PrepU ch. 20 practice quiz

In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which of the following levels indicates inadequate renal perfusion? 1. 20 mL/hour 2. 40—20 mL/hour 3. 60—40 mL/hour 4. 80—60 mL/hour

1

Which of the following statements regarding heart failure is true? 1. Compensated congestive heart failure may be clinically asymptomatic. 2. The average patient with congestive heart failure has a normal life span. 3. A frequent symptom of right-sided failure is dyspnea. 4. Aortic stenosis is a major cause of congestive heart failure.

1 Aortic stenosis occasionally causes congestive heart failure. Dyspnea is a frequent symptom of left-sided failure as blood backs up in the pulmonary circulation. The average patient with congestive heart failure is at risk of early death unless the failure can be compensated. Compensated failure may be asymptomatic if compensatory mechanisms are able to support cardiac output. 491

An 86-year-old male client is disappointed to learn that he has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which of the following age-related changes predisposes older adults to developing heart failure? 1. Increased vascular stiffness 2. Increased cardiac contractility 3. Loss of action potential 4. Orthostatic hypotension

1 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.

A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which of the following statements demonstrates an accurate understanding of his new diagnosis? 1. "I'm trying to think of ways that I can cut down the amount of salt that I usually eat." 2. "I'm going to avoid as much physical activity as I can so that I preserve my strength." 3. "I'll be sure to take my beta blocker whenever I feel short of breath." 4. "I know it's healthy to drink a lot of water, and I'm going to make sure I do this from now on."

1 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, physical activity within the limits of their condition. 494

After a long bout with vomiting and diarrhea, a client is suspected to be in hypovolemic shock. Which clinical manifestations will the nurse assess that substantiates this diagnosis? Select all that apply. 1. Apprehension 2. Tachycardia 3. Acidosis 4. Warm dry skin 5. Slow shallow respiration

1, 2, 3 A patient in hypovolemic shock will have reflex tachycardia, which attempts to compensate for the fall in cardiac output. Skin will be cool and clammy as peripheral blood vessels constrict to shunt blood to vital organs. Metabolic acidosis arises as body cells switch to anaerobic metabolism. Rapid, deep respiration is a response to acidosis. Apprehension results from cerebral hypoxia. 501

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is: 1. 60 mL/hour 2. 20 mL/hour 3. 40 mL/hour 4. 80 mL/hour

2 Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion. 504

The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be: 1. Maintaining higher oxygen levels to decrease the work of breathing 2. Placing a stent for fluid drainage from the heart 3. Improving quality of life by relieving symptoms 4. Eliminating CHF through curing the disease

3 A primary treatment goal for a client with CHF is to improve the quality of life through symptom management. CHF will not be cured, and maintaining a higher oxygen level will assist with dyspnea associated with CHF. A stent is not an option for treatment of CHF. 497

The nurse knows that persons with atrial fibrillation are at risk of developing which cardiac complication? 1. Systolic dysfunction 2. Hypovolemic shock 3. Diastolic dysfunction 4. Cardiogenic shock

3 In atrial fibrillation, the lack of coordinated atrial contraction will decrease ventricular filling and thus decrease the volume of blood available for cardiac output. Systolic dysfunction, a decrease in myocardial contractility, is not affected by atrial fibrillation. Cardiogenic shock, a decrease in the pumping ability of the heart, and hypovolemic shock, a decrease in blood volume, also are not affected by atrial fibrillation. 495

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client: 1. complains of dyspnea and has adventitious breath sounds on auscultation (listening). 2. has a distended bladder, facial edema, and nighttime difficulty breathing. 3. has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain. 4. has cyanotic lips and extremities, low urine output, and low blood pressure.

3 Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-side failure when the liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine output and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs/symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion. 499

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? 1. Administration of 2L of oxygen by nasal cannula 2. Inserting an IV to begin a normal saline infusion 3. Raising the head of the bed to a high Fowler's position 4. Placing a pulse oximeter on the client to monitor oxygenation status

3 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. 506

A patient 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 which of the following? 1. Infective endocarditis 2. Pericardial effusion 3. Valvular regurgitation 4. Valvular stenosis

3 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. 493

Assessment of an elderly female client reveals the presence of bilateral pitting edema of the client's feet and ankles and pedal pulses that are difficult to palpate. Auscultation of the client's lungs reveals clear air entry to bases, and the client's oxygen saturation level is 93%, and vital signs are within reference ranges. What is this client's most likely health problem? 1. Cor pulmonale 2. Pericarditis 3. Cardiogenic shock 4. Right-sided heart failure

4 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. 499