Lewis- Chapter 37: Nursing Management Inflammatory and Structural Heart Disorders

When caring for a patient with infective endocarditis, the nurse will assess the patient for which of the following vascular manifestations (select all that apply)? a. Osler's nodes b. Janeway's lesions c. Splinter hemorrhages d. Subcutaneous nodules e. Erythema marginatum lesions

A, B, C a. Osler's nodes b. Janeway's lesions c. Splinter hemorrhages Rationale: Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.

When performing discharge teaching for the patient with any type of cardiomyopathy, the nurse instructs the patient to (select all that apply) a. eat a low-sodium diet b. suggest that caregivers learn CPR c. engage in stress reduction activities d. abstain from alcohol and caffeine intake e. avoid strenuous activity and allow for periods of rest

A, B, C, D, E (all) a. eat a low-sodium diet b. suggest that caregivers learn CPR c. engage in stress reduction activities d. abstain from alcohol and caffeine intake e. avoid strenuous activity and allow for periods of rest Rationale: These are all points that can apply to any cardiomyopathy.

A 20-year old patient has acute infective endocarditis. While obtaining a nursing history, the nurse should ask the patient about which of the following (select all that apply) a. renal dialysis b. IV drug abuse c. recent dental work d. cardiac catheterization e. recent urinary tract infection

A, B, C, D, E (all) a. renal dialysis b. IV drug abuse c. recent dental work d. cardiac catheterization e. recent urinary tract infection Rationale: recent dental, urologic, surgical, or gynecologic procedures and history of IV drug abuse, heart disease, cardiac catheterization or surgery, renal dialysis, and infections all increase the risk of IE.

Assessment of an IV cocaine user with infective endocarditis should focus on which signs and symptoms (select all that apply) a) Retinal hemorrhages b) splinter hemorrhages c) presence of Osler's nodes d) Painless nodules over bony prominences e) painless erythematous macules on the palms and soles

A, B, C, E a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes e. painless erythematous macules on the palms and soles Rationale: Clinical manifestations of infective endocarditis may include hemorrhagic retinal lesions (Roth's spots), splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) on the palms and soles.

A patient is admitted with myocarditis. While performing the initial assessment, which clinical signs and symptoms might the nurse find (select all that apply)? a) angina b) pleuritic chest pain c) splinter hemorrhages d) pericardial friction rub e) presence of Osler's nodes

A, B, D a. angina b. pleuritic chest pain d. pericardial friction rub Rationale: Clinical manifestations of myocarditis may include early systemic manifestations (i.e., fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and nausea and vomiting), early cardiac manifestations (i.e., pleuritic chest pain with a pericardial friction rub and effusion), and late cardiac signs (i.e., S3 heart sound, crackles, jugular venous distention [JVD], syncope, peripheral edema, and angina).

A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to nursing assistant personnel (NAP) (select all that apply)? a. obtain and record daily weight b. determine apical-radial pulse rate c. observe for overt signs of bleeding d. obtain and record vital signs, including pulse oximetry e. teach the patient how to purchase a Medic Alert bracelet

A, C, D a. obtain and record daily weight c. observe for overt signs of bleeding d. obtain and record vital signs, including pulse oximetry Rationale: The nurse may delegate routine procedures such as obtaining weights and vital signs. The nurse may give specific directions to the nursing assistive personnel (NAP) to observe and report obvious signs of bleeding. The nurse cannot delegate teaching, assessment, or activities that require clinical judgment. Obtaining an apical-radial pulse rate is an assessment.

26. The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.

ANS: A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

28. The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has bilateral crackles. b. The patient has bilateral, 4+ peripheral edema. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.

ANS: A Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

5. A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of a. echocardiography. b. daily blood cultures. c. cardiac catheterization. d. 24-hour Holter monitor.

ANS: A Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis.

7. The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should a. note when Korotkoff sounds are auscultated during both inspiration and expiration. b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP). c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

ANS: A Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

16. While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.

ANS: A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

27. Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Notify the patient's health care provider. d. Give the PRN acetaminophen (Tylenol).

