143 Module 3 - Heart Failure (PRACTICE QUESTIONS)

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)? A. decrease in renal perfusion B. vasodilation of skin C. dehydration D. increased blood volume ejected from ventricle

A. A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tamponade has been relieved? A. Decrease in central venous pressure (CVP) B. Increase in CVP C. Absence of cough D. Decrease in blood pressure

A. A resulting decrease in CVP and an associated increase in blood pressure after withdrawal of pericardial fluid indicate that the cardiac tamponade has been relieved. An absence of cough would not indicate the absence of cardiac tamponade.

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? A. The client says his rings have become tight and are difficult to remove. B. The client says that he has been urinating less frequently at night. C. The client says he is short of breath when ambulating. D. The client says he has been hungry in the evening.

A. Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.

A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis? A. orthopnea B. bibasilar rales cleared with coughing C. resting bradycardia D. increased appetite

A. Decreased left ventricular function would be characterized by orthopnea, dyspnea, anorexia, bibasilar rales not cleared with coughing, and resting tachycardia.

A client presents to the emergency department with rales, wheezing, and blood-tinged sputum. The nurse should select interventions to address what health problem? A. pulmonary edema B. cardiomegaly C. valvular heart disease D. cardiomyopathy

A. In left-sided heart failure, the left ventricle pumps inefficiently resulting in a backup of blood into the lungs causing pulmonary vessel congestion and fluid leaks into the alveoli and lung tissue. As more fluid continues to collect in the alveoli, pulmonary edema develops. The client will present with rales, wheezes, blood-tinged sputum, low oxygenation, and development of a third heart sound. Cardiomyopathy can occur as a result of a viral infection, alcoholism, anabolic steroid abuse, or a collagen disorder. It causes muscle alterations and ineffective contraction and pumping. Cardiomegaly is an enlargement of the heart due to compensatory mechanisms in congestive heart failure (CHF) and leads to ineffective pumping and eventually exacerbated CHF. Valvular heart disease leads to an overload of the ventricles because the valves do not close adequately causing blood to leak backward. This causes muscle stretching and increased demand for oxygen and energy.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema? A. decreased left ventricular pumping B. increased right atrial resistance C. increased left atrial contractility D. decreased right ventricular elasticity

A. Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A. Facilitate the presence of friends and family whenever possible. B. Teach the client about the harmful effects of anxiety on cardiac function. C. Provide supplemental oxygen, as needed. D. Provide validation of the client's expressions of anxiety. E. Administer benzodiazepines two to three times daily.

ANS: A, C, D Rationale: The nurse should empathically validate the client's sensations of anxiety. The presence of friends and family is frequently beneficial, and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some clients, but alternative methods of relief should be prioritized. As well, medications are given on a PRN basis. Teaching the client about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.

The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock? A. The client admitted with acute renal failure B. The client admitted following an MI C. The client admitted with malignant hypertension D. The client admitted following a stroke

ANS: B Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and clients experiencing a stroke are at risk for thrombus formation, the client admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.

The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise? A. Do not exercise unsupervised. B. Eventually aim to work up to 30 minutes of exercise each day. C. Keep exercising but slow down if you get dizzy or short of breath. D. Start your exercise program with high-impact activities.

ANS: B Rationale: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not necessarily required and the emergence of symptoms, such as dizziness or shortness of breath, should prompt the client to stop exercising, not simply to slow the pace. Low-impact activities should be prioritized.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry cough D. Orthopnea

ANS: B Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure.

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication? A. Pulmonary edema B. Pericardiocentesis C. Cardiac tamponade D. Pericarditis

ANS: C Rationale: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart, eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and pulmonary edema do not result from this pathophysiologic process.

The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem? A. Pericarditis B. Cardiomyopathy C. Pulmonary edema D. Right ventricular hypertrophy

ANS: C Rationale: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.

The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for? A. Jugular vein distention B. Right upper quadrant pain C. Bibasilar fine crackles D. Dependent edema

ANS: C Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? A. Monitor and record blood pressure daily. B. Monitor and record radial pulses daily. C. Monitor weight daily. D. Monitor bowel movements.

ANS: C Rationale: To assess fluid balance at home, the client should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.

