Hinkle Chapter 28: Management of Patients with Structural, Infectious and Inflammatory Cardiac Disorders

During a teaching session, a client who is having a valvuloplasty tomorrow asks the nurse about the difference between a mechanical valve replacement and a tissue valve. What answer from the nurse is correct?

"A mechanical valve is thought to be more durable and so requires replacement less often." Mechanical valves are thought to be more durable than tissue valves and so require replacement less often. Tissue valves are less likely to generate blood clots and so long-term anticoagulation therapy is not required. Homografts (human valves) are not always available and are very expensive.

An asymptomatic client questions the nurse about mitral regurgitation and inquires about continuing exercises. Which is the most appropriate response by the nurse?

"Continue exercising until mild symptoms develop" Exercise is not limited until mild symptoms develop. It is not important for an asymptomatic client to avoid exercise or to take ample rest after exercise.

An asymptomatic client questions the nurse about the diagnosis of mitral regurgitation and inquires about continuing an exercise routine. Which is the most appropriate response by the nurse?

"Continue the exercise routine unless symptoms such as shortness of breath or fatigue develop." Exercise is not limited until mild symptoms develop. Once symptoms of heart failure develop, the client needs to restrict his or her activity level to minimize symptoms. It is not important for an asymptomatic client to avoid exercise and to take ample rest after exercise.

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching?

"I can still drink coffee and tea" The client requires more teaching if he states that he may drink coffee and tea. Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.

The nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement?

"I have to call my doctor so I can get antibiotics before seeing the dentist" Antibiotic prophylaxis is recommended for high-risk clients immediately before and sometimes after dental procedures.

When teaching a client with rheumatic carditis and a history of recurrent rheumatic fever, which statement by the client indicates that teaching has been successful?

"I may have to take prophylactic antibiotics for up to 10 years" Antibiotic prophylaxis for recurrent rheumatic fever with rheumatic carditis may require 10 or more years of antibiotic coverage (e.g., penicillin G intramuscularly every 4 weeks, penicillin V orally twice a day [BID], sulfadiazine orally daily, or erythromycin orally BID). Clients with a history of rheumatic fever are susceptible to infective endocarditis and should be asked to take prophylactic antibiotics before any invasive procedure, including dental work. Steroids are prescribed to suppress the inflammatory response and aspirin to control the formation of blood clots around heart valves. Activities that require minimal activity are recommended to reduce the work of the myocardium and counteract the boredom of weeks of bed rest.

A client with a confirmed DVT is being discharged from the ED. Which client statement indicates that the client has received proper nursing instruction and understands how to manage this condition?

"I need to do my leg exercises five times or more every hour" Exercise prevents venous stasis by promoting venous circulation, relieves swelling, and reduces pain. Promoting venous blood flow prevents the formation of thrombi and subsequent potential for emboli in the unaffected extremity. Bending the knees is contraindicated for a client with DVT because it interferes with venous circulation and may increase the size of the existing clot or contribute to the formation of additional thrombi. Clients with DVT should apply warm, moist compresses to the area of discomfort because warmth dilates blood vessels, improves circulation, and relieves swelling, all of which relieve discomfort; moist heat is more comforting than dry heat. Adequate fluid volume dilutes blood cells in plasma and reduces the risk for platelet aggregation.

The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse. What statement made by the client demonstrates understanding of the teaching?

"I will avoid caffeine, alcohol, and smoking" The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse. What statement made by the client demonstrates understanding of the teaching?

A nurse is teaching a client who is awaiting a heart transplant. Which statement indicates the client understands what is required to help minimize rejection?

"I will need to take three different types of medications for the rest of my life to help prevent rejection." Clients who have had heart transplants are constantly balancing the risk of rejection with the risk of infection. They must adhere to a complex regimen of diet, medications, activity, follow-up laboratory studies, biopsies of the transplanted heart (to diagnose rejection), and clinic visits. Three classes of medications are prescribed for a transplant client to help minimize rejection: corticosteroids (e.g., prednisone), calcineurin inhibitors (tacrolimus, cyclosporin), and antiproliferative agents (mycophenolate mofetil, azathioprine, or sirolimus).

A client needs to have a cardiac valve replacement. The nurse offers client education about the procedures involved—including the benefits and risks. Which client statement indicates the need for more education?

"I'm anxious because I'll need to have a cardiopulmonary bypass" Cardiopulmonary bypass is not normally required for valve replacement, though it is kept available as an option should the need arise. Minimally invasive techniques generally involve less pain, trauma, and blood loss than alternative techniques.

The nurse completes an assessment of a client with mitral regurgitation. What statement represents the appropriate physical finding for a client with this condition?

"The high-pitched blowing sound at the apex is indicative of a systolic murmur." A systolic murmur is heard as a high-pitched, blowing sound at the apex. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath on exertion, and cough from pulmonary congestion also occur. A mitral click will be present with valve replacement. A diastolic murmur is not heard with mitral regurgitation.

A nurse and a nursing student are performing a physical assessment of a client with pericarditis. The client has an audible pericardial friction rub on auscultation. When leaving the room, the student asks the nurse what causes the sound. The nurse's best response is which of the following?

