Adult Health 1 Exam 1 - Cardiac

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? a. slurred speech b. irregular pulse c. dependent edema d. persistant fatigue

slurred speech The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with a fib. Slurred speech can indicate inadequate circulation by the brain because of an embolus. The nurse should report this finding immediately.

What is paroxysmal nocturnal dyspnea?

sudden awakening from sleeping with shortness of breath

A nurse is providing discharge reaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statement is appropriate response by the nurse? a. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink" b. "Each glass contains 8 oz. There are 30 mL per oz, so you can have a total of 8 glasses or cups of fluid per day." c. "This is the same as 2 quarts or about the same as 2 pots of coffee" d. "Take sips of water or ice chips so you will not take in too much fluid"

"Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink" Visual guide and helps plan

What is cardiogenic shock?

A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart.

A client arrives at the ED with an exacerbation of left-sided heart failure and reports a shortness of breath. Which is the priority nursing intervention?

Assess oxygen saturation

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?

persistent cough May indicate an onset of left-sided failure.

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? a. Obtain the client's weight b. Assist the client into high-Fowler's position c. Auscultate lung sounds d. Check O2 saturation with pulse oximeter

Assist the client into high-Fowler's position Using the airway, breathing, and circulation (ABC_ priority approach to client care. This will decrease venous return to the heart (preload) and help relieve lung congestion.

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patients medical history, what is a potential primary cause of the patients heart failure? A) Endocarditis B) Pleural effusion C) Atherosclerosis D) Atrial-septal defect

Atherosclerosis

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Atrial fibrillation The altered electrical stimulation impairs myocardial contraction and decreases overall efficiency of myocardial function.

A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? a. 1 medium apple b. 1 medium baked potato c. 1 slice toast with 1 tbsp peanut butter d. 1 large scrambled egg

Baked potato

What is a key diagnostic indicator of heart failure?

Brain natriuretic peptide (BNP) High levels of BNP is a sign of high cardiac filling pressure.

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

preload

Which particular areas should be to examined to assess peripheral edema?

Dependent parts of the body such as feet, ankles, fingers, hands, sacrum.

What is the importance of the BNP lab?

Confirms diagnosis of heart failure and directs the aggressiveness of the treatment.

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath

Confusion and bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia.

What medication reverses digitalis toxicity?

Digoxin immune FAB

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

Distended neck veins Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness

Which medication is classified as a loop diuretic? a. furosemide b. spironolactone c. chlorthalidone d. chlorothiazide

Furosemide (Lasix) Commonly used to treat cardiac failure. Ethacrynic acid is also a loop diuretic.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

A nurse is assessing a client with congestive heart failure for jugular vein distention. Which observation is important to report to the physician? a. no JVD present b. JVD is noted 2 cm above the sternal angle c. JVD is noted at the level of the sternal angle d. JVD is noted 4 cm above the sternal angle

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

Describe the difference between left- and right-sided heart failure.

Left-side heart failure results in adequate output from the left ventricle, leading to poor tissue perfusion. Systolic failure includes an ejection fraction below 40% with pulmonary and systemic congestion. Diastolic failure includes stiffening or inadequate relaxation of the ventricle. Right-sided heart failure results in inadequate output from the right ventricle, leading to systemic venous congestion and peripheral edema.

A nurse is teaching a client who is starting to take an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify his provider if he experiences which common adverse effect of this medication?

Persistent cough Persistent cough is an adverse effect of ace inhibitors. The client should report this finding to the provider and discontinue the medication.

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy

Pulmonary edema As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patients 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

A nurse is caring for a client who was admitted for treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness with an irregular heart rate. Which action should the nurse take first?

Review serum electrolyte values Weakness and irregular heart rate indicate that a client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The nurse should particularly look at potassium levels because the client is at risk for dysarrythmias from hypokalemia.

What is a potassium-sparing diuretic used in the treatment of heart failure?

Spironolactone

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings. Select all that apply. a. Tachypnea b. Persistent cough c. Increased urinary output d. Thick, yellow sputum e. Orthopnea

Tachypnea Persistent cough - with pink, frosty sputum Orthnopea

Older adults with heart and blood vessel diseases are susceptible to _________ because of impaired mobility, reduced activity, and compromised circulation.

Thrombophlebitis an inflammatory process that causes a blood clot to form and block one or more veins

The nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a. Weight gain of 0.9 kg (2 lbs) in 24 hours. b. Increase in 10 mm Hg in systolic blood pressure c. Dyspnea with exertion d. Dizziness when rising quickly

Weight gain of 0.9 kg (2 lbs) in 24 hours. When using urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the weight gain. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

Which nursing intervention should a nurse perform when a client with a valvular disorder of the heart has a heart rate less than 60 beats per min before administering a beta-blocker?