The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action? A. Palpate the client's carotid pulse. B. Illuminate the client's call light. C. Begin performing chest compressions. D. Activate the Emergency Response System (ERS).

ANS: D Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.

The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first? A. Check for a carotid pulse. B. Apply supplemental oxygen. C. Give two full breaths. D. Gently shake and shout, Are you OK?

ANS: D Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A. A diastolic blood pressure that is lower during exhalation B. A diastolic blood pressure that is higher during inhalation C. A systolic blood pressure that is higher during exhalation D. A systolic blood pressure that is lower during inhalation

ANS: D Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.

A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient's care would consider which physiology when explaining this disorder to the patient's family? 1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema. 2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema. 3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema. 4. The arteries of the pulmonary circuit are single layer.

Answer: 2 Explanation: 1. The pulmonary circuit is normally a low-pressure system. 2. There are no valves in the pulmonary veins, so when pressures elevate in the left heart (left heart failure) it results in blood backing up into the lungs and increased pulmonary vascular pressure. This pressure results in pulmonary edema. 3. The blood that enters the pulmonary circuit is oxygen-poor. 4. The capillaries in the lungs are single layer, but the arteries have three layers.

A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse? 1. I still sleep better in a recliner. 2. I do pretty well as long as I don't try to do too much at one time. 3. My heart rate runs around 60 to 64 most of the time. 4. I've gained 4 pounds since yesterday.

Answer: 4 Explanation: 1. Since this patient says I still there is no indication of change in status. 2. Spacing out of activities is a technique taught to patients with heart failure. This patient is reporting success with this strategy. 3. A heart rate of 60 to 64 is common in patients with heart failure due to the effects of medication. 4. A weight gain of 3 to 4 pounds in 24 hours indicates an increase in fluid volume status and should be further evaluated.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? A. Assessing for peripheral edema B. Weighing the client daily at the same time each day C. Assessing the client's vital signs every 4 hours D. Checking the client's lungs for crackles during every shift

B. Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered? A. A ventriculogram B. An echocardiogram C. An electrocardiogram D. A chest x-ray

B. Increasing shortness of breath (dyspnea) and fatigue are common signs of left-sided heart failure (HF). However, some of the physical signs that suggest HF may also occur with other diseases, such as renal failure and chronic obstructive pulmonary disease; therefore, diagnostic testing is essential to confirm a diagnosis of HF. Assessment of ventricular function is an essential part of the initial diagnostic workup. An echocardiogram is usually performed to determine the ejection fraction, identify anatomic features such as structural abnormalities and valve malfunction, and confirm the diagnosis of HF.

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload? A. Head of the bed elevated 30 degrees and legs elevated on pillows B. Head of the bed elevated 45 degrees and lower arms supported by pillows C. Prone with legs elevated on pillows D. Supine with arms elevated on pillows above the level of the heart

B. Preload refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the client's weight on the shoulder muscles.

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of A. myocardial infarction. B. pulmonary embolism. C. pneumonia. D. pulmonary edema.

B. Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided heart failure? A. weight loss B. ascites C. resting bradycardia D. warm extremities

B. Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? A. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction. B. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. C. The pericardial space is eliminated with scar tissue and thickened pericardium. D. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction.

B. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

The pathophysiology of pericardial effusion is associated with all of the following except: A. Inability of the ventricles to fill adequately. B. Increased venous return. C. Increased right and left ventricular end-diastolic pressures. D. Atrial compression.

B. Venous return is decreased (not increased) with Pericardial effusion because there is an increase in the pericardial fluid, which raises the pressure within the pericardial sac and compresses the heart. Increased right and left ventricular end-diastolic pressures, inability of the ventricles to fill adequately, and atrial compression are all effects of pericardial effusion.

The nurse is performing an initial assessment of a client diagnosed with heart failure (HF) that includes the client's sensorium and level of consciousness (LOC). Why is the assessment of the client's sensorium and LOC important in clients with HF? A. The most significant adverse effect of medications used for HF treatment is altered LOC. B. Decreased LOC causes an exacerbation of the signs and symptoms of HF. C. HF ultimately affects oxygen transportation to the brain. D. Clients with HF are susceptible to overstimulation of the sympathetic nervous system.

C. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in clients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular (CV).