"The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other" A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid due to inflammation. The rub is audible on auscultation and is synchronous with the heartbeat. The layers of the heart never become loose from each other. The great vessels are not in contact with the inside of the pericardium, where the inflammation is located. The lungs have nothing to do with a pericardial friction rub.

A nurse is teaching a client about valve replacement surgery. Which statement by the client indicates an understanding of the benefit of an autograft replacement valve?

"The valve is made from my own heart valve, and I will not have to take any blood thinning drugs when I am discharged" Autografts (i.e., autologous valves) are obtained by excising the client's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the client's own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age, young adults, clients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.

A client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" What is the nurse's best response?

"You are at risk of developing an infection in your heart" The patient is at risk for endocarditis and should take prophylactic antibiotics before any invasive procedure. Antibiotics have nothing to do with how much the teeth bleed. Cleaning of the teeth will not cause the valve to malfunction. Using the word "vegetative" with the patient may not be understood; therefore, it is not the most appropriate answer.

A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider?

3.8 Warfarin patients usually have individualized target international normalized ratios (INRs) between 2 to 3.5 to maintain adequate anticoagulation. Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.

A client with mitral stenosis is admitted to the hospital. What assessment findings would indicate right ventricular failure?

Distended jugular veins, pedal edema, nausea Signs and symptoms of progressive right ventricular failure include distended jugular veins, pedal edema, and nausea resulting from blood backing up into the superior vena cava and inferior vena cava, jugular veins, and gastrointestinal tract. Dyspnea, orthopnea, and pulmonary edema are signs and symptoms of left-sided heart failure.

A client with aortic regurgitation is admitted to the hospital. Which assessment findings would indicate left ventricular failure?

Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND) Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea and PND. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right-sided heart failure.

A nurse is preparing home care instructions for a client with infective endocarditis. What will the nurse include in the instructions? Select all that apply.

Monitor intravenous catheter sites for signs of infection. Encourage oral hygiene at least twice daily with a soft toothbrush. Inform all health care providers of the history of endocarditis. Increased vigilance is required for patients with intravenous catheters and during invasive procedures. Equally important is ongoing good oral hygiene. Poor dental hygiene can lead to bacteremia, particularly in the setting of a dental procedure. Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures, so making dentists and other health care professionals aware of the history is important. Recording urine output is not necessary.

A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?

a client 4 days postoperative after mitral valve replacement Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.

The nurse is caring for a five-client assignment on a cardiac unit. In caring for which client would the nurse be most correct to assess for an effusion?

a client with chest trauma An effusion, which is the accumulation of fluid between two layers of tissue, commonly occurs with pericarditis, which is the inflammation of the pericardium. Common causes of pericarditis include endocarditis, myocarditis, chest trauma, post heart surgery, or a myocardial infarction. Clients with chest pain, aortic stenosis, and mitral valve prolapse have conditions without current inflammation.

The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's international normalized ratio is 2.7. What action will the nurse take?

administer the medication as ordered Patients with mechanical valve replacements who take warfarin usually have individualized target international normalized ratios (INRs) between *2.0 and 3.5*. The nurse would give the medication as ordered. There is no need to administer the antidote vitamin K. The medication should not be held because the INR is normal. The client should not have bleeding with the normal INR.

A nurse plans to have an education session with a client with cardiomyopathy and the client's spouse about ways to increase activity tolerance. What instructions would the nurse provide?

alternate active periods with rest periods The client should plan activities to occur in cycles, alternating rest with active periods. The client with cardiomyopathy must avoid strenuous activity and isometric exercises. It is impossible to avoid all physical and emotional stress.

The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse?

an extra heart sound Often the first and only sign of mitral valve prolapse is identified when a physical examination of the heart reveals an extra heart sound, referred to as a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral valve prolapse.

The medical plan of treatment for chronic mitral regurgitation would include medications to reduce afterload, such as:

angiotensin converting enzyme (ACE) inhibitors Afterload reduction refers to arterial dilation, which occurs with ACE inhibitors.

The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder?

aortic regurgitation The pulse pressure (i.e., difference between systolic and diastolic pressures) is considerably widened in patients with aortic regurgitation. One characteristic sign is the water-hammer (Corrigan's) pulse, in which the pulse strikes a palpating finger with a quick, sharp stroke and then suddenly collapses.

While assessing a patient with pericarditis, the nurse cannot auscultate a friction rub. Which action should the nurse implement?

ask the patient to lean forward and listen again The most characteristic sign of pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border. Having the patient lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. These assessment data are not life-threatening and do not require a call to the health care provider. The nurse should try multiple times to auscultate the friction rub before deciding that the rub is gone. Chest tubes are not the treatment of choice for not hearing friction rubs.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's first priority ?

assess the client for bleeding and notify the health care provider of the results For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the health care provider of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a health care provider's order. The nurse should notify the health care provider before holding a medication scheduled to be administered during another shift.

