Ch. 37 Inflammatory & Structural Heart Disorders

A 25-yr-old patient with a group A streptococcal pharyngitis does not want to take the antibiotics prescribed. How should the nurse respond? "You will not feel well if you do not take the medicine and get over this infection." "Once you have been treated for a group A streptococcal infection, you will not get it again." "Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease." "You may not want to take the antibiotics for this infection, but you will be sorry if you do not."

"Without treatment, you could get rheumatic fever, which can lead to rheumatic heart disease."

The nurse provides discharge instructions for a 40-yr-old woman newly diagnosed with cardiomyopathy. Which statement indicates that further teaching is necessary? "I will avoid lifting heavy objects." "I can drink alcohol in moderation." "My family will need to take a CPR course." "I will reduce stress by learning guided imagery."

"I can drink alcohol in moderation."

37. A client is being seen in the clinic to R/O mitral valve stenosis. Which assessment data would be most significant? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3+ pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client's liver is enlarged and the abdomen is edematous.

. 1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis.

46. The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client's fluids as ordered. 2. Keep the client in the supine position. 3. Maintain oxygen saturation at 90%. 4. Monitor the total parenteral nutrition.

1. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit.

2. A patient has an admitting diagnosis of acute left-sided infective endocarditis. What is the best test to confirm this diagnosis? a. Blood cultures b. Complete blood count c. Cardiac catheterization d. Transesophageal echocardiogram

. a. Blood cultures are the primary diagnostic tool for infective endocarditis. Although a complete blood count (CBC) will reveal a mild leukocytosis, this is a nonspecific finding. Transesophageal echocardiograms can identify vegetations on valves but are used when blood cultures are negative. Cardiac catheterizations are used when surgical intervention is being considered.

66. The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade.

62. The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider.

42. Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardial friction rub. 5. Pulsus paradoxus.

1. Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress, usually occurring at night because of the reclining position, and occurs in valvular disorders. 2. This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders. 3. Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity.

45. The client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. "You are at risk of developing an infection in your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves."

1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure.

71. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

1. The nurse should monitor the vital signs for any client who has just undergone surgery. 2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure. 3. The pericardial fluid is documented as output. 4. Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis.

41. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's international normalized ratio (INR) is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding.

1. The therapeutic range for most clients' INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.

70. The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health

67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.

68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus. 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.

2. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues.

48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post-myocardial infarction being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5).

2. Because this client is being discharged, it would be an appropriate assignment for the new graduate.

61. The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

2. Because this client is being discharged, it would be an appropriate assignment for the new graduate.

72. The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.

47. Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60-year-old female with congestive heart failure. 2. A 23-year-old male with Marfan's syndrome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome.

2. Clients with Marfan's syndrome have life-threatening cardiovascular problems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness of the arterial walls, and they usually do not live past the age of 40 because of dissection and rupture of the aorta.

63. The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it.

38. Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1, S2 split, and a mitral opening snap. 2. A holosystolic murmur heard best at the cardiac apex. 3. A midsystolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the third left intercostal space.

2. The murmur associated with mitral valve insufficiency is loud, highpitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex.

39. The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity.

3. Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily.

64. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.

65. The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider.

69. Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function

4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

40. The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client's infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently.

4. Biological valves deteriorate and need to be replaced frequently; this is a disadvantage of them. Mechanical valves do not deteriorate and do not have to be replaced often.

44. The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line. 4. Keep the client's affected leg straight.

4. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to prevent hemorrhaging at the insertion site.

43. The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for 10 years. 4. The client has a history of rheumatic heart disease.

4. Rheumatic heart disease is the most common cause of valvular heart disease.

What should the nurse teach the patient who has had a valve replacement with a biologic valve? Long-term anticoagulation therapy Antibiotic prophylaxis for dental care Exercise plan to increase cardiac tolerance β-Adrenergic blockers to control palpitations

Antibiotic prophylaxis for dental care

The nurse is caring for a patient who received a mechanical aortic valve replacement 2 years ago. Current lab values include an international normalized ratio (INR) of 1.5, platelet count of 150,000/µL, and hemoglobin of 8.6g/dL. Which nursing action is most appropriate? Assess the vital signs. Start intravenous fluids. Monitor for signs of bleeding. Contact the health care provider.

Contact the health care provider.

A patient who has myocarditis now has fatigue, weakness, palpitations, and dyspnea at rest. The nurse assesses pulmonary crackles, edema, and weak peripheral pulses. Sinoatrial tachycardia is evident on the cardiac monitor. The Doppler echocardiography shows dilated cardiomyopathy. What should collaborative care accomplish to improve cardiac output and quality of life? Decrease preload and afterload. Relieve left ventricular outflow obstruction. Improve diastolic filling and the underlying disease process. Improve ventricular filling by reducing ventricular contractility.

