Patho Exam 3 & 4 Ch 27
c) Anaphylactic shock Pg. 724 Anaphylactic Shock Anaphylactic shock is initiated through an immunologically mediated reaction to an irritant. Neurogenic shock is caused by decreased sympathetic control of blood vessel tone due to a defect in the vasomotor center in the brain stem or the sympathetic outflow to the blood vessels. Cardiogenic shock occurs when the heart fails to pump blood sufficiently to meet the body's demands. Septic shock, which is the most common type of distributive shock, is associated with the systemic immune response to severe infection.
1. A 20-year-old male client is experiencing a severe immunologically mediated reaction in which histamines have been released into the blood. Which type of reaction is most likely occurring with this client? a) Septic shock b) Neurogenic shock c) Anaphylactic shock d) Cardiogenic shock
c) Obstructive shock Pg. 725 Obstructive Shock Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.
12. A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing? a) Distributive shock b) Hypovolemic shock c) Obstructive shock d) Cardiogenic shock
d) "The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs" Pg. 696 Right Ventricular Dysfunction In left-sided failure, the left ventricle pumps inefficiently, blood backs up in the pulmonary circulation, and less, rather than more, blood enters the carotid arteries. Right-sided rather that left-sided heart failure causes blood to back up in the venous circulation, resulting in edema. Congestion of the gastrointestinal tract is usually characteristic of advanced heart failure.
6. A client in the nursing home wonders why he is having these signs and symptoms of left-sided heart failure. Which explanation will the nurse give the client? a) "The left ventricle is not adequately perfusing your gastrointestinal tract, leading to diarrhea and vomiting" b) "The left ventricle is having problems pumping blood forward, so blood is backing up systemically causing edema in your feet" c) "The left ventricle is pumping excessive amounts of blood through the carotid arteries causing headache" d) "The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs"
c) Hypovolemic shock due to acute intravascular volume loss Pg. 721 Hypovolemic Shock Hypovolemic shock is characterized by diminished blood volume such that there is inadequate filling of the vascular compartment. Hypovolemic shock also can result from an internal hemorrhage or from third-space losses, when extracellular fluid is shifted from the vascular compartment to the interstitial space or compartment, without fluid movement in/out of the cells. Within seconds after the onset of hemorrhage or the loss of blood volume, compensatory manifestations of tachycardia, vasoconstriction, and other signs of sympathetic and adrenal medullary activity appear. There is no indication that this client has developed a pulmonary embolism, is having side effects from versed administration, or is going into renal failure due to an overdose of medication.
10. A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of: a) Pulmonary embolism due to development of deep vein thrombosis b) Renal failure due to an overdose of medication c) Hypovolemic shock due to acute intravascular volume loss d) Side effects from the administration of midazolam, causing excessive vasoconstriction
d) Right-sided heart failure Pg. 682 Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia A major effect of right-sided heart failure is the development of peripheral edema. A client who is in shock would not have stable vital signs. Cor pulmonale would be accompanied by manifestations of lung disease. Pericarditis is an inflammation of the pericardium exhibited by fever, precordial pain, dyspnea, and palpitations.
11. Assessment of an older adult client reveals bilateral pitting edema of the client's feet and ankles; difficult to palpate pedal pulses; breath sounds clear on auscultation; oxygen saturation level of 93% (0.93); and vital signs normal. What is this client's most likely health problem? a) Cardiogenic shock b) Cor pulmonale c) Pericarditis d) Right-sided heart failure
c) The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta Pg. 691 Aortic Valve Stenosis Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. This increases the work and volume of the chamber emptying through the narrowed valve—the left atrium in the case of mitral stenosis and the left ventricle in aortic stenosis. An incompetent or regurgitant valve permits backward flow to occur when the valve should be closed—flowing back into the left ventricle during diastole when the aortic valve is affected and back into the left atrium during systole when the mitral valve is diseased.
13. A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be: a) The valve opening permits backward flow to occur when the valve should be closed b) The valve opens backward, permitting blood to flow from the right ventricle into the right atrium c) The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta d) The valve opening is incompetent, thereby allowing blood to flow back from the pulmonary artery and into the left atrium
c) Infective endocarditis Pg. 685 Infective Endocarditis Infective endocarditis is a serious and potentially life-threatening infection of the inner surface of the heart. Pericarditis involves an inflammatory response of the pericardium. Myocardial infarction is a heart attack while cardiomyopathy is a heart disorder that is confined to the myocardium and can sometimes represent myocardial changes that occur with a variety of systemic disorders.
14. A client has just been told that he has an infection of the inner surface of the heart. He is also told that the bacteria has invaded his heart valves. What term is used for this disease process? a) Myocardial infarction b) Cardiomyopathy c) Infective endocarditis d) Pericarditis
d) The disabling effects that result from involvement of heart valves Pg. 686 Rheumatic Heart Disease Rheumatic fever is a very important cause of heart disease and its most serious and disabling effects result from involvement of the heart valves.