The nurse is interviewing a client during an initial visit at a cardiologist's office. What symptom will the nurse expect to find as an early symptom of chronic heart failure? A. nocturia B. irregular pulse C. fatigue D. pedal edema

C. Fatigue is commonly the earliest symptom of chronic heart failure; it is caused by decreased cardiac output and tissue oxygenation. Pedal edema and nocturia are symptoms of heart failure, but they occur later in the course of the condition. An irregular pulse can be a complication of heart failure, but it is not necessarily an early indication of the condition.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? A. JVD is noted 2 cm above the sternal angle. B. JVD is noted at the level of the sternal angle. C. JVD is noted 4 cm above the sternal angle. D. No JVD is present.

C. JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure.

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? A. Hypotension B. Decreased urinary output C. Dyspnea on exertion D. Tachycardia

C. Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.

Which describes difficulty breathing when a client is lying flat? A. Bradypnea B. Tachypnea C. Orthopnea D. Paroxysmal nocturnal dyspnea (PND)

C. Orthopnea occurs when the client is having difficulty breathing when lying flat. Sudden attacks of dyspnea at night are known as paroxysmal nocturnal dyspnea. Tachypnea is a rapid breathing rate and bradypnea is a slow breathing rate.

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? A. Jugular venous distention B. Pedal edema C. Pulmonary congestion D. Nausea

C. When the left ventricle cannot effectively pump blood out of the ventricle into the aorta, the blood backs up into the pulmonary system and causes congestion, dyspnea, and shortness of breath. All the other choices are symptoms of right-sided heart failure. They are all symptoms of systolic failure.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? A. The development of chronic obstructive pulmonary disease (COPD) B. The development of right-sided heart failure C. The development of left-sided heart failure D. The development of cor pulmonale

C. When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.

A new client has been admitted with right-sided heart failure. When assessing this client, the nurse knows to look for which finding? A. Dyspnea B. Cough C. Jugular venous distention D. Pulmonary congestion

C. When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.

A 65-year-old client presents to the health care provider's office with reports of shortness of breath on exertion, edema in the ankles, and waking up in the middle of the night unable to breathe. The nurse suspects that the symptoms are indicative of which condition? A. Asthmatic bronchitis B. Pulmonary edema C. Myocardial infarction D. Heart failure

D. Cardinal manifestations of HF are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention resulting in pulmonary congestion and peripheral edema.

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)? A. Ascites B. Tachycardia C. Nocturia D. Dizziness

D. Cerebrovascular manifestations of heart failure stemming from decreased brain perfusion include dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow.

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience? A. Increased perspiration B. Increased urine output C. Sleeping in a chair or recliner D. Gradual unexplained weight gain

D. Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.

The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? A. My best time of the day is the morning. B. I've stopped eating foods with salt, though I miss the taste. C. I eat six small meals a day when I am hungry. D. I'm having trouble going up the steps during the day.

D. Difficulty with activities like climbing stairs is an indication of a lessened ability to exercise. Eating small meals and not using salt are usually indicated for clients with heart failure. The client's assertion about morning being the best time of day is a vague statement.

The nurse is assessing a newly admitted client with chest pain. What medical disorder is most likely causing the client to have jugular vein distention? A. abdominal aortic aneurysm B. pneumothorax C. myocardial infarction (MI) D. heart failure

D. Elevated venous pressure, exhibited as jugular vein distention, indicates the heart's failure to pump. Jugular vein distention isn't a symptom of abdominal aortic aneurysm or pneumothorax. If severe enough, an MI can progress to heart failure, but an MI alone doesn't cause jugular vein distention.

Which is a manifestation of right-sided heart failure? A. Paroxysmal nocturnal dyspnea B. Accumulation of blood in the lungs C. Increase in forward flow D. Systemic venous congestion

D. Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.

A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure? A. Left-sided heart failure B. Chronic heart failure C. Acute heart failure D. Right-sided heart failure

D. Signs and symptoms of Right Ventricular Failure include: Weakness; Ascites; Weight gain; Nausea, vomiting; Dysrhythmias; Elevated central venous pressure; Jugular vein distention. The scenario does not indicate whether the heart failure is chronic or acute. Therefore, options A, B, and C are incorrect.

