Chapter 28: Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders

A patient is admitted with aortic regurgitation. Which of the following medication classifications are contraindicated since they can cause bradycardia and decrease ventricular contractility? a) Calcium channel blockers b) Beta blockers c) Ace inhibitors d) Nitrates

a) Calcium channel blockers The calcium channel blockers diltiazem (Cardizem) and verapamil (Calan, Isoptin) are contraindicated for patients with aortic regurgitation as they decrease ventricular contractility and may cause bradycardia.

Patient with myocarditis are sensitive to which of the following medications? a) Corticosteroids b) Digoxin c) Lasix d) Penicillin

b) 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.

The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)? a) First-degree atrioventricular block b) Ventricular tachycardia c) Atrial fibrillation d) Sinus dysrhythmia

c) Atrial fibrillation In mitral stenosis, the pulse is weak and often irregular because of atrial fibrillation (caused by strain on the atrium).

A patient who had a prosthetic valve replacement was taking Coumadin to reduce the risk of postoperative thrombosis. He visited the nurse practitioner at the Coumadin clinic once a week. Select the INR level that would alert the nurse to notify the health care provider. a) 3.0 b) 2.6 c) 3.4 d) 3.8

d) 3.8 Coumadin 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 patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty. What should the nurse teach the patient about valvuloplasty? A) "For some patients, valvuloplasty can be done in a cardiac catheterization laboratory." B) "Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well." C) "Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an overnight hospital stay." D) "It's prudent to get a second opinion before deciding to have valvuloplasty."

Ans: "For some patients, valvuloplasty can be done in a cardiac catheterization laboratory." Feedback: Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and the procedure does not carry exceptional risks that would designate it as being dangerous. Normally there is no need for the nurse to advocate for a second opinion.

A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect her busy work schedule. What guidance should the nurse provide to the patient? A) "Patients generally stay in the hospital for 6 to 8 days." B) "Patients are kept in the hospital until they are independent with all aspects of their care." C) "Patients need to stay in the hospital until they regain normal heart function for their age." D) "Patients usually remain at the hospital for 24 to 48 hours."

Ans: "Patients usually remain at the hospital for 24 to 48 hours." Feedback: After undergoing percutaneous balloon valvuloplasty, the patient usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the patient does not need to be wholly independent prior to discharge.

A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder? A) "I get chest pain from time to time, but it usually resolves when I rest." B) "Sometimes when I'm resting, I can feel my heart skip a beat." C) "Whenever I do any form of exercise I get terribly short of breath." D) "My feet and ankles have gotten terribly puffy the last few weeks."

Ans: "Whenever I do any form of exercise I get terribly short of breath." Feedback: The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. Palpitations occur in some patients, but dyspnea is a characteristic early symptom. Peripheral edema and chest pain are atypical.

A patient with pericarditis has just been admitted to the CCU. The nurse planning the patient's care should prioritize what nursing diagnosis? A) Anxiety related to pericarditis B) Acute pain related to pericarditis C) Ineffective tissue perfusion related to pericarditis D) Ineffective breathing pattern related to pericarditis

Ans: Acute pain related to pericarditis Feedback: 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. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.

A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient knows the importance of taking which of the following drugs? A) Enoxaparin (Lovenox) B) Metoprolol (Lopressor) C) Azathioprine (Imuran) D) Amoxicillin (Amoxil)

Ans: Amoxicillin (Amoxil) Feedback: Although rare, bacterial endocarditis may be life-threatening. A key strategy is primary prevention in high-risk patients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.

Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply. A) Anxiety B) Fatigue C) Shoulder pain D) Tachypnea E) Palpitations

Ans: Anxiety, Fatigue, Palpitations Feedback: Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.

A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm? A) Ventricular fibrillation (VF) B) Ventricular tachycardia (VT) C) Atrial fibrillation D) Sinus bradycardia

Ans: Atrial fibrillation Feedback: In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation. Bradycardia, VF, and VT are not characteristic of this valvular disorder.

A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the patient's symptoms, the nurse should teach the patient to do which of the following? A) Eat a high-protein, low-carbohydrate diet. B) Avoid activities that cause an increased heart rate. C) Avoid large crowds and public events. D) Perform deep breathing and coughing exercises.

Ans: Avoid activities that cause an increased heart rate. Feedback: Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which increase heart rate. Infection prevention is important, but avoiding crowds is not usually necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and increased protein intake is not necessary.