15. The nursing instructor is teaching the students about rheumatic fever. She tells the students that it is an important cause of heart disease and is very serious mainly for which reason? a) That there is no definitive test used for diagnoses b) The fact that it affects young and old c) The cost associated with treating the disease d) The disabling effects that result from involvement of heart valves
b) Decreased level of consciousness Pg. 675 Clinical Manifestations Fibrinolytic therapy is most effective in treating STEMI when administered within 30 minutes after the onset of symptoms. It can still be beneficial up to 12 hours after the onset of ischemic pain. Clients who should not receive fibrinolytic therapy are those with a history of intracranial hemorrhage or significant trauma within the preceding 3 months. The primary complication of fibrinolytic treatment is intracranial bleeding that usually occurs within the first 24 hours following treatment. This would be evident with a change in mental status or level of consciousness (LOC).
16. A client who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which manifestation alerts the nurse to a developing complication? a) Symmetrical joint pain b) Decreased level of consciousness c) Hypoglycemia d) Diarrhea
a) Dyspnea b) Extreme fatigue with activity c) Orthopnea Pg. 682 Dilated Cardiomyopathy The most common clinical manifestations of DCM are those related to heart failure, such as dyspnea, orthopnea, and reduced exercise capacity. Hypertrophic cardiomyopathy (HCM) is characterized by myocardial thickening and abnormal diastolic filling. The person experiences fainting/syncope. Restrictive cardiomyopathy, in which there is excessive rigidity of the ventricular wall, increases the work of ventricular emptying and causes cardiac hypertrophy. These clients experience excess abdominal fluid (ascites).
17. A client is admitted with dilated cardiomyopathy with left ventricular dysfunction. The nurse should assess for which clinical manifestations? Select all that apply. a) Dyspnea b) Extreme fatigue with activity c) Orthopnea d) Excess abdominal fluid e) Fainting
d) Hypertrophic cardiomyopathy Pg. 681 Hypertrophic Cardiomyopathy HCM is an autosomal dominant heart disease caused by mutations in the genes encoding proteins of the cardiac sarcomere. HCM is the most common cause of sudden cardiac death (SCD) in young athletes. Dilated cardiomyopathy, mitral valve prolapse, and atrial regurgitation all lead to heart failure but much later in life.
18. A 17-year-old athlete died suddenly during a track meet and it was subsequently determined that he had heart disease. Which condition was the most likely cause of his heart failure? a) Dilated cardiomyopathy b) Atrial regurgitation c) Mitral valve prolapse d) Hypertrophic cardiomyopathy
c) Ca2+ levels in the myocardium Pg. 670 Myocardial Oxygen Supply and Demand Calcium is responsible for allowing actin and myosin to interact due to its binding to troponin. The levels of hydrogen ions do not directly influence cardiac contractility. Sodium and potassium levels are important, but it is variations in extracellular potassium levels that cause variations in contractility. Serum sodium levels affect contractility to a lesser degree than calcium.
19. A client has been diagnosed with heart failure. The client's cardiac contractility will be primarily affected by which factor? a) The gradient between intracellular and extracellular H+ levels b) Intracellular K+ levels c) Ca2+ levels in the myocardium d) Serum Na+ levels
b) Weight gain Pg. 696 Right Ventricular Dysfunction In right-sided heart failure, blood backs up into the venous system and increased capillary hydrostatic pressure forces plasma out of the circulatory system, resulting in edema. The accumulation of fluid is evidenced by rapid weight gain. Shortness of breath and decreased renal perfusion and output are characteristic of left-sided failure.
2. A telehealth nurse is talking with a client who has a history of right-sided heart failure. The nurse should question the client about which assessment finding that would indicate the client's condition is worsening? a) Decreased blood pressure b) Weight gain c) Shortness of breath d) Copious urination
b) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat" Pg. 699 Natriuretic Peptides Salt and fluid restrictions are indicated for most clients with heart failure (HF). Beta-blockers do not address shortness of breath, and cardiac medications are not normally taken in response to acute symptoms. Clients should be encouraged to maintain—and increase, if possible—physical activity within the limits of their condition.
20. A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which statement demonstrates an accurate understanding of his new diagnosis? a) "I'm going to avoid as much physical activity as I can so that I preserve my strength" b) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat" c) "I'll be sure to take my beta-blocker whenever I feel short of breath" d) "I know it's healthy to drink a lot of water, and I'm going to make sure I do this from now on"
a) At the apex of the heart Pg. 690 Diagnosis The murmur of mitral valve stenosis is heard during diastole when blood is flowing through the constricted valve; it is characteristically a low-pitched, rumbling murmur best heard at the apex of the heart. The other locations would not be effective.