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? A. Serum electrolytes B. Complete blood count (CBC) C. Blood urea nitrogen (BUN) D. B-type natriuretic peptide (BNP)

D. The BNP level is a key diagnostic indicator of HF; high levels are a sign of high cardiac filling pressure and can aid in both the diagnosis and management of HF

The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy? A. decreased right ventricular workload B. decreased renal perfusion C. decreased peripheral perfusion to the extremities D. decreased left ventricular workload

D. The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The therapeutic effect is decreased left ventricular workload. The IABP does not change right ventricular workload. The IABP increases perfusion to the coronary and peripheral arteries. The renal perfusion is not affected by IABP.

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? A. moist, gurgling respirations B. increased cardiac output C. drowsiness, numbness D. hypertension

A. Clients with acute pulmonary edema experience sudden dyspnea, wheezing, orthopnea, cough, cyanosis, and tachycardia. Respirations sound moist or gurgling. Drowsiness and numbness are not considered issues. Increased cardiac output is not part of this checklist. Hypertension is not an immediate symptom.

The nurse is caring for a client experiencing a rapidly developing pericardial effusion. Which assessment findings indicate to the nurse that the client is developing cardiac tamponade? Select all that apply. A. Jugular vein distention B. Distant heart sounds C. Anuria D. Dyspnea E. Tachycardia

A, B, D, E. Pericardial fluid may build up slowly without causing noticeable symptoms until a large amount (1 to 2 L) accumulates. However, a rapidly developing effusion can quickly stretch the pericardium to its maximum size and cause an acute problem. As pericardial fluid increases, pericardial pressure increases, reducing venous return to the heart and decreasing CO. This can result in cardiac tamponade, which causes low CO and obstructive shock. Symptoms of cardiac tamponade include dyspnea, tachycardia, distant heart rounds, and jugular vein distention. Anuria is not a symptom of cardiac tamponade.

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.) A. Dyspnea B. Ascites C. Cough D. Pulmonary crackles E. Jugular vein distention

A, C, D. The clinical manifestations of pulmonary congestion associated with left-sided heart failure include dyspnea, cough, pulmonary crackles, and low oxygen saturation levels, but not ascites or jugular vein distention.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure? A. An S3 heart sound B. Pleural friction rub C. Faint breath sounds D. A heart murmur

ANS: A Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Heart failure does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of heart failure.

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A. Improve functional status B. Prevent endocarditis. C. Extend survival. D. Limit physical activity. E. Relieve client symptoms.

ANS: A, C, E Rationale: The overall goals of management of heart failure are to relieve the client's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care.

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A. Right-sided heart failure B. Acute pulmonary edema C. Pneumonia D. Cardiogenic shock

ANS: B Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia

The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? A. Monitoring liver function studies B. Blood pressure C. Vitamin D intake D. Monitoring potassium levels

ANS: B Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.

The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect

ANS: C Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure.

The nurse is caring for a client with heart failure. What are the management goals for the client with heart failure? Select all that apply. A. Increasing preload and afterload B. Promoting a healthy lifestyle C. Reducing the amount of circulating blood volume D. Increasing cardiac output by strengthening muscle contractions E. Lowering the risk for hospitalization

B, D, E. The management of a client with heart failure includes promotion of a healthy lifestyle, increasing cardiac output by strengthening muscle contractions, and lowering the risk for hospitalization. There is no need to reduce circulating blood volume for clients with heart failure. The goal in treating heart failure is to decrease preload and afterload, both of which increase stress on the ventricular wall, causing an increase in the workload of the heart.

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure? A. Supraventricular tachycardia B. Atrial fibrillation C. Sinus tachycardia D. First-degree heart block

B. Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? A. Right ventricular function B. Left ventricular function C. Left atrial function D. Right atrial function

B. The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

Which feature is the hallmark of systolic heart failure? A. Basilar crackles B. Pulmonary congestion C. Low ejection fraction (EF) D. Limited activities of daily living (ADLs)

C. A low EF is a hallmark of systolic heart failure (HF); the severity of HF is frequently classified according to the client's symptoms.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure? A. Serum electrolytes B. Electrocardiogram (ECG) C. Echocardiogram D. Blood urea nitrogen (BUN)

C. An echocardiogram is usually performed to confirm the diagnosis of heart failure. ECG, serum electrolytes, and a BUN are usually completed during the initial workup.

