Med-Surge Nursing Cardio Prep U ch 28

If a client were to develop rheumatic carditis, which cardiac structure would most likely be affected?

mitral valve In rheumatic carditis, cardiac structures that usually are affected include the heart valves (particularly the mitral valve), endocardium, myocardium, and pericardium.

During a teaching session, a client who is having a valuloplasty 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.

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 patient about the care related to a new diagnosis of mitral valve prolapse. What statement made by the patient demonstrates understanding?

"I will avoid caffeine, alcohol, and smoking." In mitral valve prolapse, if dysrhythmias are documented and cause symptoms, the patient is advised to eliminate caffeine and alcohol from the diet and to stop the use of tobacco products.

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 need 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 nursing student is assigned to a patient with a mechanical valve replacement. The patient asks the student, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nursing student is most appropriate?

"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 nurse is assessing a patient who has had valvular heart disease for more than 15 years. Which signs and symptoms should the nurse expect? (Choose all that apply.)

1. Paroxysmal nocturnal dyspnea 2. Orthopnea 3. Cough Paroxymal nocturnal dyspnea, orthopnea, and coughing occur in long-term valvular disease. Pericardial friction rub is a sound auscultated in clients with pericarditis, not valvular disease. Pulsus paradoxus is a marked decrease in amplitude during inspiration, a sign of cardiac tamponade.

What are the first symptoms of cardiac tamponade? Select all that apply.

1. Shortness of breath 2. Chest tightness 3. Dizziness The first symptoms of cardiac tamponade are often shortness of breath, chest tightness, dizziness, or restlessness. The client may have tachycardia. Neck vein distention and other signs of rising central venous pressure develop.

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 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 (Coumadin), an oral anticoagulant, to a patient with a mechanical valve replacement. The patient's INR is 2.7. Which action should the nurse take?

Administer the medication as ordered. Patients with mechanical valve replacements who take warfarin (Coumadin) usually have individualized target international normalized ratios (INRs) between 2.0 and 3.5. The nurse would give the medication as ordered.

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.

Which describes a valve used in replacement surgery that is made from the client's own heart valve?

Autograft An example of an autograft is when the surgeon excises the pulmonic valve and uses it for an aortic valve replacement. An allograft, also called a homograft, refers to replacement using human tissue. Xenograft refers to animal tissue used in tissue replacement.

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 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.

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.

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.

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased cardiac output A primary nursing diagnosis for cardiomyopathy is decreased cardiac output related to structural disorders caused by cardiomyopathy or to dysrhythmia from the disease process and medical treatments. Dyspnea on exertion, fatigue, and fluid retention are related to poor cardiac output. Nausea is related to poor perfusion of the gastrointestinal system. Autonomic dysreflexia is related to a spinal cord injury. Ineffective airway clearance relates to the inability to clear secretions from the airway, which is not an initial problem with cardiomyopathy. Disturbed sensory perception is related to specific senses and not to initial cardiomyopathy.

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate?

Decreased cardiac output Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

Clients with myocarditis are sensitive to which medication?

Digoxin The nurse must closely monitor these clients for digoxin toxicity, which is evidenced by arrhythmia, anorexia, nausea, vomiting, headache, and malaise. If the cause of the myocarditis is hemolytic streptococci, penicillin will be given. The use of corticosteroids remains controversial.

The nurse is caring for a patient diagnosed with myocarditis. The nurse is aware that patients with myocarditis are sensitive to what medication?

Digoxin The nurse must closely monitor these patients for digoxin toxicity, which is evidenced by arrhythmia, anorexia, nausea, vomiting, headache, and malaise. If the cause of the myocarditis is haemolytic streptococci, penicillin will be given. The use of corticosteroids remains controversial.

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

Dyspnea, orthopnea, 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.

The diagnosis of aortic regurgitation (AR) is confirmed by which of the following?

Echocardiography Diagnosis is confirmed by echocardiography. Cardiac catheterization is not necessary in most patients with AR. Exercise stress testing will assess functional capacity and symptom response. A myocardial biopsy may be performed to analyze myocardial tissue cells in patients with cardiomyopathy.

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 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.

Which signs and symptoms accompany a diagnosis of 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.

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.

A client is diagnosed with rheumatic endocarditis. What bacterium is the nurse aware causes this inflammatory response?

Group A, beta-hemolytic streptococcus Acute rheumatic fever, which occurs most often in school-age children, may develop after an episode of group A beta-hemolytic streptococcal pharyngitis (Chart 28-2). Clients with rheumatic fever may develop rheumatic heart disease as evidenced by a new heart murmur, cardiomegaly, pericarditis, and heart failure.

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.

A nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the student to clarify one of the last treatment options available that the physician mentioned. After checking with the primary nurse, the student would most likely discuss which of the following? Heart transplantation Xenograft tissue valve Annuloplasty Valvuloplasty

Heart transplantation When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. The other three choices have to do with failing valves and valve repairs.

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.

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.

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.

A patient was diagnosed with mitral regurgitation. The nurse is aware that the patient should be observed for indicators of left- and right-sided heart failure. This understanding is based on the mechanics of cardiac hemodynamics. With mitral regurgitation, due to thickened valve leaflets, blood flows backward from the:

Left ventricle into 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 left atrial pressure to rise.