The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse best respond? A) Azathioprine decreases the risk of thrombus formation. B) Azathioprine ensures adequate cardiac output. C) Azathioprine increases the number of white blood cells. D) Azathioprine minimizes rejection of the transplant.

Ans: Azathioprine minimizes rejection of the transplant. Feedback: After heart transplant, patients are constantly balancing the risk of rejection with the risk of infection. Most commonly, patients receive cyclosporine or tacrolimus (FK506, Prograf), azathioprine (Imuran), or mycophenolate mofetil (CellCept), and corticosteroids (prednisone) to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance cardiac output, or increase white cell counts.

A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test? A) Echocardiography B) Blood cultures C) Cardiac aspiration D) Complete blood count

Ans: Blood cultures Feedback: To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test.

An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patient's echocardiogram? A) Blood to flow back from the aorta to the left ventricle B) Obstruction of blood flow from the left ventricle C) Blood to flow back from the left atrium to the left ventricle D) Obstruction of blood from the left atrium to left ventricle

Ans: Blood to flow back from the aorta to the left ventricle Feedback: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.

The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding? A) Decreased ejection fraction B) Decreased heart rate C) Ventricular hypertrophy D) Mitral valve regurgitation

Ans: Decreased ejection fraction Feedback: DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia and mitral valve regurgitation do not typically occur in patients with DCM.

A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? A) Exposure to immunocompromised individuals B) Future hospital admissions C) Dental procedures D) Live vaccinations

Ans: Dental procedures Feedback: Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed.

The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM? A) Dilated ventricles with atrophy of the ventricles B) Dilated ventricles without hypertrophy of the ventricles C) Dilation and hypertrophy of all four heart chambers D) Dilation of the atria and hypertrophy of the ventricles

Ans: Dilated ventricles without hypertrophy of the ventricles Feedback: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in patients with DCM.

The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what? Select all that apply. A) Emboli B) Mitral valve damage C) Ventricular dysrhythmia D) Atrial-septal defect E) Plaque formation

Ans: Emboli, Mitral valve damage, Ventricular dysrhythmia Feedback: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.

A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis? A) Sudden changes in level of consciousness (LOC) B) Peripheral edema and pulmonary edema C) Pleuritic chest pain D) Flulike symptoms

Ans: Flulike symptoms Feedback: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis.

The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent with this diagnosis? A) Wheezes B) Friction rub C) Fine crackles D) Coarse crackles

Ans: Friction rub Feedback: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis.

A patient has been living with dilated cardiomyopathy for several years but has experienced worsening symptoms despite aggressive medical management. The nurse should anticipate what potential treatment? A) Heart transplantation B) Balloon valvuloplasty C) Cardiac catheterization D) Stent placement

Ans: Heart transplantation Feedback: When heart failure progresses and medical treatment is no longer effective, surgical intervention, including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization will not address the pathophysiology of cardiomyopathy.

The nurse on the hospital's infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients. What classification of patients would be at greatest risk for hospital-acquired endocarditis? A) Hemodialysis patients B) Patients on immunoglobulins C) Patients who undergo intermittent urinary catheterization D) Children under the age of 12

Ans: Hemodialysis patients Feedback: Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis.

A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is particularly common among young people who appear otherwise healthy? A) Dilated cardiomyopathy (DCM). B) Arrhythmogenic right ventricular cardiomyopathy (ARVC) C) Hypertrophic cardiomyopathy (HCM) D) Restrictive or constrictive cardiomyopathy (RCM)

Ans: Hypertrophic cardiomyopathy (HCM) Feedback: With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people, including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear otherwise healthy.

The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? A) Absence of complications B) Adherence to the self-care program C) Improved cardiac output D) Increased activity tolerance

Ans: Improved cardiac output Feedback: The priority nursing diagnosis of a patient with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output.

A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the nurse's admission interview, the patient states that she takes over-the-counter "water pills" on a regular basis. How should the nurse best respond to the fact that the patient has been taking diuretics? A) Encourage the patient to drink at least 2 liters of fluid daily. B) Increase the patient's oral sodium intake. C) Inform the care provider because diuretics are contraindicated. D) Ensure that the patient's fluid balance is monitored vigilantly.

Ans: Inform the care provider because diuretics are contraindicated. Feedback: Diuretics are contraindicated in patients with HCM, so the primary care provider should be made aware. Adjusting the patient's sodium or fluid intake or fluid monitoring does not address this important contraindication.