3. The nurse is preparing to auscultate for a mitral valve stenosis murmur. Where is the best location to place the stethoscope? a) At the apex of the heart b) Over the aorta c) At the carotid arteries d) Over the sternum
b) Increased vascular stiffness Pg. 717 Heart Failure in Older Adults Increased vascular stiffness in older adults causes a progressive increase in systolic blood pressure with advancing age, which in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. A loss of action potential does not typically accompany aging, and contractility tends to decrease as a result of cardiac stiffness. Orthostatic hypotension is neither a normal age-related change nor a cause of heart failure.
21. An 86-year-old client is disappointed to learn that he or she has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which age-related change predisposes older adults to the development of heart failure? a) Loss of action potential b) Increased vascular stiffness c) Orthostatic hypotension d) Increased cardiac contractility
c) Vasodilating effects reducing preload and afterload Pg. 670 Nitroglycerin produces its effects by releasing nitric oxide in vascular smooth muscle of the target tissues, resulting in relaxation of this muscle and increased blood flow. Nitroglycerin's effect on the vessels decreases venous return (reduce preload) and arterial blood pressure (reduce afterload). This drug does not decrease heart rate. Because it vasodilates, it decreases preload. Nitroglycerine does not affect cardiac refractory periods.
22. A client who lives with angina pectoris has taken a sublingual dose of nitroglycerin to treat the chest pain he experiences while mowing his lawn. This drug facilitates release of nitric oxide, which will have what physiologic effect? a) Increased preload b) Decreased heart rate and increased stroke volume c) Vasodilating effects reducing preload and afterload d) Reduction of cardiac refractory periods
a) Myocardial infarction Pg. 673 Acute Coronary Syndrome Myocardial infarction causing damage to the left ventricular wall can decrease ventricular efficiency and result in left-sided failure. Pulmonary edema, hypotension, and stroke are not causes of left-sided heart failure.
23. A client has developed left-sided heart failure. Which symptom might have precipitated this condition? a) Myocardial infarction b) Stroke c) Hypotension d) Pulmonary edema
a) Hypertrophy Pg. 681 Hypertrophic Cardiomyopathy Myocardial hypertrophy is a compensatory mechanism in heart failure as the heart attempts to maintain adequate pumping ability. Paradoxically, hypertrophy can gradually decrease cardiac efficiency.
24. Increased cardiac workload with left-sided heart failure can result in which change to the myocardial cells? a) Hypertrophy b) Dysplasia c) Hyperplasia d) Atrophy
c) Tests help to determine aerobic fitness by measuring heart rate while under the stress of exercise Pg. 671 Exercise Stress Testing Aerobic fitness is often measured with heart rate performance during exercise on a bicycle, treadmill, or step machine.
25. How can the health care provider determine if the client has "aerobic fitness"? a) This is only completed with self-reported tools b) Aerobic fitness cannot be measured c) Tests help to determine aerobic fitness by measuring heart rate while under the stress of exercise d) The client is the only one that can determine if he/she is able to perform aerobic exercise
a) Acute coronary syndrome b) Chronic ischemic heart disease Pg. 669 Coronary Artery Disease Coronary heart disease is commonly divided into 2 types of disorders: the acute coronary syndrome and chronic ischemic heart disease.
26. The nursing student, when studying about coronary artery disease, learns that it is commonly divided into different types of disorders. Which disorders would be included? Select all that apply. a) Acute coronary syndrome b) Chronic ischemic heart disease c) Tertiary heart disease d) Primary heart disease e) Secondary heart disease
d) Morphine Pg. 675 Management of Acute Coronary Syndrome Although a number of analgesic agents have been used to treat pain of myocardial infarction, morphine is the drug of choice and is usually indicated if chest pain is unrelieved with oxygen and nitrates.
27. The nurse working in the emergency room triages a client who comes in reporting chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myocardial infarction. The client is given a nitrate, which does nothing for his pain. Which medication should the nurse suspect the doctor will order next for the pain? a) Fentanyl b) Demerol c) Codeine d) Morphine
b) "Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water" Pg. 697 Frank-Starling Mechanism In heart failure with a reduced ejection fraction, a decrease in cardiac output and renal blood flow leads to increased sodium and water retention by the kidney with a resultant increase in vascular volume and venous return to the heart and an increase in ventricular end-diastolic volume. Drinking water may increase volume but is not the physiologic reason for retention of fluid. Diuretics do decrease weight as a result of diuresis, but weight loss is not the purpose for giving diuretics. The lungs are not the primary cause of heart failure.