A nurse plans to have an education session with a client who has cardiomyopathy and the client's spouse about ways to decrease the sense of powerlessness. What action by the nurse will provide this information?

assist the client in identifying life areas over which the client still has control The client should be assisted to identify the things in life that have been lost. The nurse will then assist the client to identify the amount of control that the client still has (e.g., low-sodium food choices, medication schedule). The nurse should never encourage the client to forget what has been lost or change the subject if a client wants to talk about something. The nurse should encourage this discussion. It is important that the client adhere closely to a low-sodium diet. The nurse should encourage this adherence and never suggest otherwise.

A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed?

balloon percutaneous valvuloplasty Definitive treatment for aortic stenosis is surgical replacement of the aortic valve. Clients who are symptomatic, but not good surgical candidates may benefit from a one or two balloon percutaneous valvuloplasty. Antibiotic therapy will not open the valve. The client does not want to have a valve replacement of any kind.

A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complication(s)?

bleeding and infection Possible complications of an aortic balloon valvuloplasty include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, infection, and bleeding from the catheter insertion sites.

The nurse is assessing a client admitted with acute left-sided infective endocarditis. What is the best diagnostic test to confirm the diagnosis?

blood cultures A definitive diagnosis of acute left-sided infective endocarditis is made when a micro-organism is found in two separate blood cultures. A complete blood count, urinalysis, and a transesophageal echocardiogram may contribute to the diagnosis, but are not the most definitive diagnostic tests for endocarditis.

A client is diagnosed with mitral regurgitation. What does the nurse consider with the mechanics of cardiac hemodynamics?

blood flows backward from the left ventricle to the left atrium during systole When the mitral valve leaflets thicken, fibrose, and contract, they cannot close completely. With each heartbeat, blood is forced backward into the left atrium during systole. Regurgitation of blood into the left atrium causes the left atrial pressure to rise.

The client with which characteristic is considered at high risk for the development of infective endocarditis?

cyanotic congenital malformation The client who has unrepaired cyanotic disease is at high risk for the development of infective endocarditis. Clients with mitral valve prolapse with valvular regurgitation, hypertrophic cardiomyopathy, or acquired valvular dysfunction are at moderate risk for the development of infective endocarditis.

A patient has had a successful heart transplant for end-stage heart disease. What immunosuppressant will be necessary for this patient to take to prevent rejection?

cyclosporine Because of advances in surgical techniques and immunosuppressive therapies, heart transplantation is now a therapeutic option for patients with end-stage heart disease. Cyclosporine and tacrolimus are immunosuppressants that decrease the body's rejection of foreign proteins, such as transplanted organs.

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for?

cardiac tamponade The inflammatory process of pericarditis may lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade (see Chapter 29).

Which nursing intervention should a nurse perform when a client with cardiomyopathy receives a diuretic?

check regularly for dependent edema The nurse should regularly monitor for dependent edema if the client with cardiomyopathy receives a diuretic. Oxygen is administered either continuously or when dyspnea or dysrhythmias develop. Bed rest is not necessary. The nurse should ensure that the client's activity level is reduced and should sequence any activity that is slightly exertional between periods of rest.

A nurse evaluates a client and suspects pericarditis. What indicator is considered the most characteristic symptom of pericarditis?

chest pain The most characteristic symptom of pericarditis is chest pain. The pain is typically persistent, sharp, pleuritic, and usually felt in the mid chest, although it also may be located beneath the clavicle, in the neck, or in the left trapezius region. The discomfort is usually fairly constant, but is aggravated by deep inspiration, coughing, lying down, or turning. It may be relieved with a forward-leaning or sitting position.

A client is diagnosed with dilated cardiomyopathy. What is the most likely cause of the client's condition?

chronic alcohol abuse Chronic alcohol ingestion is one of the main causes of dilated cardiomyopathy. Other causes include history of viral myocarditis, an autoimmune response, and exposure to other chemicals in addition to alcohol. Heredity is considered the main cause of hypertrophic cardiomyopathy. Scleroderma is a connective tissue disorder thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.

The nurse is administering medications to a client with pericarditis. What medications will be commonly prescribed to treat pericarditis? Select all that apply.

colchicine ibuprofen prednisone Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, may be prescribed for pain relief during the acute phase. Indomethacin is contraindicated because it may decrease coronary blood flow. Corticosteroids (e.g., prednisone) may be prescribed if the pericarditis is severe or the patient does not respond to NSAIDs. Colchicine may also be used as alternative therapy.

A patient has been diagnosed with fused mitral leaflets, causing a backward flow of blood. What type of procedure does the nurse know is commonly performed for this type of problem?

commissurotomy The most common valvuloplasty procedure is commissurotomy. Each valve has leaflets; the site where the leaflets meet is called the commissure. Leaflets may adhere to one another and close the commissure (i.e., stenosis). Less commonly, leaflets fuse in such a way that in addition to stenosis, the leaflets also are prevented from closing completely, resulting in backward flow of blood (i.e., regurgitation). A commissurotomy is the procedure performed to separate the fused leaflets.

The nurse determines that a patient has a characteristic symptom of pericarditis. What symptom does the nurse recognize as significant for this diagnosis?

constant chest pain The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. Pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning.

