcification. Real-time 3-D echocardiography helps to assess mitral valve and congenital heart diseases. An ECG identifies heart rate, rhythm, and any ischemia or ventricular hypertrophy.
Which diagnostic study is used to diagnose mitral valve prolapse? 1 Electrocardiogram 2 Cardiac catheterization 3 Real-time 3-D echocardiography 4 CT scan of the chest with contrast
3. Rationale: Echocardiogram is the diagnostic study that is used to diagnose mitral valve prolapse. All echocardiograms are done in two or three dimensions. Echocardiogram is used to monitor progression of valvular heart disease. A CT scan of the chest with contrast is the gold standard for evaluating aortic disorders. An electrocardiogram is used to identify heart rate, rhythm, ischemia, or ventricular hypertrophy. Cardiac catheterization is used to detect pressure changes in the cardiac chambers.
Which complication occurs due to obstruction to aortic outflow during increased activity? 1 Angina 2 Fatigue 3 Dyspnea 4 Syncope
4 Rationale: Syncope occurs when blood flow is obstructed and is insufficient to meet the demands associated with activity. Increased left ventricular muscle mass by the hypertrophic ventricular myocardium will result in angina. A decrease in cardiac output and in exercise-induced flow obstruction leads to fatigue. Dyspnea occurs due to increased left ventricular diastolic pressure.
A patient with a history of rheumatic fever is diagnosed with mitral valve stenosis. The patient is scheduled for prosthetic valve replacement surgery. The nurse should inform the patient that what protective mechanism will be implemented after the surgery? 1 Exercise plan to increase cardiac tolerance 2 β-adrenergic blockers to control palpitations 3 Immunosuppressive therapy to prevent rejection 4 Antibiotic prophylaxis for dental manipulation involving the gums of the teeth
4 Rationale: The patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Immunosuppressive therapy is not necessary. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.
A patient has been diagnosed with mitral valve prolapse. What should be included in the treatment plan of the patient? Select all that apply. 1 Fluid restriction 2 Maintain bed rest 3 Nitrates for chest pain 4 Avoiding caffeine or ephedrine 5 β-adrenergic blockers to control palpitations
4, 5 Rationale: A patient with mitral valve prolapse should avoid caffeine or ephedrine because these can exacerbate the symptoms. The patient should also be kept hydrated to maintain hemodynamic stability. β-adrenergic blockers should be prescribed for palpitations and chest pain. Inactivity may cause stasis of blood; hence, bed rest is not recommended. The patient with mitral valve prolapse does not respond to antianginal treatment such as nitrates when administered for chest pain.
A patient with atrial fibrillation has been scheduled to undergo biologic valve replacement surgery. What should the nurse tell the patient about the benefits of a biologic valve versus a mechanical valve? Select all that apply. 1 Biologic valves do not leak. 2 Biologic valves are more durable. 3 Biologic valves do not cause endocarditis. 4 Biologic valves lower the risk of tissue rejection. 5 Biologic valves do not require anticoagulation therapy.
4, 5 Rationale: Biologic valves are made from bovine, porcine, or human tissues. Therefore they have a low risk of eliciting an immune response and tissue rejection. Because they have low thrombogenicity, they do not require anticoagulation therapy, unlike mechanical valves. However, biologic valves may tend to leak or cause endocarditis, similarly to mechanical valves. Biologic valves are also less durable than mechanical valves.
The nurse is auscultating the heart sounds of a patient with valvular heart disease. Which assessment findings may indicate mitral valve regurgitation? Select all that apply. 1 An Austin Flint murmur 2 A soft S1 heart sound 3 A prominent S4 heart sound 4 A diminished S2 heart sound 5 Audible third heart sound (S3) 6 A loud holosystolic murmur at the apex radiating to the left axilla.
5, 6 Rationale: Auscultation of heart sounds in the presence of mitral valve regurgitation reveals an audible third heart sound (S3), even with normal left ventricular function, because of increased left ventricular volume. The murmur is a loud holosystolic murmur at the apex radiating to the left axilla. A systolic murmur, a soft S1 heart sound, a prominent S4heart sound, and a diminished S2 heart sound are found upon assessment of aortic valve stenosis. An Austin Flint murmur is due to aortic regurgitation, originating at the mitral valve when blood enters simultaneously from both the aorta and the left atrium.