28. A client with heart failure asks, "Why am I taking a 'water pill' when it's my heart that is having a problem?" While educating the client about the Frank-Starling mechanism, which explanation is most appropriate to share? a) "Your heart muscle is overstretched, so it's not able to pump all the blood out. The prescribed 'water pills' help by decreasing your weight" b) "Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water" c) "Since your heart function is impaired, the lungs are not able to oxygenate the blood and your kidneys are wearing out" d) "You must be drinking way too many liquids. Your kidneys cannot filter all that you are drinking during the day"
c) Hypertrophic cardiomyopathy (HCM) Pg. 681 Hypertrophic Cardiomyopathy The most frequent symptoms of HCM are dyspnea and chest pain in the absence of coronary artery disease. Syncope (fainting) is also common and is typically postexertional, when diastolic filling diminishes and outflow obstruction increases. Ventricular dysrhythmias are also common, and sudden death may occur, often in athletes after extensive exertion. Risk factors for sudden cardiac death among clients with HCM include a family history of syncope or sudden cardiac death, certain mutations, and extreme hypertrophy of the left ventricle. HCM is characterized by a massively hypertrophied left ventricle with a reduced chamber size.
29. Football fans at a college have been shocked to learn of the sudden death of a star player, an event that was attributed in the media to "an enlarged heart." Which disorder was the player's most likely cause of death? a) Takotsubo cardiomyopathy b) Dilated cardiomyopathy (DCM) c) Hypertrophic cardiomyopathy (HCM) d) Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)
c) Low blood pressure Pg. 675 Management of Acute Coronary Syndrome Low blood pressure is characteristic of most occurrences of shock. Hypoperfusion of the systemic tissue results from deficient cardiac output. Most often, hypotension and hypoperfusion are present. Elevated pulse rate may be a compensatory effort to support blood pressure. Elevated temperature can occur with septic shock. Decreased respiratory rate is not characteristic of shock.
30. A 30-year-old client arrives with these vital signs: Blood pressure 50/30 mm Hg, pulse 100 beats/min, respiratory rate 12 breaths/min, temperature 101°F (38.3°C). The nurse interprets these results as the client being in shock based on which reading? a) Elevated pulse rate b) Elevated temperature c) Low blood pressure d) Slow respiratory rate
b) Myocardial infarction Pg. 672 Acute Coronary Syndrome The ST-segment elevation with myocardial infarction could be caused by a decrease in blood supply to that area of cardiac muscle. Hypokalemia results in flattening or inversion of T waves.
31. A client reports severe indigestion that has been intermittent; however, the pain is now constant and feels like a vise. The nurse does an ECG and recognizes that the situation is possibly emergent due to ST-segment elevation, which could indicate: a) Decreased intracranial pressure b) Myocardial infarction c) Benign late repolarization d) Advanced hypokalemia
b) Administer epinephrine (adrenaline) Pg. 724 Treatment Treatment includes immediate discontinuation of the inciting agent or institution of measures to decrease its absorption; close monitoring of cardiovascular and respiratory function; maintenance of respiratory gas exchange, cardiac output, and tissue perfusion. Epinephrine is given in an anaphylactic reaction because it constricts blood vessels and relaxes the smooth muscle in the bronchioles, thus restoring cardiac and respiratory function.
32. A client is transported to the emergency department in respiratory distress after eating peanuts. The following interventions are ordered by the health care provider. Which intervention should the nurse complete first? a) Complete a 12-lead ECG b) Administer epinephrine (adrenaline) c) Administer diphenhydramine d) Start a normal saline infusion
b) Respiratory dysfunction Pg. 727 Multiple Organ Dysfunction Syndrome Major risk factors for the development of MODS are severe trauma, sepsis, prolonged periods of hypotension, hepatic dysfunction, infarcted bowel, advanced age, and alcohol abuse. Respiratory dysfunction is not a major risk factor in MODS.
33. The pathogenesis of multi-organ dysfunction syndrome (MODS) is not clearly understood at this time. Supportive management is currently the focus of treatment in this disorder. What is not a major risk factor in MODS? a) Infarcted bowel b) Respiratory dysfunction c) Advanced age d) Alcohol abuse
c) Laryngeal edema Pg. 724 Anaphylactic Shock Anaphylaxis is a clinical syndrome that represents the most severe form of systemic allergic reaction. Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema.
34. Anaphylactic shock is the most severe form of systemic allergic reaction. Immunologically medicated substances are released into the blood, causing vasodilation and an increase in capillary permeability. What physiologic response often follows the vascular response in anaphylaxis? a) Uterine smooth muscle relaxation b) Gastrointestinal relaxation c) Laryngeal edema d) Bronchodilation
b) Septic shock Pg. 724 Sepsis and Septic Shock Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.
35. The nurse should anticipate administering intravenous antibiotic therapy as a priority to a client experiencing which type of shock? a) Cardiogenic shock b) Septic shock c) Hypovolemic shock d) Anaphylactic shock
b) Vasodilator drugs like nitroprusside Pg. 721 Treatment Vasodilator drugs like nitroprusside are used in acute heart failure syndromes to improve left heart performance by decreasing the preload (through vasodilation) or reducing the afterload (through arteriolar dilation). ACE inhibitors prevent the conversion of angiotensin I to angiotensin II. Early in the course of heart failure, the renin-angiotensin-aldosterone system is activated. It results in an increase in angiotensin II, which causes vasoconstriction, ventricular remodeling, and increased aldosterone production with increased water retention by the kidneys. ACE inhibitors limit these harmful complications. Beta blockers are used to decrease left ventricular dysfunction associated with activation of the sympathetic nervous system. Cardiac glycosides like digitalis improve cardiac function by increasing the force and strength of ventricular contractions.
