Adult Health II Quiz 2: Heart Failure / Infectious & Inflammatory Cardiac Disorders

The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? a) Rheumatic fever b) Croup c) Severe staphylococcal infection d) Medullary sponge kidney

Answer: A Rationale: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.

A physical assessment finding that the nurse would expect to be present in the patient with acute left-sided heart failure is a) bubbling crackles and dyspnea b) hepatosplenomegaly and tachypnea c) peripheral edema and cool, diaphoretic skin d) frothy, blood-tinged sputum and distended jugular veins

Answer: A Rationale: Clinical manifestations of cute left-sided heart failure are those of pulmonary edema, with bubbling crackles and tachycardia; frothy, blood-tinged sputum; severe dyspnea; tachypnea; and orthopnea. Severe tachycardia and cool, clammy, skin are present as a result of stimulation of the sympathetic nervous system from hypoxemia. Systemic edema reflected by jugular vein distention, peripheral edema, and hepatosplenomegaly are characteristic of right-sided heart failure.

The health care provider prescribes spironolactone (Aldactone) for the patient with chronic heart failure. Diet modification related to the use of this drug that the nurse includes in patent teaching include a) decreasing both sodium and potassium intake b) increasing calcium intake and decreasing sodium intake c) decreasing sodium intake and increasing potassium intake d) decreasing sodium intake and using salt substitutes for seasoning

Answer: A Rationale: Spironolactone is a potassium-sparing diuretic, and when it is the only diuretic used in the treatment of heart failure, moderate to low levels of potassium should be maintained to prevent development of hyperkalemia. Sodium intake is usually reduced to at least 2300 mg/day in patients with heart failure, but salt substitutes cannot be freely used because most contain high concentrations of potassium.

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation? a) exertion dyspnea b) confusion c) elevated creatine phosphokinase concentration d) chest pain

Answer: A Rationale: Weight gain, due to fluid retention and worsening heart failure, causes exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow.

A patient with myocardial infarction is developing cariogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the patient for? a) bradycardia b) ventricular dysrhythmias c) rising diastolic blood pressure d) falling central venous pressure

Answer: B Rationale: Classic signs of cariogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The complication the nurse will constantly observe for is: a) presence of heart murmur b) systemic emboli c) fever d) congestive heart failure

Answer: B Rationale: Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever, and night sweats may be present, but do not indicate a problem with emboli. CHF may be a result, but this is not as dangerous an outcome as emboli

The pathophysiologic mechanism that results in the pulmonary edema of left-sided heart failure is a) increased right ventricular preload b) increased pulmonary hydrostatic pressure c) impaired alveolar oxygen and carbon dioxide exchange d) increased lymphatic flow of pulmonary extravascular fluid

Answer: B Rationale: In left-sided heart failure, blood backs up into the pulmonary veins and capillaries. This increased hydrostatic pressure in the vessels causes fluid to move out of the vessels and into the pulmonary interstitial space. When increased lymphatic flow cannot remove enough fluid from the interstitial space, fluid moves into the alveoli, resulting in pulmonary edema and impaired alveolar oxygen and carbon dioxide exchange. Initially the right side of the heart is not involved.

Drugs that the nurse would expect to be prescribed for patients with a mechanical valve replacement include: a. oral nitrates b. anticoagulants c. atrial antidysrhythmics d. beta adrenergic blocking agents

Answer: B Rationale: Patients with mechanical valves have an increased risk for thrombus formation as a result of RBC lysis. Therefore prophylactic anticoagulation therapy is used to prevent thrombus formation and systemic or pulmonary embolization. Nitrates are contraindicated for the patient with aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve. Antidysrhythmics are used only if dysrhythmias occur, and alpha or beta adrenergic blocking agents may be used to control the HR as needed.

When assessing a patient with a diagnosis of left ventricular failure, the nurse expects to identify: a) crushing chest pain b) dyspnea on exertion c) jugular vein distention d) extensive peripheral edema

Answer: B Rationale: Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing.

A patient is admitted to the medical unit with a diagnosis of right ventricular heart failure. The nursing assessment that supports this medical diagnosis is: a) nocturnal orthopnea b) distended jugular veins c) shortness of breath on exertion d) decreased arterial blood pressure

Answer: B Rationale: Symptoms of right ventricular heart failure relate to retention of fluid; neck veins become distended because of increased back pressure from the right atrium.