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 nursing student is caring for a client with end-stage cardiomyopathy. The client's spouse asks the nurse to clarify one of the last treatment options available that the physician mentioned earlier. After checking with the primary nurse, the nursing student would most likely discuss which of the following? Left ventricular assist device Chordoplasty Annuloplasty Open commissurotomy

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.

For patients diagnosed with aortic stenosis, digoxin would be ordered for which of the following clinical manifestations?

Left ventricular dysfunction Digoxin may be used to treat left ventricular dysfunction, and 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 bed rest. The nurse should maintain the client on bed rest to reduce cardiac workload and promote healing. Bed rest also helps decrease myocardial damage and the complications of myocarditis. 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 such as 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.

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 patient has been admitted with acute pericarditis. The nurse has created a care plan with a nursing diagnosis of acute pain related to pericardial inflammation. An appropriate nursing intervention for this patient is:

Placing the patient in the high-Fowler's position with an over-the-bed table for the patient to lean on Patients 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.

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.

A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis?

Pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.

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 nursing student is assigned to the medical intensive care unit for the first time. The nurse preceptor asks the student to listen to a water-hammer pulse. The nursing student knows that the sound will resemble which of the following?

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.

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 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.

Rest and sleep in a chair or sit in bed with 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 intervention should the nurse include in the plan of care for a client with valvular heart disease who is experiencing pulmonary congestion?

Rest and sleep in a chair or sit in bed with 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 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.

Which of the following is the most significant risk factor 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's syndrome, and a dissecting aortic aneurysm.

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?

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

Teach individuals 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 30-year-old client diagnosed with atrial fibrillation who has just had a mitral valve replacement. The client is being discharged with prescribed warfarin (Comaudin). She mentions to you that she relies on the rhythm method for birth control. What education would 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.

A nurse caring for a patient with mitral stenosis understands that the initial cause of disruption to the normal flow of blood through the heart is due to:

The 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.

The nursing instructor is teaching a class on thrombophlebitis. What should the nurse tell the students about the inflammatory response in thrombophlebitis?

The inflammatory response is caused by accumulated waste products in the blocked vessel. Accumulated waste products in the blocked vessel irritate the vein wall, initiating an inflammatory response. The other options are incorrect because they do not cause the inflammatory response in thrombophlebitis.

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 when 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.

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.

Following a coronary artery bypass graft, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiogram (ECG) strip for interpretation. In looking at the strip, what change in the QRS complex would most support the nurse's suspicion?

amplitude decrease An amplitude decrease would support the nurse's suspicion because fluid surrounding the heart, such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing and widening complexes as well as an amplitude increase aren't expected findings on the ECG of an individual with cardiac tamponade.

A nurse is caring for a client receiving warfarin (Coumadin) therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m., before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to:

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician 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 physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.

A patient has an admitting diagnosis of acute left-sided infective endocarditis. The nurse instructs the patient that the best diagnostic test to confirm this diagnosis is

blood cultures A definitive diagnosis is made when a micro-organism is found in two separate blood cultures. All others mentioned may contribute to the diagnosis but are not the most definitive.

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.

Which procedure describes splitting or separating fused cardiac valve leaflets?

commissurotomy Commissurotomy is frequently used to repair mitral stenosis. Annuloplasty refers to repair of a cardiac valve's outer ring. Chordoplasty refers to repair of the chordae tendineae of atrioventricular valve leaflets. Valvuloplasty is a general term that refers to repair of a stenosed or regurgitant cardiac valve by commissurotomy, annuloplasty, leaflet repair, and/or chordoplasty.

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 caring for a client with cardiomyopathy determines a diagnosis of anxiety related to a fear of death. Which behavior would indicate to the nurse recognizes that the client's level of anxiety has decreased when the client

is able to discuss the prognosis freely. As anxiety decreases, clients will be able to discuss prognosis freely, verbalize fears and concerns, participate in support groups, and demonstrate appropriate coping mechanisms.

One of the most common causes of mitral valve regurgitation in people living in developed countries is

ischemia of the left ventricle. The most common causes of mitral valve regurgitation in people living in developed countries are degenerative changes in the mitral valve and ischemia of the left ventricle. Other conditions leading to mitral regurgitation include myxomatous changes, which enlarge and stretch the left atrium and ventricle, causing leaflets and chordate tendineae to stretch or rupture and ischemic heart disease. Rheumatic fever and its sequelae is the most common cause of mitral valve regurgitation for people living in developing countries.

A client with a recent history of atrial fibrillation has been prescribed warfarin. When confirming whether the prescribed dose is safe and appropriate for the client, the nurse should:

review the client's international normalized ratio (INR).

While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate:

valve damage. Acute rheumatic fever may lead to cardiac complications; a heart murmur suggests valve damage. Endocarditis may lead to cardiac complications; a pericardial friction rub indicates pericarditis. Muffled heart sounds may indicate cardiac tamponade in clients with pericarditis. Atrial gallop is an abnormal heart sound, or S4, and is often associated with hypertensive heart disease.