36. The nurse is caring for a client with chronic heart failure. Which drug category may be prescribed for acute heart failure to improve heart performance by decreasing preload? a) Cardiac glycosides like digitalis b) Vasodilator drugs like nitroprusside c) Angiotensin-converting enzyme (ACE) inhibitors like captopril d) Beta-adrenergic receptor blocking agents like atenolol
d) Left side of the heart to the right side of the heart Pg. 707 Cyanotic versus Acyanotic Disorders Defects that result in a left-to-right shunt are categorized as acyanotic disorders since they do not compromise oxygenation of blood in the pulmonary circulation.
37. The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states the blood is shunted to which part of the body? a) Left lung to the right lung b) Right lung to the left lung c) Right side of the heart to the left side of the heart d) Left side of the heart to the right side of the heart
d) "This test evaluates cardiac function" Pg. 725 Treatment Ergometry is a procedure for determining physical performance capacity and cardiac functioning. It can be done on a bicycle or treadmill and the client does not have to jog to do the test. It is not an invasive test. Clients can eat a light meal prior to the test.
38. What should the nurse teach the client prior to ergometry? a) "You must be able to jog to do this test" b) "Do not eat prior to having this test" c) "This is an invasive test" d) "This test evaluates cardiac function"
b) "The test is used to measure functional status during stress" Pg. 671 Exercise Stress Testing The exercise stress test is used to measure aerobic fitness. It does not help the client endure exercise or assess tolerance of isometric exercise. It is not done prior to starting medication therapy for obesity.
39. A client asks the purpose of an exercise stress test. What is the nurse's best response? a) "This test is necessary prior to starting medication therapy for obesity" b) "The test is used to measure functional status during stress" c) "This is to assess your tolerance of isometric exercise" d) "This will help you endure exercise"
a) Troponin Pg. 673 Serum Biomarkers The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.
4. Which serum biomarker is highly specific for myocardial tissue? a) Troponin b) Creatine kinase c) C-reactive protein d) White blood cells
c) Pericardial effusion Pg. 667 Pericardial Effusion and Cardiac Tamponade Pericardial effusion refers to the accumulation of fluid in the pericardial cavity, usually as a result of an inflammatory or infectious process. A sudden accumulation of even 200 mL of fluid may raise intracardiac pressure to levels that will cause symptoms similar to right-sided heart failure. Pericarditis is inflammation of the pericardium while COPD is a respiratory disease.
40. A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250 mL of fluid in the pericardial cavity. Which disease should the nurse suspect this client is suffering? a) Myocardial infarction b) COPD c) Pericardial effusion d) Pericarditis
b) Raising the head of the bed to a high Fowler's position Pg. 693 Clinical Manifestations and Diagnosis Treatment measures include close monitoring of cardiovascular and respiratory function; maintenance of respiratory gas exchange, cardiac output, and tissue perfusion; and the administration of oxygen, antihistamine drugs, and corticosteroids. The person should be placed in a supine position. This is extremely important because venous return can be severely compromised in the sitting position. This in turn produces a pulseless mechanical contraction of the heart and predisposes to arrhythmias. In several cases, death has occurred immediately after assuming the sitting position.
41. A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education? a) Administration of 2L of oxygen by nasal cannula b) Raising the head of the bed to a high Fowler's position c) Inserting an IV to begin a normal saline infusion d) Placing a pulse oximeter on the client to monitor oxygenation status
a) Vasoconstriction d) Dysrhythmias e) Increased oxygen demand Pg. 706 Fetal and Perinatal Circulation The sympathetic nervous system response is meant to maintain blood pressure and cardiac output; however, it quickly becomes maladaptive and contributes to the deterioration of heart function. An increase in sympathetic activity can lead to tachycardia, vasoconstriction, and cardiac dysrhythmias. Acutely, tachycardia significantly increases the workload of the heart, thus increasing myocardial oxygen demand and leading to cardiac ischemia, myocyte damage, and decreased contractility (inotropy).
42. A client who has progressed to late-stage heart failure is experiencing sympathetic stimulation. The nurse would correlate which manifestations with sympathetic response? Select all that apply. a) Vasoconstriction b) Bradycardia c) Increased cardiac contractility d) Dysrhythmias e) Increased oxygen demand
c) Valvular regurgitation Pg. 685 Etiology and Pathogenesis When cardiac valves such as the aortic or mitral fail to close properly, blood does not efficiently exit from the left ventricle. This condition is valvular regurgitation. Valvular stenosis is a narrowing of the lumen of the valve. Pericardial effusion, an accumulation of fluid in the pericardial sac, causes obstructive shock, as it impedes ventricular filling. Infective endocarditis could trigger septic shock.