Decrease preload and afterload.

A 55-yr-old female patient develops acute pericarditis after a myocardial infarction. Which assessment finding indicates a possible complication? Presence of a pericardial friction rub Distant and muffled apical heart sounds Increased chest pain with deep breathing Decreased blood pressure with tachycardia

Decreased blood pressure with tachycardia

On admission to the emergency department, a patient with cardiomyopathy has an ejection fraction of 10%. On assessment, the nurse notes bilateral crackles and shortness of breath. Which additional assessment finding would most indicate patient decline? Increased heart rate Increased blood pressure Decreased respiratory rate Decreased level of consciousness

Decreased level of consciousness

Which patients are most at risk for developing endocarditis? (Select all that apply.) Older woman with histoplasmosis Man with reports of chest pain and dyspnea Man who is homeless with history of IV drug use Patient with end-stage renal disease on peritoneal dialysis Adolescent with exertional palpitations and clubbing of fingers Female with peripheral intravenous site for medication administration

Man who is homeless with history of IV drug use Patient with end-stage renal disease on peritoneal dialysis

A 72-yr-old man with a history of aortic stenosis is admitted to the emergency department. He reports severe left-sided chest pressure radiating to the jaw. Which medication, if ordered by the health care provider, should the nurse question? Aspirin Oxygen Nitroglycerin Morphine sulfate

Nitroglycerin

The patient with pericarditis is reporting chest pain. After assessment, which intervention should the nurse expect to implement to provide pain relief? Corticosteroids Morphine sulfate Proton pump inhibitor Nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs

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

Osler's nodes Janeway's lesions Splinter hemorrhages

An 80-yr-old patient with uncontrolled type 1 diabetes is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to do or have what done? Aortic valve replacement Have a pacemaker inserted Open commissurotomy (valvulotomy) procedure Percutaneous transluminal balloon valvuloplasty (PTBV) procedure

Percutaneous transluminal balloon valvuloplasty (PTBV) procedure

The nurse is teaching a community group about preventing rheumatic fever. What information should the nurse include? Prompt recognition and treatment of streptococcal pharyngitis Avoiding respiratory infections in children born with heart defects Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis Requesting antibiotics before dental surgery for individuals with rheumatoid arthritis

Prompt recognition and treatment of streptococcal pharyngitis

While admitting a patient with pericarditis, the nurse will assess for what manifestations of this disorder? Pulsus paradoxus Prolonged PR intervals Widened pulse pressure Clubbing of the fingers

Pulsus paradoxus

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? Regurgitant murmur at the mitral valve area Point of maximal impulse palpable in fourth intercostal space Heart rate of 94 beats/min and capillary refill time of 2 seconds Respiratory rate of 18 breaths/min and heart rate of 90 beats/min

Regurgitant murmur at the mitral valve area

10. The most commonly occurring cardiomyopathy is: a. dilated. b. hypertrophic. c. idiopathic. d. restrictive.

a

13. Rheumatic endocarditis is an inflammatory reaction to: a. group A, beta-hemolytic streptococcus. b. Pseudomonas aeruginosa. c. Serratia marcescens. d. Staphylococcus aureus.

a

14. The causative microorganism for rheumatic endocarditis can be accurately identified only by: a. a throat culture. b. an echocardiogram. c. roentgenography. d. serum analysis.

a

17. The characteristic sign of pericarditis is: a. a friction rub. b. dyspnea. c. fever. d. hypoxia.

a

19. A serious consequence of pericarditis is: a. cardiac tamponade. b. decreased venous pressure. c. hypertension. d. left ventricular hypertrophy.

a

5. The presence of a water-hammer pulse (quick, sharp strokes that suddenly collapse) is diagnostic for: a. aortic regurgitation. b. mitral insufficiency. c. tricuspid insufficiency. d. tricuspid stenosis.

a

6. Severe aortic stenotic disease is consistent with all of the following except: a. increased cardiac output. b. left ventricular hypertrophy. c. pulmonary edema. d. right-sided heart failure.

a

Mr. Fontana, a 60-year-old executive, is admitted to the hospital with a diagnosis of infective endocarditis. Pertinent history includes a previous diagnosis of mitral valve prolapse. A physical examination at his physician's office before admission reveals complaints of anorexia, joint pain, intermittent fever, and a 10-lb weight loss in the past 2 months. 2. While examining Mr. Fontana's eyes during the admission assessment, the nurse notes conjunctival hemorrhages with pale centers caused by emboli in the nerve fiber of the eye. These are known as: a. Roth's spots. b. Osler's nodes. c. Janeway's lesions. d. Heberden's nodes.