ANS: A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased temperature) the PRN acetaminophen (Tylenol) is ordered.

3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking

ANS: B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.

32. After receiving report on the following patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

ANS: B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

31. The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? a. Leukocytosis b. Irregular pulse c. Generalized myalgia d. Complaint of fatigue

ANS: B Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.

2. During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find a. substernal chest pressure. b. a new regurgitant murmur. c. a pruritic rash on the chest. d. involuntary muscle movement.

ANS: B New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

6. To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border. c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

ANS: B Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

9. The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? a. "Do you use any illegal IV drugs?" b. "Have you had a recent sore throat?" c. "Have you injured your chest in the last few weeks?" d. "Do you have a family history of congenital heart disease?"

ANS: B Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching b. Sudden onset right flank pain c. Janeway's lesions on the palms d. Temperature 100.7° F (38.1° C)

ANS: B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.

12. When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? a. Vaccinate high-risk groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Teach about the importance of monitoring temperature when sore throats occur. d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.

ANS: B The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.

33. After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first? a. Patient with acute pericarditis who has a pericardial friction rub b. Patient who has just returned to the unit after balloon valvuloplasty c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 d. Patient with a mitral valve replacement who has an anticoagulant scheduled

ANS: B The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention.

10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate? a. Pain related to permanent joint fixation b. Activity intolerance related to arthralgia c. Risk for infection related to open skin lesions d. Risk for impaired skin integrity related to pruritus

ANS: B The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.

4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? a. Monitor labs for streptococcal antibodies. b. Arrange for placement of a long-term IV catheter. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.

ANS: B Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

23. Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone (Rocephin) 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.

ANS: B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

17. During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.

ANS: C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

29. Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective? a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.

ANS: C Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis.

22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction. b. Patient being discharged after an exacerbation of heart failure. c. Patient who had a mitral valve replacement with a mechanical valve. d. Patient being treated for rheumatic fever after a streptococcal infection.

ANS: C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

19. When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of a. flank pain. b. splenomegaly. c. shortness of breath. d. mental status changes.

ANS: C Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves.

14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

ANS: C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.

30. Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been most effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I will need to limit my intake of salt and fluids even in hot weather." c. "I will take antibiotics when my teeth are cleaned at the dental office." d. "I should begin an exercise program that includes things like biking or swimming."

ANS: C Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or NSAIDs.

25. Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 168/94 c. Jugular venous distention (JVD) to jaw level d. Level 6 (0 to 10 scale) chest pain with a deep breath

ANS: C The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.

18. A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give? a. Fentanyl 1 mg IV b. IV morphine sulfate 4 mg c. Oral ibuprofen (Motrin) 600 mg d. Oral acetaminophen (Tylenol) 650 mg

ANS: C The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.

13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.

ANS: C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.

21. The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important? a. The patient has a history of a recent upper respiratory infection. b. The patient has a family history of coronary artery disease (CAD). c. The patient reports using cocaine a "couple of times" as a teenager. d. The patient's 29-year-old brother died from a sudden cardiac arrest.

ANS: D About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC.

1. The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"

ANS: D Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever without carditis says which of the following? a. "I will need prophylactic antibiotic therapy for 5 years." b. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain." c. "I will call the doctor if I develop excessive fatigue or difficulty breathing." d. "I will be immune to further episodes of rheumatic fever after this infection."

ANS: D Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.

8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to a. teach the patient to take deep, slow breaths to control the pain. b. force fluids to 3000 mL/day to decrease fever and inflammation. c. remind the patient to request opioid pain medication every 4 hours. d. place the patient in Fowler's position, leaning forward on the overbed table.

ANS: D Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).

35. The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear any murmur that the patient has? a. 1 b. 2 c. 3 d. 4

ANS: D Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line.

20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the doctor about any symptoms of heart failure such as shortness of breath.

ANS: D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation.

34. Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

ANS: D Under the supervision of registered nurses (RNs), UAP check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

15. While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. take an aspirin a day to prevent clots from forming on the valve. d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.