A client with a history of cardiomyopathy experiences dyspnea on exertion, fatigue, leg swelling, and chest pain. This client has which type of cardiomyopathy?

dilated cardiomyopathy Dilated cardiomyopathy, the most common type, is accompanied by dyspnea on exertion and when lying down. The client experiences fatigue and leg swelling and may also have palpitations and chest pain. Peripartum cardiomyopathy may develop in women shortly before or after giving birth. Hypertrophic cardiomyopathy is associated with syncope, fatigue, SOB, and chest pain. Restrictive cardiomyopathy has symptoms of exertional dyspnea, dependent edema in the legs, ascites (fluid in the abdomen), and hepatomegaly (enlarged liver).

A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate the development of left ventricular failure?

dyspnea, orthopnea, and pulmonary edema Signs and symptoms of progressive left ventricular failure include breathing difficulties, such as orthopnea, PND, and pulmonary edema. Distended jugular veins, pedal edema, and nausea are signs and symptoms of right sided heart failure. A client with aortic regurgitation is admitted to the hospital. Which assessment findings would indicate left ventricular failure?

A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?

echocardiography Echocardiography is useful in detecting the presence of pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

A client is diagnosed with infective endocarditis. What laboratory values will the nurse assess? Select all that apply.

elevated C-reactive protein elevated erythrocyte sedimentation rate (ESR) elevated white blood cell (WBC) count Abnormal findings include anemia, elevated WBC counts, elevated ESR, and elevated c-reactive protein.

A client reporting heart palpitations is diagnosed with atrial fibrillation caused by mitral valve prolapse. To relieve the symptoms, the nurse should teach the client which dietary intervention?

eliminate caffeine and alcohol To minimize symptoms of mitral valve prolapse, the nurse should instruct the client to avoid caffeine and alcohol. The nurse encourages the client to read product labels, particularly on over-the-counter products such as cough medicine, because these products may contain alcohol, caffeine, ephedrine, and adrenaline, which may produce arrhythmias and other symptoms. The nurse also explores possible diet, activity, sleep, and other lifestyle factors that may correlate with symptoms.

A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart have begun to fail. The nurse will monitor the client carefully for which initial symptoms?

exertional dyspnea, orthopnea, and pulmonary edema When symptoms develop, clients with aortic stenosis usually first have exertional dyspnea, caused by increased pulmonary venous pressure from left heart failure. Orthopnea, paroxysmal nocturnal dyspnea, dizziness, and pulmonary edema may also occur. Nausea and vomiting may be signs of gastrointestinal congestion, but would be related to right heart failure, which does not occur initially with aortic stenosis.

The nurse suspects a client has developed pericarditis after a week of cold-like symptoms. Which of the client's signs and symptoms indicate pericarditis?

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema, result from acute renal failure.

The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?" The nurse is most safe to speculate which of the following?

from a break in the skin The microorganisms that cause infective endocarditis include bacteria and fungi. Streptococci and staphylococci are the bacteria most frequently responsible for this disorder. Both bacteria are abundantly found on the skin. These organisms are not found in the other locations.

A young mother brings her 4-year-old in to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The mother states the child has been healthy until about 3 weeks ago when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis?

group A beta hemolytic strep The inflammatory symptoms of rheumatic carditis are believed to be induced by antibodies originally formed to destroy the group A beta-hemolytic streptococcal microorganisms. Staphylococcus aureus and Streptococcus viridians are associated with infectious endocarditis. The Epstein-Barr virus is associated with myocarditis.

Which changes occur to the heart as a result of heart transplant?

heart beats faster than the natural heart The transplanted heart beats faster than the client's natural heart, averaging *90 to 110 beats/minute*, because sympathetic and vagus nerves that affect heart rate have been severed. The new heart also takes longer to increase the heart rate in response to exercise. Coronary artery disease is a common problem among heart transplant recipients.

Which type of graft is used when a heart valve replacement is made of tissue from an animal heart valve?

heterograft Heterograft, also called bioprosthesis, refers to replacement of tissue from animal tissue, usually pigs but also cows or horses. An autograft is a heart valve replacement made from the client's own heart valve. Allograft refers to replacement using human tissue and is a synonym for homograft.

A nurse reviewing a client's echocardiogram report reads the following statements: "The heart muscle is asymmetrically thickened and the overall size and mass are increased, especially along the septum. The ventricular walls are thickened, reducing the size of the ventricular cavities. Several areas of the myocardium show evidence of scaring." The nurse knows these manifestations are indicative of which type of cardiomyopathy?

hypertrophic In hypertrophic cardiomyopathy (HCM), the heart muscle asymmetrically increases in size and mass, especially along the septum. It often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole. The coronary arteriole walls are also thickened, which decreases the internal diameter of the arterioles. The narrow arterioles restrict the blood supply to the myocardium, causing numerous small areas of ischemia and necrosis. The necrotic areas of the myocardium ultimately fibrose and scar, further impeding ventricular contraction. Because of the structural changes, HCM had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH). Restrictive (or constrictive) cardiomyopathy (RCM) is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum?