A patient with acute pericarditis has markedly distended jugular veins, decreased BP, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes that these symptoms occur when: a) the pericardial space is obliterated with scar tissue and thickened pericardium b) excess pericardial fluid compresses the heart and prevents adequate diastolic filling c) the parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction d) fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

Answer: B Rationale: The patient is experiencing a cardiac tamponade that consists of excess fluid in the pericardial sac, which compresses the heart and the adjoining structures, preventing normal filling and cardiac output. Fibrin accumulation, a scarred and thickened pericardium, and adherent pericardial membranes occur in chronic constrictive pericarditis.

The diagnostic test that is most useful in differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease is a) exercise stress testing b) a cardiac catheterization c) b-type natriuretic peptide (BNP) levels d) determination of blood urea nitrogen (BUN)

Answer: C Rationale: bNP is released from the ventricles in response to ventricular stretch and is a good marker for heart failure. If bNP is elevated, shortness of breath is due to heart failure; if the bNP is normal, dyspnea is due to pulmonary disease. bNP opposes the actions of the renin-angiotensin-aldosterone system (RAAS), resulting in vasodilation and reduction of blood volume. Exercise stress testing and cardiac catheterization are more important tests to diagnose coronary artery disease, and although BUN may be elevated in heart failure, it is a reflection of decreased renal perfusion.

What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? a) Cardiac pacemaker b) Hypothermia-hyperthermia machine c) Defibrillator d) Intra-aortic balloon pump

Answer: D Rationale: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.

The nurse is evaluating the condition of a client after pericardicentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? a) rising blood pressure b) clearly audible heart sounds c) client expressions of relief d) rising central venous pressure

Answer: D Rationale: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The patient usually expresses immediate relief. Heart sounds are no longer muffled or distant.

The nurse determines that additional discharge teaching is needed when the patient with chronic heart failure says, a) "I will take my pulse every day and call the clinic if it is irregular or less than 50." b) "I should hold my digitalis and call a doctor if I experience nausea and vomiting." c) "I plan to organize my household tasks so I don't have to constantly go up and down the stairs." d) "I should weigh myself every morning and go on a diet if I gain more than 2 or 3 pounds in 2 days."

Answer: D Rationale: Further teaching is needed if the patient believes that a weight gain of 2 to 3 pounds in 2 days is an indication for dieting. In a patient with heart failure, this type of weight gain reflects fluid retention and is a sign of heart failure that should be reported to the health care provider.

A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The nurse suspects that the patient is experiencing: a) vegetative embolization to the coronary arteries b) pulmonary embolization from valve vegetations c) nonspecific manifestations that accompany infectious diseases d) valvular incompetence with possible infectious invasion of the myocardium

Answer: D Rationale: The dyspnea, crackles, and restlessness the patient is manifesting are symptoms of heart failure and decreased cardiac output (CO) that occurs in up to 80% of patients with aortic valve endocarditis as a result of aortic valve incompetence. Vegetative embolization from the aortic valve occurs throughout the arterial system and may affect any body organ. Pulmonary emboli occur in right-sided endocarditis.

The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a) aorta b) right atrium c) superior vena cava d) pulmonary circulation

Answer: D Rationale: When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.

Identify whether the following statements are true (T) or false (F). _____a. Systolic failure is characterized by abnormal resistance to ventricular filling. _____b. A primary risk factor for heart failure is coronary artery disease. _____c. A common cause of diastolic failure is left ventricular hypertrophy. _____d. The mechanisms by which hypervolemia acts as a precipitating cause of heart failure include decreasing cardiac output (CO) and increasing the workload and oxygen requirements of the myocardium. _____e. Systolic heart failure results in a normal left ventricular ejection fraction.

Answers: a. F, systolic failure --> diastolic failure b. T c. T d. F, hypervolemia --> dysrhythmia e. F, normal --> reduced

The nurse in a medical unit is caring for a patient with heart failure. The patient suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. a) administering oxygen b) inserting a Foley catheter c) administering furosemide (Lasix) d) administering morphine sulfate intravenously e) transporting the patient to the coronary care unit f) placing the patient in a low Fowler's side-lying position *you will never have a SATA question on your quizzes, however, they frequently show up on the HESI and NCLEX exams*

Answers: 1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the patient is placed in high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

Assessment of an IV cocaine user with infective endocarditis should focus on which signs and symptoms (select all that apply). a) splinter hemorrhages b) presence of Osler's nodes c) Painless nodules over bony prominences d) painless erythematous macules on the palms and soles *you will never have a SATA question on your quizzes, however, they frequently show up on the HESI and NCLEX exams*

Answers: A, B, D Rationale: Clinical manifestations of infective endocarditis may include splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) on the palms and soles.