43. A client is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as: a) Infective endocarditis b) Valvular stenosis c) Valvular regurgitation d) Pericardial effusion
a) Blood culture Pg. 686 Diagnosis The blood culture remains the most definitive diagnostic procedure and is essential to guide treatment. An echo, ECG, clinical findings, and lab information are also used to help in the diagnosis.
44. A client is admitted to the intensive care unit suspected of having infective endocarditis. Which test is the most definitive diagnostic procedure that is done and used to guide treatment for this type of client? a) Blood culture b) ECG c) CBC d) Echocardiogram
b) Vascular stiffness Pg. 717 Heart Failure in Older Adults There are four changes associated with aging that contribute to the development of heart failure in the older adults. Reduced responsiveness to beta-adrenergic stimulation limits the heart's capacity to maximally increase heart rate and contractility during an increase in activity or stress. A second major effect of aging is increased vascular stiffness; third, in addition to increased vascular stiffness, the heart itself becomes stiffer and less compliant with age. Fourth, aging alters myocardial metabolism at the level of the mitochondria.
45. An older adult client asks the nurse why so many older people develop heart failure. The best response would be increased: a) Response to beta-adrenergic stimulation b) Vascular stiffness c) Cardiac tone and compliance d) Myocardial metabolism
a) Vasoconstriction Pg. 719 Pathophysiology of Circulatory Shock Endothelins are secreted by many cell types, including the endothelial lining of the circulatory system. Clients with heart failure may have increased blood levels of endothelins as the body tries to compensate for a decrease in cardiac output. However, most actions of endothelins—for example, vasoconstriction and sodium and water retention—are counterproductive in heart failure.
53. Levels of endothelins may be increased in clients with heart failure. Which of the following is the primary action of endothelins? a) Vasoconstriction b) Vasodilation c) Diuretic d) Natriuretic
c) "This device will decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure" Pg. 702 Treatment Refractory heart failure reflects deterioration in cardiac function that is unresponsive to medical or surgical interventions. Ventricular assist devices (VADs) are mechanical pumps used to support ventricular function. VADs are used to decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure. This decreases the workload on the ventricle and allows it to rest and recover. The rest of the distractors relate to the monitoring in an ICU of cardiac functioning. Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. With the balloon inflated, the catheter monitors pulmonary capillary pressures (i.e., pulmonary capillary wedge pressure or pulmonary artery occlusion pressure), which reflect pressures from the left ventricle. The pulmonary capillary pressures provide a means of assessing the pumping ability of the left ventricle. One type of pulmonary artery catheter is equipped with a thermistor probe to obtain thermodilutionmeasurements of cardiac output.
46. A client awaiting a heart transplant is experiencing decompensation of her left ventricle that will not respond to medications. The physicians suggest placing the client on a ventricular assist device (VAD). The client asks what this equipment will do. The health care providers respond: a) "Have a probe at the end of a catheter to obtain thermodilution measures, so cardiac output can be calculated" b) "Measure the pressures inside your heart continuously to assess pumping ability of your left ventricle" c) "This device will decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure" d) "Pull your blood from the right side of the heart and run it through a machine to oxygenate it better, and then return it to your body"
a) Have the client sit up and lean forward Pg. 666 Acute Pericarditis With acute pericarditis, the pain typically is pleuritic (aggravated by inspiration and swallowing) and positional (decreases with sitting and leaning forward; increases with moving to the side) because of changes in venous return and cardiac filling.
47. Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis? a) Have the client sit up and lean forward b) Have the client swallow slowly and frequently c) Have the client breathe deeply d) Have the client change positions to unaffected side
a) Congenital heart defects occur between the 3rd and 8th weeks of development before you know you are pregnant Pg. 707 Congenital Heart Defects Congenital heart defects occur during the 3rd week as the heart is the first functional organ system to develop. This may be before a woman realizes she is pregnant. Congenital heart defects can, to some degree, be prevented. They do not occur prior to conception or during conception, but during the growth of the fetus.
48. What should the nurse teach the pregnant woman about congenital heart defects? a) Congenital heart defects occur between the 3rd and 8th weeks of development before you know you are pregnant b) Congenital heart defects occur during conception c) Congenial heart defects occur prior to conception as a result of exposure to toxins d) Congenital heart defects cannot be prevented
a) Troponin assays Pg. 673 Serum Biomarkers The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction. Creatine kinase is an intracellular enzyme found in muscle cells. The troponin level identifies necrosis in cardiac muscles earlier than creatine kinase. The others are not necessarily used when suspecting a myocardial infarction.