hypertrophic Because of structural changes, hypertrophic cardiomyopathy had also been called idiopathic hypertrophic subaortic stenosis or asymmetric septal hypertrophy. Restrictive cardiomyopathy is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

Statistics show an increase in the prevalence of infective endocarditis among older adults. Which factor places older adults at risk for developing infective endocarditis?

increase use of prosthetic valve replacements The prevalence of infective endocarditis among older adults has increased in part due to the increased number of prosthetic valve replacements, including replacements for older adults, and an increase in hospital-acquired bacteremia. While history of a repaired congenital heart defect does place a client at greater risk for developing infective endocarditis in the future, it has not been shown as a contributing factor in the prevalence of infective endocarditis among older adults. IV drug use and IV drug abuse places individuals at greater risk for infective endocarditis. However, this risk has not been attributed to an increase in its prevalence among older adults. Tuberculosis is known to contribute to pericarditis among the general population and is not specific to the older adult client.

A nurse is teaching a client about mitral stenosis and the effect on blood flow in the heart. What is teaching point of the disruption to the normal flow of blood through the heart from the mitral stenosis? Which valve lies between the right ventricle and the pulmonary artery?

increased resistance of a narrowed orifice between the left atrium and the left ventricle Left atrial pressure increases because of the slowed blood flow into the LV through the narrowed orifice. The left atrium dilates and hypertrophies because of the increased blood volume. Pulmonary venous pressure rises, and the circulation becomes congested. As a result, the RV and right atrium become enlarged. Eventually, the ventricle fails.

What medication order would the nurse question for a patient being treated for pericarditis?

indomethacin Analgesic medications and NSAIDs such as aspirin or ibuprofen may be prescribed for pain relief during the acute phase of pericarditis. These agents also hasten reabsorption of fluid in patients with rheumatic pericarditis. *Indomethacin is contraindicated because it may decrease coronary blood flow*. Colchicine or corticosteroids (e.g., prednisone) may be prescribed if the pericarditis is severe or if the patient does not respond to NSAIDs. Colchicine also may be used instead of NSAIDs during the acute phase.

A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate:

infective endocarditis Subacute endocarditis infections progress insidiously over weeks to months with vague manifestations, such as headache, malaise, fatigue, and sleep disturbances. Small, painless, red-blue macular lesions or Janeway lesions may appear on the palms of the hands and soles of the feet. Clients with myocarditis may complain of sharp stabbing or squeezing chest discomfort that resolves upon sitting up. Clients with dilated cardiomyopathy are likely to experience fatigue and leg swelling and may also have palpitations and chest pain.

A nurse is admitting a client with hypertrophic cardiomyopathy (HCM). What medication order will the nurse question?

isosorbide dinitrate Isosorbide dinitrate is a nitrates that should be avoided in HCM to maintain cardiac output. Enalapril is an ACE inhibitor, metoprolol is a beta blocker, and spironolactone is an aldosterone antagonist used for HCM.

A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement?

keep the patient's affected leg straight Balloon valvuloplasty is performed in the cardiac catheterization laboratory. A catheter is inserted into the femoral artery. The patient must keep the affected leg straight to prevent hemorrhage at the insertion site. It is not an open heart surgery requiring chest tubes nor a chest dressing. ET tubes are placed when someone has general anesthesia, and this procedure is performed using light or moderate sedation.

A client who suffered blunt chest trauma in a motor vehicle accident reports chest pain during deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. To relieve this chest pain, which position should the nurse encourage the client to assume?

leaning forward while sitting The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, thus helping to relieve chest pain caused by pericarditis. The semi-Fowler's, supine, and prone positions don't cause this pulling-away action, and therefore, do not relieve chest pain associated with pericarditis.

Incomplete closure of the mitral valve results in backflow of blood from the:

left ventricle to left atrium Incompetent closure of the mitral valve can result from disease processes that alter valve leaflets, mitral annulus, chordae tendineae, and the papillary muscle. When mitral valve leaflets thicken, fibrose, and contract, they cannot close completely during systole. This forces blood backward from the left ventricle into the left atrium during systole.

A nurse is caring for a client with end-stage cardiomyopathy and the client's spouse asks the nurse to clarify one of the last treatment options available that the health care provider mentioned earlier. What option will the nurse most likely discuss?

left ventricular assist device When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Because of the limited number of organ donors, many clients die waiting. In some cases, a left ventricular assist device is implanted to support the failing heart until a suitable donor becomes available. The other three choices have to do with failing valves and valve repairs.

The nurse is caring for a client diagnosed with aortic stenosis prescribed digoxin. What clinical manifestation will be the rationale for the medication?

left ventricular dysfunction Digoxin may be used to treat left ventricular dysfunction. Diuretics may be used for dyspnea. Nitrates may be prescribed for the treatment of angina, but must be used with caution due to the risk of orthostatic hypotension and syncope.

Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis?

maintain the client on bedrest The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. The nurse should administer supplemental oxygen to relieve tachycardia that may develop from hypoxemia. If the client has a fever, the nurse should administer a prescribed antipyretic along with independent nursing measures like minimizing layers of bed linen, promoting air circulation and evaporation of perspiration, and offering oral fluids. The nurse should elevate the client's head to promote maximal breathing potential.

A patient at the clinic describes shortness of breath, periods of feeling "lightheaded," and feeling fatigued despite a full night's sleep. The nurse obtains vital signs and auscultates a systolic click. What does the nurse suspect from the assessment findings?

mitral valve prolapse Most people with mitral valve prolapse never have symptoms. A few have fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, or anxiety. Fatigue may occur regardless of activity level and amount of rest or sleep. Often the first and only sign of mitral valve prolapse is an extra heart sound, referred to as a mitral click. A systolic click is an early sign that a valve leaflet is ballooning into the left atrium.

The nurse is caring for a client with aortic regurgitation. What medication will the nurse administer to reduce afterload?

nitroprusside Vasodilators such as nitroprusside are used for afterload reduction to lower the volume and pressure overload of the left ventricle. Calcium channel blockers such as diltiazem are contraindicated due to their negative inotropic effects (decreases the strength of the contraction) and their potential to cause bradycardia. Beta blockers like metoprolol should be avoided to allow for compensatory tachycardia. Nitrates and isosorbide are used to treat angina.

The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following?

obtaining a throat culture When a child has a sore throat and symptoms of a possible infection occur, it is essential that a culture is obtained. A culture can identify group A beta-hemolytic streptococcal infection, which needs to be eliminated with use of an antibiotic. Warm, salt gargles; increasing fluids; and administering antiseptic lozenges are helpful for symptom control. Obtaining a throat culture is a priority.

A client with infective endocarditis (IE) and a fever is admitted to the intensive care unit. Which of these physician orders should the nurse implement first?

order blood cultures drawn from two sites Blood cultures (with each set including one aerobic and one anaerobic culture) drawn from different venipuncture sites over a 24-hour period (each set at least 12 hours apart), or every 30 minutes if the client's condition is unstable, should be obtained before any antimicrobial agents are administered. It is essential to obtain blood cultures before initiating antibiotic therapy in order to obtain accurate sensitivity results.

A client comes into the emergency department reporting about chest pain that gets worse when taking deep breaths and lying down. After ruling out a myocardial infarction, a nurse would assess for which diagnosis?

pericarditis The primary symptom of pericarditis is pain, which is assessed by evaluating the client in various positions. The nurse tries to identify whether pain is influenced by respiratory movements while holding an inhaled breath or holding an exhaled breath; by flexing, extending, or rotating the spine, including the neck; by moving the shoulders and arms; by coughing; or by swallowing. Recognizing events that precipitate or intensify pain may help establish a diagnosis and differentiate pain of pericarditis from pain of myocardial infarction.

The nurse has created a care plan for a client admitted with acute pericarditis and a nursing diagnosis of acute pain related to pericardial inflammation. What is an appropriate nursing intervention for this client?

placing the patient in the high flowers position with an over the bed table for the patient to lean on Clients with acute pericarditis require pain management with analgesics, positioning, and psychological support. Relief of pain is achieved by rest. Because sitting upright and leaning forward is the posture that tends to relieve pain, chair rest may be more comfortable. The pain has a sharp, pleuritic quality that changes with respiration, and patients take shallow breaths. Anti-inflammatory medications may be used to help pain; opioids are not usually indicated.

The nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis?

positive blood culture A positive blood culture identifies the microorganism circulating in the blood. Slight leukocytosis is common but can be associated with other disease processes. Serum cardiac antigens and immunosuppressant assay are not typical diagnostic studies.

The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer?

precordial pain Precordial pain is the main characteristic of pericarditis. Dyspnea, fever, and respiratory symptoms are not the main characteristics of pericarditis.

A patient with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this patient?

prepare for a pericardiocentesis The nurse notifies the physician immediately and prepares to assist with pericardiocentesis, the emergency treatment for cardiac tamponade. Cardiac enzymes may be elevated but would not be ordered nor would a 12-lead ECG. The nurse's assessment of the lungs and heart is not a collaborative, but an independent action.

Which mitral valve condition generally produces no symptoms?

prolapse Mitral valve prolapse is a deformity that usually produces no symptoms and has been diagnosed more frequently in recent years, probably as a result of improved diagnostic methods. Mitral valve stenosis usually causes progressive fatigue. Mitral valve regurgitation, in its acute stage, usually presents as severe heart failure. Mitral valve infection, when acute, produces symptoms typical of infective endocarditis.

Which valve lies between the right ventricle and the pulmonary artery?

pulmonic valve The pulmonic valve is a semilunar valve located between the right ventricle and the pulmonary artery. The tricuspid valve is an atrioventricular valve located between the right atrium and right ventricle. The mitral valve is an atrioventricular valve located between the left atrium and left ventricle. Chordae tendineae anchor the valve leaflets to the papillary muscle and ventricular wall.