ANS: D Use of stimulant medications should be avoided by patients with MVP because these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes? a. Endocarditis b. Acute renal failure c. Myocardial infarction d. Chronic thrombophlebitis

a. Endocarditis Rationale: Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency.

While admitting a patient with pericarditis, the nurse will assess for which of the following signs, symptoms, and complications of this disorder? a. Pulsus paradoxus b. Prolonged PR intervals c. Widened pulse pressure d. Clubbing of the fingers

a. Pulsus paradoxus Rationale: Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus >10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis.

Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? a. administration of antibiotics as ordered b. management of pain with opioid analgesics c. encouragement of fluid intake for hydration d. performance of frequent, active range-of motion exercises

a. administration of antibiotics as ordered Rationale: The primary goal of managing a patient with acute rheumatic fever is to control and eradicate the infecting organism. The nurse should administer antibiotics as ordered to treat the streptococcal infection and teach the patient that completion of the full course of antibiotic therapy is essential for successful treatment.

A patient has an admitting diagnosis of acute left-sided infective endocarditis. The nurse explains to the patient that this diagnosis is best confirmed with a. blood cultures b. a complete blood count c. a cardiac catheterization d. a transesophageal echocardiogram

a. blood cultures Rationale: Although a complete blood cell count (CBC) will reveal a mild leukocytosis and erythrocyte sedimentation rates (ESRs) will be elevated in patients with infective endocarditis, these are nonspecific findings, and blood cultures are the primary diagnostic tool for infective endocarditis. Transesophageal echocardiograms can identify vegetations on valves but are used when blood cultures are negative, and cardiac catheterizations are used when surgical intervention is being considered.

The diagnosis of acute rheumatic fever is most strongly supported in the patient with a. carditis, polyarthritis, and erythema marginatum b. polyarthritis, chorea, and increased antistreptolysin O titer c. positive C-reactive protein, elevated WBC, subcutaneous nodules d. organic heart murmurs, fever, and elevated erythrocyte sedimentation rate (ESR)

a. carditis, polyarthritis, and erythema marginatum Rationale: Major criteria for the diagnosis of rheumatic fever include evidence of carditis, polyarthritis, chorea (often very late), erythema marginatum, and subcutaneous nodules. Minor criteria include all laboratory findings as well as fever, arthralgia, and a history of previous rheumatic fever.

Which of the following diagnostic study best differentiates the various types of cardiomyopathy? a. echocardiography b. arterial blood gases c. cardiac catheterization d. endomyocardial biopsy

a. echocardiography Rationale: The echocardiogram is the primary diagnostic tool used to differentiate between the different types of cardiomyopathies and other structural cardiac abnormalities.

When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of a) valvular heart disease b) pulmonary hypertension c) superior vena cava syndrome d) hypertrophy of the right ventricle

a. valvular heart disease Rationale: Rheumatic heart disease is a chronic condition resulting from rheumatic fever that is characterized by scarring and deformity of the heart valves.

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which of the following findings are significant? a. Respiratory rate of 18 and heart rate of 90 b. Regurgitant murmur at the mitral valve area c. Heart rate of 94 and capillary refill time of 2 seconds d. Point of maximal impulse palpable in fourth intercostal space

b. Regurgitant murmur at the mitral valve area Rationale: A regurgitant murmur would indicate valvular disease, which can be a complication of endocarditis. All the other findings are within normal limits.

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

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

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

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

A patient with symptomatic mitral valve prolapse has atrial and ventricular dysrhythmias. In addition to monitoring for decreased cardiac output related to the dysrhythmias, an appropriate nursing diagnosis related to the dysthymias identified by the nurse is a. ineffective breathing pattern related to hypervolemia b. risk for injury related to dizziness and lightheadedness c. disturbed sleep pattern related to paroxysmal nocturnal dyspnea d. ineffective self-health management related to lack of knowledge of prevention and treatment strategies

b. risk for injury related to dizziness and lightheadedness Rationale: Dysrhythmias frequently cause palpitations, lightheadedness, and dizziness, and the patient should be carefully attended to prevent falls. Hypervolemia and paroxysmal nocturnal dyspnea (PND) would be apparent in the patient with heart failure.