.The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes what? A) Cardiac tamponade B) Left ventricular hypertrophy C) Right-sided heart failure D) Ventricular insufficiency

Ans: Left ventricular hypertrophy Feedback: Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency.

The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient education should include which of the following? A) Use of patient-controlled analgesia B) Long-term anticoagulant therapy C) Steroid therapy D) Use of IV diuretics

Ans: Long-term anticoagulant therapy Feedback: Mechanical valves necessitate long-term use of required anticoagulants. Diuretics and steroids are not indicated and patient-controlled analgesia may or may be not be used in the immediate postoperative period.

A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient? A) Aortic regurgitation B) Mitral stenosis C) Mitral valve prolapse D) Aortic stenosis

Ans: Mitral stenosis Feedback: The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not typically caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.

The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right ventricular function. What valvular disorder may have contributed to this patient's diagnosis? A) Mitral valve regurgitation B) Aortic stenosis C) Aortic regurgitation D) Mitral valve stenosis

Ans: Mitral valve stenosis Feedback: Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails. None of the other listed valvular disorders has this pathophysiological effect.

A patient has been admitted with an aortic valve stenosis and has been scheduled for a balloon valvuloplasty in the cardiac catheterization lab later today. During the admission assessment, the patient tells the nurse he has thoracolumbar scoliosis and is concerned about lying down for any extended period of time. What is a priority action for the nurse? A) Arrange for an alternative bed. B) Measure the degree of the curvature. C) Notify the surgeon immediately. D) Note the scoliosis on the intake assessment.

Ans: Notify the surgeon immediately. Feedback: Most often used for mitral and aortic valve stenosis, balloon valvuloplasty is contraindicated for patients with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation, thoracolumbar scoliosis, rotation of the great vessels, and other cardiac conditions that require open heart surgery. Therefore notifying the physician would be the priority over further physical assessment. An alternative bed would be unnecessary and documentation is not a sufficient response.

The nurse is preparing a patient for cardiac surgery. During the procedure, the patient's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this patient undergo? A) Orthotopic transplant B) Xenograft C) Heterotropic transplant D) Homograft

Ans: Orthotopic transplant Feedback: Orthotopic transplantation is the most common surgical procedure for cardiac transplantation. The recipient's heart is removed, and the donor heart is implanted at the vena cava and pulmonary veins. Some surgeons still prefer to remove the recipient's heart, leaving a portion of the recipient's atria (with the vena cava and pulmonary veins) in place. Homografts, or allografts (i.e., human valves), are obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement. Xenografts and heterotropic transplantation are not terms used to describe heart transplantation.

A cardiac surgery patient's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action? A) Prepare to assist with pericardiocentesis. B) Reposition the patient into a prone position. C) Administer a dose of metoprolol. D) Administer a bolus of normal saline.

Ans: Prepare to assist with pericardiocentesis. Feedback: Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not relieve the pressure on the heart and prone positioning would likely exacerbate symptoms.

A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease? A) Recognizing and promptly treating streptococcal infections B) Prophylactic use of calcium channel blockers in high-risk populations C) Adhering closely to the recommended child immunization schedule D) Smoking cessation

Ans: Recognizing and promptly treating streptococcal infections Feedback: Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease.

The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repairing it. What is an advantage of valvuloplasty that the nurse should cite? A) The procedure can be performed on an outpatient basis in a physician's office. B) Repaired valves tend to function longer than replaced valves. C) The procedure is not associated with a risk for infection. D) Lower doses of antirejection drugs are required than with valve replacement.

Ans: Repaired valves tend to function longer than replaced valves. Feedback: In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and patients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all surgical procedures, and it is not performed in a physician's office. Antirejection drugs are unnecessary because foreign tissue is not introduced.

The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The nurse should know that in developing countries the most common cause of mitral valve regurgitation is what? A) A decrease in gamma globulins B) An insect bite C) Rheumatic heart disease and its sequelae D) Sepsis and its sequelae

Ans: Rheumatic heart disease and its sequelae Feedback: The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease and its sequelae.

A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patient's medication regimen, what nursing diagnosis should be prioritized? A) Risk for injury B) Risk for infection C) Risk for peripheral neurovascular dysfunction D) Risk for unstable blood glucose

Ans: Risk for infection Feedback: Immunosuppressants decrease the body's ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels.