A nurse is assigned to the medical intensive care unit. The nurse auscultates a water-hammer pulse. What will the sound resemble?

quick, sharp strokes that suddenly collapse With the water-hammer (*Corrigan's*) pulse, the pulse strikes the palpating finger with a quick, sharp stroke and then suddenly collapses. Water-hammer pulse is not low or high pitched. A clicking sound is heard with a valve replacement.

A client with infective endocarditis is assessed by the nurse for the presence of Janeway lesions. On inspection, the nurse recognizes these lesions by identifying which characteristic sign?

red or purple macules found on the palms of the hands Janeway lesions are painless, red or purple macules found on the palms and soles.

The nurse completes an assessment of a client admitted with pericarditis. What client symptom will the nurse correlate with the diagnosis of pericarditis?

reports of constant chest pain The most characteristic symptom of pericarditis is chest pain. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Other signs may include a mild fever, increased WBC count, anemia, and an elevated ESR or C-reactive protein level. Dyspnea and other signs and symptoms of heart failure may occur.

Which intervention should the nurse include in the plan of care for a client with valvular heart disease who is experiencing pulmonary congestion?

rest or sleep in a chair or sit in a bed with the head elevated Clients who experience symptoms of pulmonary congestion are advised to rest and sleep sitting in a chair or bed with the head elevated. In addition, the nurse educates the client to measure weight daily and report gains of 3 pounds in 1 day or 5 pounds in 1 week to the primary provider. The nurse may assist the client with planning activity and rest periods to achieve an acceptable lifestyle.

Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch.

restrictive cardiomyopathy (RCM) RCM may be associated with amyloidosis (amyloid, a protein substance, is deposited within cells) and other such infiltrative diseases. However, the cause is idiopathic in most cases. Hypertrophic cardiomyopathy occurs when the heart muscle asymmetrically increases in size and mass, especially along the septum. Dilated cardiomyopathy is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A client with a recent history of atrial fibrillation has been prescribed warfarin. What action will the nurse take to confirm safe dosing?

review the clients international normalized ratio (INR) Warfarin doses are adjusted on the basis of the client's INR. Blood levels are not taken for the drug, and the client's heart rate is not the indicator of efficacy or safety.

What is the most common cause of mitral stenosis?

rheumatic endocarditis Mitral stenosis is most often caused by rheumatic endocarditis, which progressively thickens the mitral valve leaflets and chordate tendineae. In adults, aortic stenosis is often a result of degenerative calcifications. Congestive heart failure and myocardial infarction are not the most common cause of mitral stenosis.

A nurse is conducting a heath history on a client with a primary diagnosis of mitral stenosis. Which disorder reported by the client is the most common cause of mitral stenosis?

rheumatic endocarditis Mitral stenosis is most often caused by rheumatic endocarditis, which progressively thickens the mitral valve leaflets and chordate tendineae. Leaflets often fuse together. Eventually, the mitral valve orifice narrows and progressively obstructs blood flow into the ventricle.

A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential to avoid which preventable disease?

rheumatic fever Rheumatic fever is a preventable disease. Diagnosing and effectively treating streptococcal pharyngitis can prevent rheumatic fever and thereby rheumatic heart disease.

The nurse is teaching a school community parent group about heart wellness. What risk factor is a common leading cause for mitral stenosis?

rheumatic fever The most significant risk factor for mitral stenosis is rheumatic fever, which gradually causes the mitral valve leaflets to thicken and can result in leaflet fusion. Risk factors for aortic regurgitation are infective endocarditis, Marfan syndrome, and a dissecting aortic aneurysm.

It is important for a nurse to be aware of the normal hemodynamics of blood flow to recognize and understand pathology when it occurs. The nurse should know that incomplete closure of the tricuspid valve results in a backward flow of blood from the:

right ventricle to the right atrium The tricuspid valve is located between the right atrium and the right ventricle. Therefore, incomplete closure results in the backward flow of blood from the right ventricle to the right atrium.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? r

risk for infection Clients with endocarditis have a Risk for infection. The nurse should stress to the client that he'll need to continue antibiotics for a minimum of 5 years and that he'll need to take prophylactic antibiotics before invasive procedures for life. There is no indication that the client has Chronic pain or Impaired memory. Because the client doesn't have valvular damage, Impaired gas exchange doesn't apply.

A nurse is caring for a client with acute mitral regurgitation related to an acute myocardial infarction. The nurse knows to monitor the client carefully for symptoms of which initial complication or result?

severe heart failure Acute mitral regurgitation usually manifests as severe congestive heart failure, resulting from blood flowing backward from the left ventricle to the left atria and eventually into the lungs. Kidney failure could become a problem later if cardiac output is too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation.

A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion?

shortness of breath Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitation (e.g., resulting from a myocardial infarction) usually manifests as severe congestive heart failure. Dyspnea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath upon exertion, and cough from pulmonary congestion also occur. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.

Which symptom occurs in the client diagnosed with mitral regurgitation when pulmonary congestion occurs?

shortness of breath If pulmonary congestion occurs, the client with mitral regurgitation develops shortness of breath. A loud, blowing murmur often is heard throughout ventricular systole at the apex of the heart. Hypertension may develop when reduced cardiac output triggers the renin-angiotensin-aldosterone cycle. Tachycardia is a compensatory mechanism when stroke volume decreases.