A patient with infective endocarditis of a prosthetic mitral valve develops a left hemiparesis and visual changes. The nurse expects that collaborative management of the patient will include a. an embolectomy b. surgical valve replacement c. administration of anticoagulants d. higher than usual antibiotic dosages

b. surgical valve replacement Rationale: Drug therapy for patients who develop endocarditis of prosthetic valves is often unsuccessful in eliminating the infection and preventing embolization, and early valve replacement followed by prolonged drug therapy is recommended for these patients.

A patient with rheumatic heart disease with carditis asks the nurse how long his activity will be restricted. The best answer by the nurse is that he a. can perform non- strenuous activities as soon as antibiotics are started b. will be confined to bed until symptoms of heart failure are controlled c. will be able to have full activity as soon as cute symptoms have subsided d. must be on bed rest until anti-inflammatory therapy has been discontinued

b. will be confined to bed until symptoms of heart failure are controlled Rationale: When carditis is present in the patient with rheumatic fever, ambulation is postponed until any symptoms of heart failure are controlled with treatment, and full activity cannot be resumed until anti-inflammatory therapy has been discontinued. In the patient without cardiac involvement, ambulation may be permitted as soon as acute symptoms have subsided, and normal activity can be resumed when anti-inflammatory therapy is discontinued.

Which of the following nursing actions should the nurse prioritize during the care of a patient who has recently recovered from rheumatic fever? a. Teach the patient how to manage his or her physical activity. b. Teach the patient about the need for ongoing anticoagulation. c. Teach the patient about his or her need for continuous antibiotic prophylaxis. d. Teach the patient about the need to maintain standard infection control procedures.

c. Teach the patient about his or her need for continuous antibiotic prophylaxis. Rationale: Patients with a history of rheumatic fever frequently require ongoing antibiotic prophylaxis, an intervention that necessitates education. This consideration is more important than activity management in preventing recurrence. Anticoagulation and standard precautions are not indicated in this patient population.

A mechanical prosthetic valve is most likely to be preferred over a biologic valve for valve replacement in a a. 41-year-old man with peptic ulcer disease b. a 22-year-old woman who desires to have children c. a 35-year-old man with a history of seasonal asthma d. 62-year-old woman with early Alzheimer's disease

c. a 35-year-old man with a history of seasonal asthma Rationale: Mechanical prosthetic valves require long-term anticoagulation, and this is a factor in making a decision about the type of valve to use for replacement. Patients who cannot take anticoagulant therapy, such as women of childbearing age, patients at risk for hemorrhage, or patient who may not be compliant with anticoagulation therapy, may be candidates for the less durable biologic valves.

The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition? a) fatigue b) peripheral edema c) jugular venous distention d) thickened pericardium on echocardiography

c. jugular venous distention Rationale: Cardiac tamponade is a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling decreases cardiac output. Neck veins usually are markedly distended because of jugular venous pressure elevation.

An RN is working with an LPN in caring for a group of patients on a cardiac telemetry unit. A patient with aortic stenosis has the nursing diagnosis of activity intolerance related to fatigue and exertional dyspnea. Which of these nursing activities could be delegated to the LPN? a. explain the reason for planning frequent periods of rest b. evaluate the patient's understanding of his disease process c. monitor BP, HR, RR, and SpO2 before, during, and after ambulation d. teach the patient which activities to choose that will gradually increase endurance

c. monitor BP, HR, RR, and SpO2 before, during, and after ambulation Rationale: Monitoring VS before and after ambulation is the collection of data. Instructions should be provided to the LPN regarding what changes in these should be reported to the RN. Other actions listed are RN responsibilities.