A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following? A) Sodium B) AST, ALT, and bilirubin C) White blood cell differential D) BUN

Ans: Sodium Feedback: Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests.

A nurse is planning discharge health education for a patient who will soon undergo placement of a mechanical valve prosthesis. What aspect of health education should the nurse prioritize in anticipation of discharge? A) The need for long-term antibiotics B) The need for 7 to 10 days of bed rest C) Strategies for preventing atherosclerosis D) Strategies for infection prevention

Ans: Strategies for infection prevention Feedback: Patients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials used in valvuloplasty) require education to prevent infective endocarditis. Despite these infections risks, antibiotics are not used long term. Activity management is important, but extended bed rest is unnecessary. Valve replacement does not create a heightened risk for atherosclerosis.

.A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A) The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) B) The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli C) The need to avoid foods that contain vitamin K D) The need to take enteric-coated ASA on a daily basis

Ans: The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) Feedback: Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.

The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications? A) The nurse keeps the patient isolated to prevent nosocomial infections. B) The nurse encourages coughing and deep breathing. C) The nurse helps the patient with activities until the pain and fever subside. D) The nurse encourages increased fluid intake until the infection resolves.

Ans: The nurse helps the patient with activities until the pain and fever subside. Feedback: To minimize complications, the nurse helps the patient with activity restrictions until the pain and fever subside. As the patient's condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the patient isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.

A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this? A) To prevent bacterial endocarditis B) To prevent hospital-acquired pneumonia C) To minimize the need for antibiotic use during the procedure D) To decrease the need for surgical asepsis

Ans: To prevent bacterial endocarditis Feedback: Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis.

The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to relieve the symptom of angina without drugs. What should the nurse teach the patient? A) To eat a small meal before taking nitroglycerin B) To drink a glass of milk before taking nitroglycerin C) To engage in 15 minutes of light exercise before taking nitroglycerin D) To rest and relax before taking nitroglycerin

Ans: To rest and relax before taking nitroglycerin Feedback: The venous dilation that results from nitroglycerin decreases blood return to the heart, thus decreasing cardiac output and increasing the risk of syncope and decreased coronary artery blood flow. The nurse teaches the patient about the importance of attempting to relieve the symptoms of angina with rest and relaxation before taking nitroglycerin and to anticipate the potential adverse effects. Exercising, eating, and drinking are not recommended prior to using nitroglycerin.

A nurse is teaching a client who is having a valuloplasty tomorrow. The client asks what the advantage is for having a tissue valve replacement instead of a mechanical valve. The correct answer by the nurse is which of the following? a) "A tissue valve is less likely to generate blood clots, and so long-term anticoagulation therapy is not required." b) "A tissue valve does not become infected as easily as mechanical valves." c) "A tissue valve is thought to be more durable and so requires replacement less often." d) "A tissue valve does not deteriorate as easily as mechanical valves."

a) "A tissue valve is less likely to generate blood clots, and so long-term anticoagulation therapy is not required." Tissue valves are less likely to generate thromoemboli, so long-term anticoagulation is not required. Mechanical valves do not deteriorate or become infected as easily as tissue valves. They are thought to be more durable than tissue valves and so require replacement less often.

The client teaching instructions for a 57-year-old male client with thrombophlebitis who is being discharged should include which of the following? Select all that apply. a) Ambulate as tolerated. b) Avoid elevating affected extremity. c) Take anticoagulant therapy when symptoms occur. d) Avoid sitting for too long. e) Perform leg exercises each hour.

a) Ambulate as tolerated. d) Avoid sitting for too long. e) Perform leg exercises each hour. Nurses instruct clients with thrombophlebitis to prevent recurrences by being active, avoiding knee bending or leg crossing, elevating legs periodically, and taking long-term anticoagulant therapy exactly as prescribed. Clients should also watch for and report signs that indicate impaired clotting: nosebleeds, bleeding gums, rectal bleeding, easy bruising, and prolonged oozing from minor cuts.

A 62-year-old female who is 2 weeks CABG returns to her cardiologist due to new symptoms, including heaviness in her chest and pain between her breasts. She reports that leaning forward decreases the pain. The cardiologist admits her to the hospital to rule out pericarditis. Which of the following is a contributing cause to pericarditis? Select all that apply. a) Chest trauma b) Cardiac surgery c) Tuberculosis d) Myocarditis e) Pneumonia

a) Chest trauma b) Cardiac surgery c) Tuberculosis d) Myocarditis Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack) or develops after cardiac surgery.

