Patho Chapter 20 ***

A 75-year-old client is being evaluated for heart failure. Which questions will the nurse ask to confirm common signs and symptoms observed in older adults experiencing heart failure? Select all that apply.

"Do you have swelling in your ankles?" -"Do you easily get tired?" -"Do you get up often during the night to urinate?" " -Are you feeling depressed?"

A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which statement demonstrates an accurate understanding of his new diagnosis?

"I'm trying to think of ways that I can cut down the amount of salt that I usually eat."

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:

20mL/hour

An acutely ill client is developing multiple organ dysfunction syndrome (MODS). The nurse knows that which statements regarding multiple organ dysfunction syndrome are accurate? Select all that apply.

-Risk factors for development of MODS include severe trauma, hepatic dysfunction, and prolonged hypotension. - Organs affected include kidneys, lungs, liver, brain, and heart. - Treatment is primarily supportive of the affected organs. - Homeostasis is disrupted.

In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which level indicates inadequate renal perfusion?

20mL/hour

A nurse is administering morning medications to a number of clients on a medical unit. Which medication regimen is most suggestive that the client has a diagnosis of heart failure?

Diuretic, ACE inhibitor, beta-blocker

Anaphylactic shock is the most severe form of systemic allergic reaction. Immunologically medicated substances are released into the blood, causing vasodilation and an increase in capillary permeability. What physiologic response often follows the vascular response in anaphylaxis?

Laryngeal edema

The health care provider is reviewing lab results of a client diagnosed with heart failure. The provider notes that the client's ANP and BNP levels have been increasing and remain significantly elevated. These results would be interpreted as:

The condition is getting progressively worse.

A client in the nursing home wonders why he is having these signs and symptoms of left-sided heart failure. Which explanation will the nurse give the client?

The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs.

Levels of endothelins may be increased in clients with heart failure. Which of the following is the primary action of endothelins?

Vasoconstriction

Dysrhythmias can occur in clients with heart failure. The dysrhythmia that occurs most frequently in heart failure is:

atrial fibrillation

An older adult client has been diagnosed with chronic heart failure. He is prescribed an ACE inhibitor to treat the symptoms and improve his quality of life. This drug will alleviate the client's symptoms of heart failure by:

blocking the conversion of angiotensin I to angiotensin II.

All of the following interventions are ordered STAT for a client stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first?

epinephrine

A nurse will be providing care for a female client who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which statement best describes the presentation that the nurse should anticipate? The client:

has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain.

Increased cardiac workload with left-sided heart failure can result in which change to the myocardial cells?

hypertrophy

The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be:

improving quality of life by relieving symptoms.

A client has developed left-sided heart failure. Which symptom might have precipitated this condition?

myocardial infraction

A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing?

obstructive shock

On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right-sided heart failure. Which manifestation exhibited by the father does the nurse know might have preceded this diagnosis?

peripheral edema, weight gain

A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education?

raising the head of the bed to a fowlers position

Assessment of an older adult client reveals bilateral pitting edema of the client's feet and ankles; difficult to palpate pedal pulses; breath sounds clear on auscultation; oxygen saturation level of 93% (0.93); and vital signs normal. What is this client's most likely health problem?

right sided heart failure

A client in the intensive care unit died shortly after developing multiple organ dysfunction syndrome (MODS). Which health problem most likely preceded the client's MODS?

sepsis

A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF (40°C) in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this client most likely is experiencing which type of shock?

septic