The nurse is caring for a patient newly admitted with heart failure secondary to dilated cardiomyopathy. Which of the following interventions would be a priority? a. encourage caregivers to learn CPR b. consider a consultation with hospice for palliative care c. monitor the patient's response to prescribed medications d. arrange for the patient to enter a cardiac rehabilitation program

c. monitor the patient's response to prescribed medications Rationale: Observing for signs and symptoms of worsening heart failure, dysrhythmias, and embolic formation in patients with dilated cardiomyopathy is essential, as is monitoring drug responsiveness. The goal of therapy is to keep the patient at an optimal level of functioning and out of the hospital. The priority intervention is to manage the acute symptoms with medications. The caregivers should learn cardiopulmonary resuscitation (CPR) before hospital discharge, and the patient may be referred to cardiac rehabilitation. Patients with dilated cardiomyopathy with progression to class IV stage D heart failure are candidates for palliative care.

A patient is scheduled for a percutaneous transluminal valvuloplasty. The nurse understands that this procedure is indicated for a. any patient with aortic regurgitation b. older patients with aortic regurgitation c. older patients with stenosis of any valve d. young adult patients with mild mitral valve stenosis

c. older patients with stenosis of any valve Rationale: This procedure has been used for repair of pulmonic, tricuspid, and mitral stenosis, but usually for those patients that are poor surgical risks.

When obtaining a nursing history for a patient with myocarditis, the nurse specifically questions the patient about a. a history of CAD with or without an MI b. prior use of digoxin for treatment of cardiac problems c. recent symptoms of a viral illness, such as fever or malaise d. a recent streptococcal infection requiring treatment with penicillin

c. recent symptoms of a viral illness, such as fever or malaise Rationale: Viruses are the most common cause of myocarditis in the US, and early manifestations of myocarditis are often those of systemic viral infections. Myocarditis may also be associated with systemic inflammatory and metabolic disorders as well as with other microorganisms, drugs, or toxins. The heart has increased sensitivity to digoxin in myocarditis, and it is used very cautiously, if at all, in treatment of the condition.

A patient is scheduled for an open surgical valvuloplasty of the mitral valve. In preparing the patient for surgery, the nurse recognizes that a. cardiopulmonary bypass is not required with this procedure b. valve repair is a palliative measure, whereas valve replacement is curative c. the operative mortality rate is lower in valve repair than in valve replacement d. patients with valve repair do not require postoperative anticoagulation as they do with valve replacement

c. the operative mortality rate is lower in valve repair than in valve replacement Rationale: Repair of mitral or tricuspid valves has a lower operative mortality rate than does replacement and is becoming the surgical procedure of choice for these valvular diseases. Open repair is more precise than closed repair and requires cardiopulmonary bypass during surgery. All types of valve surgery are palliative, not curative, and patients require lifelong health care. Anticoagulation therapy is used for all valve surgery for at least some time postoperatively.

A patient is admitted to the hospital with a suspected acute pericarditis. To establish the presence of a pericardial friction rub, the nurse listens to the patient's chest a. while timing the sound with the respiratory pattern b. with the bell of the stethoscope at the apex of the heart c. with the diaphragm of the stethoscope at the lower left sternal bored of the chest d. with the diaphragm of the stethoscope to auscultate a high-pitched continuous rumbling sound

c. with the diaphragm of the stethoscope at the lower left sternal bored of the chest Rationale: The stethoscope diaphragm at the left sternal border is the best method to use to hear the high-pitched, grating sound of a pericardial friction rub. The sound does not radiate widely and occurs with the heartbeat.

A patient hospitalized for 1 week with subacute infective endocarditis is afebrile and has no signs of heart damage. Discharge with outpatient antibiotic therapy is planned. During discharge planning with the patient, it is most important for the nurse to: a. plan how his needs will be met while he continues on bed rest b. teach the patient to avoid crowds and exposure to upper respiratory infections c. encourage the use of diversional activities to relieve boredom and restlessness d. assess the patient's home environment in terms of family assistance and hospital access

d. assess the patient's home environment in terms of family assistance and hospital access Rationale: The patient with outpatient antibiotic therapy requires vigilant home nursing care, and it is most important to determine the adequacy of the home environment for successful management of the patient. The patient is at risk for life-threatening complications, such as embolization and pulmonary edema, and must be able to access a hospital if needed. Bed rest will not be necessary for the patient without heart damage. Avoiding infections and planning diversional activities are indicated for the patient but are not the most important step while he is on outpatient antibiotic therapy.