The nurse is performing a neurovascular assessment of a client's injured extremity. Which of the following would the nurse report? a) Dusky or mottled skin color b) Positive distal pulses c) Skin warm to touch d) Capillary refill of 3 seconds

a) Dusky or mottled skin color Normally, skin color would be similar to the color in other body areas. Pale or dusky skin color indicates an abnormality that needs to be reported. Presence of pulses, capillary refill of 3 seconds, and warm skin are normal findings.

The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?"The nurse is most safe to speculate which of the following? a) From a break in the skin b) From ingestion of a food c) From droplets from a cough d) From the fecal-oral route

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

The nurse suspects a diagnosis of mitral valve regurgitation when what type of murmur is heard on auscultation? a) High-pitched blowing sound at the apex b) Diastolic murmur at the left sternal border c) Mitral click d) Low-pitched diastolic murmur at the apex

a) High-pitched blowing sound at the apex Mitral valve regurgitation is associated with a systolic murmur, which is a high-pitched, blowing sound at the apex.

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? a) Keep the patient's affected leg straight. b) Monitor the patient's chest drainage. c) Evaluate the patient's endotracheal lip line. d) Assess the patient's chest tube output.

a) 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.

On auscultation, the nurse suspects a diagnosis of mitral valve stenosis when which of the following is heard? a) Low-pitched, rumbling diastolic murmur at the apex of the heart b) High-pitched blowing sound at the apex c) Mitral valve click d) Diastolic murmur at the left sternal border of the heart

a) Low-pitched, rumbling diastolic murmur at the apex of the heart The murmur is caused by turbulent blood flow through the abnormally tight valve opening. A low-pitched, rumbling, diastolic murmur (heard on S2) is heard best at the apex. A loud S1, due to abrupt closure of the mitral valve, and an early diastolic opening snap can be heard. The snap is the premature opening of the stenotic mitral valve.

Which of the following nursing interventions should a nurse perform to reduce cardiac workload in a patient diagnosed with myocarditis? a) Maintain the patient on bed rest. b) Elevate the patient's head. c) Administer a prescribed antipyretic. d) Administer supplemental oxygen.

a) Maintain the patient on bed rest. The nurse should maintain the patient 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 patient 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 patient's head to promote maximal breathing potential.

The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which of the following findings confirms a positive outcome?(Select all that apply.) a) No bleeding or bruising noted b) Right extremity pink c) Right extremity comparable in size to left d) Client denies pain e) Homan's sign positive f) Pedal pulse thready

a) No bleeding or bruising noted b) Right extremity pink c) Right extremity comparable in size to left d) Client denies pain Evaluation of the expected outcome of thrombolytic therapy includes restoring blood flow to the extremity. Findings include no pain from impaired circulation, a pink extremity of comparable size, and no bleeding from complications of the thrombolytic medication. A thready pulse would indicate impaired circulation, and a positive Homan's sign would indicate a continuing thrombus.

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? a) Quick, sharp strokes that suddenly collapse b) Low-pitched diastolic murmur at the apex c) High-pitched blowing sound at the apex d) Mitral click

a) 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 patient was admitted to the hospital with a diagnosis of aortic regurgitation. On assessment, the nurse notes the following positive indicators for the disease process. Select all that apply. a) The pulse has a rapid upstroke, then collapses b) Systolic pressure in the lower extremities is lower than in the upper extremities c) Visible neck vein pulsations d) The presence of a diastolic murmur e) Shortened pulse pressure

a) The pulse has a rapid upstroke, then collapses c) Visible neck vein pulsations d) The presence of a diastolic murmur Pulse pressure widens and systolic blood pressure in the lower extremities is higher than in the upper extremities as a result of progressive left ventricular failure.

A patient with infective endocarditis of a prosthetic mitral valve returns to the emergency department with a second episode of left-sided weakness and visual changes. The nurse expects that collaborative management of the patient will include a) surgical valve replacement b) administration of anticoagulants c) higher than usual antibiotic dosages d) embolectomy

a) surgical valve replacement Aortic or mitral valve debridement, excision, or replacement is required in patients with more than one serious systemic embolic episode.