49. A client comes to the emergency room with all the symptoms of a myocardial infarction. Which lab value, known to have a high specificity for myocardial tissue considered the primary biomarker test for diagnosing an MI, does the nurse suspect the physician will order? a) Troponin assays b) Creatine kinase c) Potassium d) Phosphorus
c) Peripheral edema, weight gain Pg. 696 Right Ventricular Dysfunction In right-sided heart failure, blood backs up into the venous side of the circulatory system causing increased hydrostatic pressure in capillaries and leakage of plasma, which forms peripheral edema and becomes apparent as weight gain. The other manifestations listed are not characteristic of right-sided failure.
5. On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right-sided heart failure. Which manifestation exhibited by the father does the nurse know might have preceded this diagnosis? a) Weakness, palpitations b) Dyspnea, cough c) Peripheral edema, weight gain d) Vertigo, headache
a) ECG changes Pg. 673 Electrocardiographic Changes Risk stratification of people presenting with UA/NSTEMI is important because the outcome can range from excellent, with little change in treatment, to NSTEMI or death, requiring aggressive treatment. UA/NSTEMI is classified by severity based on clinical history, ECG pattern, and serum biomarkers. Chronic pulmonary disease increases pulmonary vascular resistance, leading to right-sided or left-sided heart failure. Pericardial effusion increases intracardiac pressure and venous pressure. Heart murmurs result from turbulent blood flow through a diseased valve.
50. Clients with unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) are classified as low or high risk for acute myocardial infarction and sudden death based on the severity of which characteristic? a) ECG changes b) Heart murmurs c) Pulmonary disease d) Pericardial effusion
a) Backflow from the left ventricle to left atrium Pg. 690 Mitral Valve Regurgitation The mitral valve separates the left ventricle from the left atrium; failure of this valve would cause backflow from the former to the latter during systole. Valve function does not directly affect cardiac contractility.
51. Following several weeks of increasing fatigue and a subsequent diagnostic workup, a client has been diagnosed with mitral valve regurgitation. Failure of this heart valve would have which hemodynamic consequences? a) Backflow from the left ventricle to left atrium b) Backflow from the right ventricle to the right atrium during systole c) Backup of blood from the right atrium into the superior vena cava d) Inhibition of the SA node's normal action potential
d) Prompt diagnosis of streptococcal infections with a throat culture Pg. 687 Clinical Manifestations Rheumatic heart disease is normally caused by streptococcal infections; therefore, early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a client has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the client may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.
52. A preventive measure to decrease the risk of developing rheumatic heart disease includes: a) Blood specimen assessed for rheumatoid factor b) Scheduling regular hearing examinations c) Yearly electrocardiography after the age of 50 d) Prompt diagnosis of streptococcal infections with a throat culture
c) Dyspnea, cough, fatigue Pg. 699 Clinical Manifestations of Heart Failure In left-sided heart failure, dyspnea and cough, especially when lying supine (orthopnea), results from increased pulmonary capillary pressures contributing to pulmonary congestion. Fatigue is common due to reduced cardiac output and inadequate tissue perfusion. A slowed heart rate, or bradycardia is not expected. Often the heart rate increases to compensate for the decrease in cardiac output. Weight gain due to fluid retention from the activation of renin-angiotensin-aldosterone is expected rather than weight loss. Although some gastrointestinal fullness may be experienced by some clients with heart failure, vomiting and diarrhea is not expected.
54. A nurse is concerned that a resident of a long-term care facility may be developing left-sided heart failure. The nurse would communicate which set of manifestations as possible evidence of left-sided heart failure? a) Diarrhea, nausea, vomiting b) Weakness, slowed heart rate, confusion c) Dyspnea, cough, fatigue d) Fatigue, headache, weight loss
a) Vasoconstriction c) Activation of the renin-angiotensin-aldosterone system (RAAS) e) Increased heart rate Pg. 697-699 Compensatory Mechanisms Tachycardia and vasoconstriction are reflex responses to decreased cardiac output and decreased tissue perfusion. Decreased renal perfusion activates the RAAS, which yields the vasoconstrictor angiotensin II, and aldosterone which increases sodium and water retention. There are increased levels of endothelin, which causes release of aldosterone and catecholamines with resultant retention of sodium and water and vasoconstriction.
55. In a client with hypovolemic shock, which assessment findings alert the nurse that compensatory mechanisms are attempting to support cardiac output. Select all that apply. a) Vasoconstriction b) Decreased sodium and water retention c) Activation of the renin-angiotensin-aldosterone system (RAAS) d) Decreased endothelin release e) Increased heart rate
c) Fixed coronary obstruction Pg. 679 Stable Angina Chronic stable angina is caused by fixed coronary obstruction that produces an imbalance between coronary blood flow and the metabolic demands of the myocardium. Endothelial relaxing factors relax the smooth muscle in the vessel wall and allow increased blood flow; treatment for chronic stable angina is with a vasodilating agent, such as nitroglycerine, that relaxes the vessels and enhances coronary blood flow. Intermittent vessel vasospasms, in conjunction with coronary artery stenosis, cause the vasospastic type of angina. Increased formation of collateral vessels is a compensatory response that allows adequate blood circulation to tissues distal to an obstruction.