When teaching a patient with endocarditis how to prevent recurrence of the infection, the nurse instructs the patient to: a. start on antibiotic therapy when exposed to persons with infections b. take one aspirin a day to prevent vegetative lesions from forming around the valves c. always maintain continuous antibiotic therapy to prevent the development of any systemic infection d. obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g. dental cleaning)

d. obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g. dental cleaning) Rationale: Prophylactic antibiotic therapy should be initiated before invasive dental, medical, or surgical procedures to prevent recurrence of endocarditis. Continuous antibiotic therapy is indicated only in patients with implanted devices or ongoing invasive procedures. Symptoms of infection should be treated promptly, but antibiotics are not used for exposure to infection.

Priority nursing management for a patient with myocarditis includes interventions related to a) meticulous skin care b) antibiotic prophylaxis c) tight glycemic control d) oxygenation and ventilation

d. oxygenation and ventilation Rationale: General supportive measures for management of myocarditis include interventions to improve ventilation and oxygenation (i.e., oxygen therapy, bed rest, and restricted activity).

A patient with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. An appropriate nursing intervention for the patient is a. administering opioids as prescribed on an around the clock schedule b. promoting progressive relaxation exercises with the use of deep, slow breathing c. positioning the patient on the right side with the head of the bed elevated 15 degrees d. positioning the patient in Fowler's position with a padded over the bed table for the patient to lean on

d. positioning the patient in Fowler's position with a padded over the bed table for the patient to lean on Rationale: Relief from pericardial pain is often obtained by sitting up and leaning forward. Pain is increased by lying flat. The pain has a sharp, pleuritic quality that changes with respiration, and patients take shallow breaths. Anti-inflammatory medications may also be used to help control pain, but opioids are not usually indicated.

The most important role of the nurse in preventing rheumatic fever is to a. teach patients with infective endocarditis to adhere to antibiotic prophylaxis b. identify patients with valvular heart disease who are at risk for rheumatic fever c. encourage the use of antibiotics for treatment of all infections involving a sore throat d. promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis

d. promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis Rationale: Initial attacks of rheumatic fever and the development of rheumatic heart disease can be prevented by adequate treatment of group A streptococcal pharyngitis. Because streptococcal infection accounts for only about 20% of acute pharyngitis, cultures should be done to identify the organism and direct antibiotic therapy. Viral infections should not be treated with antibiotics. Prophylactic therapy is indicated in those who have valvular heart disease or have has rheumatic heart disease.

Which clinical finding would most likely indicate decreased cardiac output in a patient with aortic valve regurgitation? a. reduction in peripheral edema and weights b. carotid venous distention and new-onset atrial fibrillation c. significant pulses paradoxus and diminished peripheral pulses d. shortness of breath on minimal exertion and a diastolic murmur

d. shortness of breath on minimal exertion and a diastolic murmur Rationale: Clinical manifestations of aortic regurgitation (AR) that indicate decreased cardiac output include severe dyspnea, chest pain, and hypotension. Other manifestations of chronic AR include water-hammer pulse (i.e., a strong, quick beat that collapses immediately), soft or absent S1, presence of S3 or S4, and soft, high-pitched diastolic murmur. A low-pitched diastolic murmur may be heard in severe AR. Early manifestations may include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

When performing discharge teaching for the patient following a mechanical valve replacement, the nurse determines that further instruction is needed when the patient says, a. I may begin an exercise program to gradually increase my cardiac tolerance b. I will always need to have my blood checked once a month for its clotting function c. I should wear a medic alert bracelet to identify my valve and anticoagulant therapy d. the biggest risk I have during invasive health procedures is bleeding because of my anticoagulants

d. the biggest risk I have during invasive health procedures is bleeding because of my anticoagulants Rationale: The greatest risk to a patient who has an artificial valve is the development of endocarditis with invasive medical or dental procedures; before any of these procedures, antibiotic prophylaxis is necessary to prevent infection. Health care providers must be informed of the presence of the valve and the anticoagulation therapy, but the most important factor is using antibiotic prophylaxis before invasive procedures.

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

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