A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The graduate nurse discusses this development with the nurse preceptor. The preceptor is assured when the graduate nurse states: a) "I instructed the patient to do coughing and deep breathing and I will reassess in 30 minutes." b) "I anticipated this complication and I will call the doctor right now." c) "I placed the patient in a semi-Fowler's position and made him NPO." d) "I told the patient that this is a normal complication and to take deep breaths."

b) "I anticipated this complication and I will call the doctor right now." With right-sided heart endocarditis, the nurse assesses for signs and symptoms of organ damage such as stroke, meningitis, heart failure, myocardial infarction, glomerulonephritis, and splenomegaly. This requires further assessment and collaborative interventions to prevent further deterioration. The other actions are not appropriate at this time.

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for? a) Left ventricular hypertrophy b) Cardiac tamponade c) Decreased venous pressure d) Hypertension

b) 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).

A 73-year-old male client is diagnosed with dilated cardiomyopathy. The nurse is aware that which of the following is the most likely cause of his condition? a) Scleroderma b) Chronic alcohol abuse c) Previous myocardial infarction d) Heredity

b) 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. This a connective tissue disorder is thought to cause restrictive cardiomyopathy. Scar tissue that forms after a myocardial infarction is thought to be a cause of restrictive cardiomyopathy.

Which of the following is a term used to describe the splitting or separating of fused cardiac valve leaflets? a) Chordoplasty b) Commissurotomy c) Valvuloplasty d) Annuloplasty

b) Commissurotomy Commissurotomy is the splitting or separating of fused cardiac valve leaflets. Annuloplasty is a repair of a cardiac valve's outer ring. Chordoplasty is repair of the stringy, tendinous fibers that connect the free edges of the atrioventricular valve leaflets to the papillary muscle. Valvuloplasty is a repair of a stenosed or regurgitant cardiac valve by commissurotomy, annuloplasty, leaflet repair, or chordoplasty.

The nurse determines that a patient has a characteristic symptom of pericarditis. What symptom does the nurse recognize as significant for this diagnosis? a) Dyspnea b) Constant chest pain c) Uncontrolled restlessness d) Fatigue lasting more than 1 month

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

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis? a) Race b) History of aortic valve replacement c) History of diabetes mellitus d) Age

b) History of aortic valve replacement A heart valve prosthesis such as an aortic valve replacement is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.

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? a) Chordoplasty b) Left ventricular assist device c) Annuloplasty d) Open commissurotomy

b) 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? a) Edema b) Left ventricular dysfunction c) Angina d) Dyspnea

b) 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 of the following is an action of the intra-aortic balloon pump (IABP)? a) Reduction of right ventricular afterload b) Reduction of left ventricular afterload c) Reduction of right ventricular preload d) Reduction of left ventricular preload

b) Reduction of left ventricular afterload The IABP decreases the workload of the heart by reducing left ventricular afterload. Additionally, it improves coronary artery blood flow by increasing coronary artery perfusion pressure. It does not reduce left or right ventricular preload.

Myocarditis is most commonly caused by which of the following? a) Bacterial infection b) Viral infection c) Toxic agents d) Immune-mediated mechanisms

b) Viral infection Myocarditis is an inflammation of the heart muscle, commonly resulting from viral infection. It may also be caused by bacterial infections, immune-mediated mechanisms, and toxic agents.

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, the change in the QRS complex that would most support her suspicion is: a) narrowing complex. b) amplitude decrease. c) widening complex. d) amplitude increase.

b) 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 teaching a patient about valve replacement surgery. Which statement by the patient indicates an understanding of the benefit of an autograft replacement valve? a) "The valve is from a tissue donor, and I will not need to take any blood thinning drugs with I am discharged." b) "The valve is mechanical, and it will not deteriorate or need replacing." c) "The valve is made from my own heart valve, and I will not need to take any blood thinning drugs when I am discharged." d) "The valve is made from a pig tissue, and I will not need to take any blood-thinning drugs when I am discharged."

c) "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 patient'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 patient'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, patients with a history of peptic ulcer disease, and people who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years.