Withold the drug and inform the primary care provider.

A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? a. absence of adventitious breath sounds b. presence of nonproductive cough c. decrease in respiratory rate at rest d. 86% O2 Sat

absence of adventitious breath sounds Adventitious breath sounds occur when there is fluid in the lungs. The absence indicates that the pulmonary edema is resolving.

Which term describes the amount of resistance to ejection of blood from the ventricle?

afterload

A client has been diagnosed with congestive heart failure. What is the cause of the crackles heard in the bases of the lungs?

pulmonary congestion

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? Select all that apply. a. 1 slice cheddar cheese b. 1 medium beef hot dog c. 3 oz Atlantic salmon d. 3 oz roasted chicken breast e. 2 oz leaned baked ham

cheddar cheese salmon chicken

Which assessment parameter is important for the client diagnoses with congestive heart failure? a. excess tears b. crepitus c. photosensitivity d. distended veins

d. distended veins During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for: dyspnea auscultates apical heart rate counts radial heart rate measures BP checks for distended neck veins documents any signs of peripheral edema, lethargy, or confusion

What is dyspnea upon exertion?

difficulty breathing with activity

Which is a cerebrovascular manifestation of heart failure? a. nocturia b. tachycardia c. ascites d. dizziness

dizziness Cerebrovascular manifestations of heart failure include dizziness, lightheadness, and confusion.

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? a. dyspnea upon exertion b. tracheal deviation c. pericardial rub d. weight loss

dyspnea upon exertion Dilated cardiomyopathy is the enlargement of the myocardium. Dyspnea upon exertion is due to ventricle compromise and decreased cardiac output.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

echocardiogram

Which term describes the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole?

ejection fraction (EF)

What is digoxin used for?

heart failure

What is hyperpnea?

increased rate and depth of respirations

Which is a characteristic of right sided heart failure? a. jugular vein distention b. pulmonary crackles c. cough d. dyspnea

jugular vein distention

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of this medication? a. shortness of breath b. lightheadedness c. dry cough d. metallic taste

lightheadedness Furosemide can cause a significant drop in BP, resulting in lightheadedness or dizziness.

Where is cyanosis observed?

lips and earlobes

medication that inhibits sodium and chloride reabsorption at the ascending loop of Henle

loop diuretic

Which is a manifestation of right sided heart failure? Select all that apply. a. systemic venous congestion b. reduction in forward flow c. reduction in cardiac output d. accumulation of blood in the lungs

systemic venous congestion (reduction in forward flow is a manifestation of both left and right HF)

medication that inhibits reabsorption of sodium and chloride at the distal renal tubule

thiazide diuretic

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)? A) The patient takes Lasix (furosemide) 20 mg/day. B) The patients potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patients age is greater than 65.

HF 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 physicians office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for HF. The fact that the patient takes Lasix 2 mg/day does not indicate an increased risk for HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate an increased risk for HF

What is the hallmark of systolic heart failure?

low ejection fraction (EF) Although a low EF is a hallmark of heart failure, the severity of heart failure is is frequently classified according to the patient's symptoms

When a client has increased difficulty breathing when laying flat, the nurse records the that the client is demonstrating:

orthopnea Clients with orthopnea prefer to not lie flat and will need to maintain their beds in a semi- to high fowler's position

What is the term that describes the amount of blood that pumped out of the ventricle with each contraction?

stroke volume

Chlorothiazide and chlorthalidone are categorized as:

thiazide diuretics

What is a classic sign of cardiogenic shock? a. increased urinary output b. hyperactive bowel sounds c. tissue hypoperfusion d. high blood pressure

tissue hypoperfusion Tissue hypoperfusion is manifested as hypoxia (restlessness, confusion, agitation). Other signs - decreased urinary output, hypoactive bowel sounds, low bp

What is digitalis toxicity?

toxic drug effects from administration of digoxin

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A) Monitor liver function studies B) Monitor for hypotension C) Assess the patients vitamin D intake D) Assess the patient for hyperkalemia

Monitor for hypotension Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients 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.

A nurse is assessing a client who has left- sided heart failure. Which of the following manifestations should the nurse expect to find? a. increased abdominal girth b. weak peripheral pulses c. jugular venous neck distention d. dependent edema

weak peripheral pulses Related to decreased cardiac output resulting from left-sided failure.