56. Chronic stable angina, associated with inadequate blood flow to meet the metabolic demands of the myocardium, is caused by: a) Increased collateral circulation b) Intermittent vessel vasospasms c) Fixed coronary obstruction d) Excessive endothelial relaxing factors
d) Pericarditis Pg. 666 Acute Pericarditis This client is demonstrating signs and symptoms of pericarditis, which includes a triad of chest pain, pericardial friction rub, and EKG changes. Other signs are that the pain is usually abrupt in onset, occurs in the pericardial area, and may radiate to the neck, back, abdomen or side. It is usually worse with deep breathing and swallowing, and the person often finds relief when sitting up and leaning forward.
57. A client is seen in the emergency room reporting sharp chest pain that started abruptly. He says it has radiated to his neck and abdomen. He also states that it is worse when he takes a deep breath or swallows. He tells the nurse that when he sits up and leans forward the pain is better. Upon examination the nurse notes a pericardial friction rub and some EKG changes. Which disease should the nurse suspect this client to have? a) Pneumonia b) Abdominal aortic aneurysm c) Myocardial infarction d) Pericarditis
a) Mitral valve stenosis Pg. 689 Mitral Valve Stenosis Mitral valve stenosis represents the incomplete opening of the mitral valve during diastole, with left atrial distention and impaired filling of the left ventricle with associated symptoms. Mitral prolapse and aortic valve disorders will lead to the development of cardiomyopathies.
58. A client is admitted for observation due to abnormal heart sounds, pulmonary congestion, nocturnal paroxysmal dyspnea, and orthopnea. Upon auscultation a low-pitched, rumbling murmur, best heard at the apex of the heart, is also heard. Which condition does the client likely have? a) Mitral valve stenosis b) Aortic valve stenosis c) Mitral valve prolapse d) Aortic valve prolapse
c) Pericardial effusion Pg. 667 Pericardial Effusion and Cardiac Tamponade Pericardial effusion is the accumulation of fluid in the pericardial cavity and may develop with neoplasms, cardiac surgery, or trauma. Pericardial effusion presents with tachycardia, jugular venous distention, a fall in systolic blood pressure, narrowed pulse pressure (little difference between systolic and diastolic blood pressure), muffled heart sounds, and if tamponade develops, signs of circulatory shock. A friction rub (a sound resulting from rubbing between the inflamed pericardial surfaces) rather than muffled heart sounds is characteristic of acute pericarditis. Cardiomyopathy has many causes, but trauma is not one of them. Also, it does not result in muffled breath sounds or a narrow pulse pressure. Pulmonary hypertension results from respiratory or congenital disorders and is not associated with trauma and does not alter pulse pressure.
59. The nurse is assessing a client involved in a motor vehicle collision who has bruising across the sternum from seat belt pressure. The nurse notes muffled heart sounds, and the client's blood pressure is 100/85 mm Hg. The nurse notifies the health care provider to present these findings as evidence of which condition? a) Pulmonary hypertension b) Pericarditis c) Pericardial effusion d) Cardiomyopathy
c) Atrial fibrillation Pg. 701 Arrhythmias and Sudden Cardiac Death In heart failure, atrial fibrillation is the most frequently occurring dysrhythmia. Occasionally, ventricular fibrillation causes sudden death in clients with heart failure. Atrioventricular heart block and nodal tachycardia are not characteristic of heart failure.
7. Dysrhythmias can occur in clients with heart failure. The dysrhythmia that occurs most frequently in heart failure is: a) Ventricular fibrillation b) Nodal tachycardia c) Atrial fibrillation d) Atrioventricular heart block
c) See the doctor for evaluation immediately Pg. 679 Stable Angina Angina that occurs at rest, is of new onset, or is increasing in intensity or duration denotes an increased risk for myocardial infarction and should be seen immediately using the criteria for acute coronary syndrome (ACS).
8. A client who is experiencing angina at rest that has been increasing in intensity should be instructed to: a) Take a second nitroglycerine b) Not worry about it as this is common for someone who has already had a myocardial infarction c) See the doctor for evaluation immediately d) Give it 5-10 minutes more to see if there is relief
c) The condition is getting progressively worse Pg. 699 Natriuretic Peptides Circulating levels of both ANP and BNP are elevated in persons with heart failure. The concentrations are well correlated with the extent of ventricular dysfunction, increasing up to 30-fold in persons with advanced heart disease. Assays of BNP are used clinically in the diagnosis of heart failure and to predict the severity of the condition.
9. The health care provider is reviewing lab results of a client diagnosed with heart failure. The provider notes that the client's ANP and BNP levels have been increasing and remain significantly elevated. These results would be interpreted as: a) Results are not significant assessment data b) The client is improving c) The condition is getting progressively worse d) The more the results continue to increase, the better outcome for the client