The nurse is aware that statistics show an increase in the prevalence of infective endocarditis among older adults. Which of the following factors places older adults at risk for developing infective endocarditis? a) Higher rate of tuberculosis b) A greater incidence of a history of repaired congenital heart defects c) An increased use in the number of prosthetic valve replacements d) An increase in IV drug use

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

A patient who has had a recent myocardial infarction develops pericarditis and complains of level 6 (on a scale of 0-10) chest pain with deep breathing. Which of these ordered pro re nata (PRN) medications will be the most appropriate for the nurse to administer? a) Morphine sulfate 6 mg IVP every 2-4 hours b) Acetaminophen (Tylenol) 650 mg per os (po) every 4 hours c) Ibuprofen (Motrin) 800 mg po every 8 hours d) Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours

c) Ibuprofen (Motrin) 800 mg po every 8 hours Pain associated with pericarditis is caused by inflammation, thus nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.

The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make? a) Assist client to bathroom every 2 hours. b) Assess abdominal girth daily. c) Place bed in a high or semi-high Fowler's position as needed. d) Instruct client to avoid strenuous activity.

c) Place bed in a high or semi-high Fowler's position as needed. Dilated cardiomyopathy has clinical manifestations of dyspnea on exertion and when lying down. Depending on level of dyspnea, placing the client in an upright Fowler's position is helpful. Clients with hypertrophic cardiomyopathy have syncopal episodes and can collapse following strenuous activity. Assistance with ambulation to avoid falls is helpful. Restrictive cardiomyopathy includes manifestations of ascites and assessment of abdominal girth.

Which of the following mitral valve conditions generally produces no symptoms? a) Regurgitation b) Infection c) Prolapse d) Stenosis

c) 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, will produce symptoms typical of infective endocarditis.

Part of the continued management of a patient with infective endocarditis is assessment for the presence of Janeway lesions. On inspection, the nurse recognizes these lesions by identifying which characteristic sign? a) Patterns of petechiae on the chest b) Splinter hemorrhages seen under the fingernails c) Red or purple macules found on the palms of the hands d) Erythematosus modules on the pads of the fingers

c) 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.

Which of the following teaching interventions should the nurse include in the plan of care for a patient with valvular heart disease who is experiencing pulmonary congestion? a) Teaching patients to take nitroglycerin if shortness of breath develops b) Teaching patients to drink at least 2 L of fluid daily and monitor urine output c) Teaching patients to rest and sleep in a chair or sit in bed with head elevated d) Teaching patients to report a weight gain of 3 pounds in 1 week

c) Teaching patients to rest and sleep in a chair or sit in bed with head elevated Patients 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 patient to take a daily weight and report gains of 3 pounds in 1 day or 5 pounds in 1 week to the primary provider. The nurse may assist the patient with planning activity and rest periods to achieve an acceptable lifestyle.

A patient with a recent myocardial infarction was admitted to the hospital with a new diagnosis of mitral valve regurgitation. Which of the following assessment data obtained by the nurse should be immediately communicated to the health care provider? a) The patient has a palpable thrill felt over the left anterior chest. b) The patient has 4+ peripheral edema in both legs. c) The patient has crackles audible throughout the lungs. d) The patient has a loud systolic murmur all across the precordium.

c) The patient has crackles audible throughout the lungs. Acute mitral regurgitation, 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 on exertion and cough from pulmonary congestion also occur. Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and need immediate interventions, such as diuretics.

The nurse understands that which of the following medications will be administered for 6 to 12 weeks following prosthetic porcine valve surgery? a) Aspirin b) Digoxin c) Warfarin d) Furosemide

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

A patient is admitted to the hospital with possible acute pericarditis and pericardial effusion. The nurse knows to prepare the patient for which diagnostic test used to confirm the patient's diagnosis? a) Chest x-ray b) Cardiac cauterization c) CT scan d) Echocardiogram

d) Echocardiogram Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. An echocardiogram may detect inflammation, pericardial effusion, tamponade, and heart failure. It may help confirm the diagnosis.

The nurse is caring for clients on a busy cardiac unit. Following morning assessment, the nurse would notify the physician with which of the following symptoms? a) A noted irregular pulse rate prior to Lanoxin (digoxin) administration b) Cyanosis with a pulse oximetry level of 92% c) Dyspnea when ambulating from the bathroom d) Pulsus paradoxus on vital sign assessment

d) Pulsus paradoxus on vital sign assessment Pulsus paradoxus is a difference of 10mm Hg or more between the first Korotkoff sound noting systolic blood pressure heard during expiration and the first that is heard during inspiration. Pulsus paradoxus can signal a deteriorating condition including diminished stroke volume, compromised cardiac output, and death. This would be of high priority to notify the physician.