The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? A. decreased O2 saturation levels B. oliguria C. S4 ventricular gallop sign D. pitting edema

D. The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be? A. 30% B. 55% C. 65% D. 5%

A. The ejection fraction is normal in diastolic heart failure, but severely reduced in systolic heart failure. The normal EF is 55%-65%. An EF of 5% is not life sustaining and an EF of 30% is about half the normal percentage.

A client has been admitted to a health care center with reports of dyspnea. The nurse suspects left-sided heart failure based on which assessment finding? A. Orthopnea B. Weight gain C. Pitting edema D. Nocturia

A. The nurse should assess for orthopnea in clients with left-sided heart failure. Orthopnea is a condition where the client has difficulty breathing when lying down. The other features of left ventricular failure include a hacking cough or wheezing, restlessness, and anxiety. Nocturia, pitting edema, and weight gain are associated with right-sided heart failure.

A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. Which action is the nurse's best action? A. Rapidly assess the client's cardiopulmonary status. B. Arrange for an electrocardiogram (ECG). C. Increase the height of the client's bed. D. Manage the client's anxiety.

ANS: A Rationale: Client management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a priority over ECG monitoring, management of anxiety, or repositioning of the client, even though each of these actions may be appropriate and necessary.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. My pants don't fit around my waist. B. I don't have the same appetite I used to. C. I sleep on three pillows each night. D. My feet are bigger than normal.

C. Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result? A. Acute pulmonary edema B. Right-sided heart failure C. Right ventricular hypertrophy D. Left-sided heart failure

ANS: A Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The client quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided heart failure, left-sided heart failure, and right ventricular hypertrophy do not directly occur.

The nurse is providing client education prior to a client's discharge home after treatment for heart failure. The nurse gives the client a home care checklist as part of the discharge teaching. What should be included on this checklist? A. Know how to recognize and prevent orthostatic hypotension. B. Weigh yourself weekly at a consistent time of day. C. Measure everything you eat and drink until otherwise instructed. D. Limit physical activity to only those tasks that are absolutely necessary.

ANS: A Rationale: Clients with heart failure should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client? A. In a high Fowler position B. On the left side-lying position C. In a flat, supine position D. In the Trendelenburg position

ANS: A Rationale: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation.

The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client? A. Insertion of an implantable cardioverter defibrillator (ICD) B. Insertion of an implantable pacemaker C. Administration of a calcium channel blocker D. Administration of a beta-blocker

ANS: A Rationale: In clients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an ICD can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the client with left ventricular dysfunction.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi? A. Atrial fibrillation B. Infective endocarditis C. Recurrent pneumonia D. Recent surgery

ANS: A Rationale: Intracardiac thrombi are especially common in clients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.

A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela? A. Stroke B. Myocardial infarction (MI) C. Hemorrhage D. Peripheral edema

ANS: A Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema.

The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure? A. The client takes furosemide 20 mg/day. B. The client's potassium level is 4.7 mEq/L. C. The client is white. D. The client's age is greater than 65.

ANS: D Rationale: Heart failure is the most common reason for hospitalization of people older than 65 years of age and is the second-most common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does not indicate an increased risk for heart failure, although this drug is often used in the treatment of heart failure. The client being white indicates a decreased risk for heart failure compared with Black and Hispanic clients.

The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated? A. Teach the client deep breathing and coughing exercises. B. Administer supplemental oxygen at all times. C. Limit the client's activity level. D. Avoid positioning the client supine.

ANS: D Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of heart failure and, consequently, the nurse should avoid positioning the client supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.

A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis? 1. I often have headaches early in the morning. 2. I have some numbness in my feet. 3. I wake up a lot at night. 4. I find I bruise more easily now.

Answer: 3 Explanation: 1. Morning headaches are not associated with heart failure. 2. Sensation loss is not associated with heart failure. 3. Paroxysmal nocturnal dyspnea or sudden dyspnea at night is a classic symptom of heart failure and can awaken a patient from sleep. 4. Bleeding tendencies are not associated with heart failure.

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit? A. The client shows signs of aneurysm rupture. B. The client is in the early stage of right-sided heart failure. C. The client is experiencing heart failure. D. The client is going into cardiogenic shock.

D. This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.