The nurse is teaching a client with an atrial septal defect (ASD) about atrial fibrillation. What risk factor will the nurse include with the teaching?

stroke Atrial fibrillation is common in patients with ASDs and further increases the risk of stroke. Anticoagulation with aspirin is often prescribed. Cardiomegaly, heart failure, and splenomegaly may occur with infective endocarditis.

Which action will a public health nurse include when planning ways to decrease the incidence of rheumatic fever in the community?

teach members in the community to seek medical treatment for streptococcal pharyngitis Prevention of acute rheumatic fever is dependent upon effective antibiotic treatment of streptococcal pharyngitis. Family history is not a risk factor for rheumatic fever. No immunization effectively decreases the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever.

A nurse is caring for a client newly diagnosed with mitral valve prolapse. The health care provider indicates the client has probably had this condition for years. What factor is important for the nurse to consider when teaching the client about valvular disease?

the client with mitral valve prolapse probably had not health symptoms Most people with mitral valve prolapse (which occurs more often in women) never have symptoms. Frequently, the first and only sign is identified during a routine physical assessment, when the examiner hears an extra heart sound on auscultation. Mitral value prolapse is treated with beta blockers or valve repair so premium insurance is not necessary. The client's religion is not a factor in teaching. The use of antiembolism stockings is not a treatment for mitral vale prolapse.

A nurse is caring for a young female adult client diagnosed with atrial fibrillation who has just had a mitral valve replacement. The client is being discharged with prescribed warfarin. The client mentions to the nurse that she relies on the rhythm method for birth control. What education will be a priority for the nurse to provide to this client?

the high risk for complications if she becomes pregnant while taking warfarin Women of childbearing age should not take warfarin (pregnancy X category) if they plan to become pregnant. There is danger to the placenta and risk for the mother to bleed. The fetus may also be affected. This client should practice a more reliable method of birth control. The rhythm method for birth control is not always accurate. The symptoms of worsening tachycardia are important, but do not correspond to the warfarin therapy. Limiting green leafy vegetables is important with warfarin therapy, but risk for fetal harm is more important.

A nurse is caring for a client with pericarditis and auscultates a pericardial friction rub. What action does the nurse ask the client to do to distinguish a pericardial friction rub from a pleural friction rub?

the nurse asks the client to hold their breath during auscultation A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid as a result of inflammation. The audible rub on auscultation is synchronous with the heartbeat. To distinguish between a pleural rub and a pericardial rub, the client should hold the breath. The pericardial rub will continue. Length of auscultation and standing would not assist in distinguishing one kind of rub from the other.

A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant?

the patient reports shortness of breath while walking Dyspnea on exertion is typically the earliest manifestation of mitral valve stenosis. Late signs of right-sided heart failure are jugular vein distention, edema, and enlarged liver. Chest pain rarely occurs with mitral valve stenosis.

The nurse is teaching a client with cardiomyopathy. Which statement is a valid teaching point?

the treatment includes medications, medical devices, surgery, or transplantation Treatments for clients with cardiomyopathy include medications, medical devices such as pacemakers, internal defibrillators, surgery or transplantation. The disease is not curable or reversible. Clients with cardiomyopathy do not need to live in a skilled facility. The main goal for clients with cardiomyopathy is to improve heart function.

A nurse is preparing a teaching plan regarding biological tissue valve replacement. What is a disadvantage of this type of valve replacement?

the valve has to be replaced frequently Biological valves deteriorate and need to be replaced frequently. They do not necessitate accompanying anticoagulant therapy. Infections are easier to treat and the risk of thromboembolism is lower as compared with mechanical valves.

Which of the following is the most common complication of prosthetic valves?

thromboembolism Thromboembolism is the most common complication of prosthetic valves and long-term anticoagulation with warfarin is initiated 48 hours after surgery. Overall, patients are at risk for thromboembolism, infection, arrhythmias, and hemolysis.

A client's chart indicates Virchow's triad. This client is at risk for which complication?

thrombophlebitis Virchow's triad refers to venous stasis (slowed circulation), altered blood coagulation, and trauma to the vein, and predisposes clients to thrombosis and thrombophlebitis. The diagnosis of Virchow's triad indicates the client already presents with venous stasis. The diagnosis of Virchow's triad indicates the client already presents with altered blood coagulation. Postphlebitic syndrome is a vascular complication that may occur for up to 5 years after the initial episode with thrombophlebitis. This client does not yet have thrombophlebitis, so is not at risk for postphlebitic syndrome.

The nurse understands that which of the following medications will be administered to the client for 6 to 12 weeks following prosthetic porcine valve surgery?

warfarin To reduce the risk of thrombosis in patients with porcine or bovine tissue valves, warfarin is required for 6 to 12 weeks, followed by aspirin therapy. Furosemide would not be given for 6 to 12 weeks following this type of surgery. Digoxin may be used for the treatment of arrhythmias, but not just for 6 to 12 weeks.