a

Mrs. Russell is a 46-year-old Caucasian who developed symptoms of acute pericarditis secondary to a viral infection. Diagnosis was based on the characteristic sign of a friction rub and pain over the pericardium. 1. On the basis of knowledge of pericardial pain, the nurse suggests the following body position to relieve the pain symptoms: a. flat in bed with feet slightly higher than the head. b. Fowler's. c. right side-lying. d. semi-Fowler's.

a

1. A 20-year-old patient has acute infective endocarditis. While obtaining a nursing history, what should the nurse ask the patient about (select all that apply)? a. Renal dialysis b. IV drug abuse c. Recent dental work d. Cardiac catheterization e. Recent urinary tract infection

a, b, c, d, e. Recent dental, urologic, surgical, or gynecologic procedures and history of IV drug abuse, heart disease, cardiac catheterization or surgery, renal dialysis, and infections all increase the risk of infective endocarditis.

16. What manifestations most strongly support a diagnosis of acute rheumatic fever? a. Carditis, polyarthritis, and erythema marginatum b. Polyarthritis, chorea, and decreased antistreptolysin O titer c. Organic heart murmurs, fever, and elevated erythrocyte sedimentation rate (ESR) d. Positive C-reactive protein, elevated white blood cells (WBCs), and subcutaneous nodules

a. Major criteria for the diagnosis of rheumatic fever include evidence of carditis, polyarthritis, chorea (often very late), erythema marginatum, and subcutaneous nodules. Minor criteria include all laboratory findings as well as fever, arthralgia, and a history of previous rheumatic fever. There also must be evidence of a previous group A streptococci infection (e.g., positive antistreptolysin O titer).

3. Which manifestation of infective endocarditis is a result of fragmentation and microembolization of vegetative lesions? a. Petechiae b. Roth's spots c. Osler's nodes d. Splinter hemorrhages

a. Petechiae are seen as small hemorrhages in the conjunctiva, lips, and buccal mucosa and over the ankles, feet, and antecubital and popliteal areas. Roth's spots are hemorrhagic retinal lesions seen with funduscopic examination. Osler's nodes are lesions on the fingertips or toes. The cause of Roth's spots and Osler's nodes is not clear. Splinter hemorrhages are black longitudinal streaks that occur on nail beds. They may be caused by vessel damage from vasculitis or microemboli.

30. The patient is admitted post-radiation therapy with symptoms of cardiomyopathy (CMP). Which type of CMP should the nurse suspect that the patient is experiencing? a. Dilated b. Restrictive c. Takotsubo d. Hypertrophic

b. A secondary cause of restrictive cardiomyopathy (CMP) is radiation treatment to the thorax with stiffness of the ventricular wall occurring. Dilated CMP may have a genetic link, follow infectious myocarditis, or be related to an autoimmune process or excess alcohol ingestion. Takotsubo CMP is an acute stress-related syndrome that mimics acute coronary syndrome. It is most common in postmenopausal women. Hypertrophic CMP has a genetic link in about one half of all cases and is frequently seen in young athletic individuals

12. An immunosuppressant that allowed heart transplantation to become a therapeutic option for end-stage heart disease is: a. Procardia. b. Cyclosporine. c. Calan. d. Vancocin.

b

16. The most characteristic symptom of pericarditis is: a. dyspnea. b. constant chest pain. c. fatigue lasting more than 1 month. d. uncontrolled restlessness.

b

18. Which of the following medications would not be used to treat pericarditis because it can decrease blood flow? a. Colchicine b. Indocin c. Motrin d. Prednisone

b

2. Backward flow of blood from the left ventricle to the left atrium is through the: a. aortic valve. b. mitral valve. c. pulmonic valve. d. tricuspid valve.

b

11. What explains the measurement of pulsus paradoxus with cardiac tamponade (select all that apply)? a. A difference of less than 10 mm Hg occurs. b. A difference of greater than 10 mm Hg occurs. c. It is measured with an automatic sphygmomanometer. d. Rapidly inflate the cuff until you hear sounds throughout the respiratory cycle. e. Subtract the number when sounds are heard in the respiratory cycle from the number when the first Korotkoff sound during expiration is heard.

b, e. Pulsus paradoxus is measured with a manually operated sphygmomanometer. The cuff is deflated slowly until the first Korotkoff sound during expiration is heard and the number is noted. The slow deflation of the cuff is continued until sounds are heard throughout the respiratory cycle and that number is subtracted from the first number. When the difference is >10 mm Hg, cardiac tamponade may be present. The difference is normally <10 mm Hg.

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

c

5. Serial blood cultures identified Streptococcus viridans as the causative organism, and parenteral antibiotic treatment was initiated. The nurse expects that Mr. Fontana will probably remain on the antibiotic intravenous infusion for: a. 5 days. b. 1 week. c. 2 to 6 weeks. d. 8 to 10 weeks.

c

23. The patient is admitted with angina, syncope, and dyspnea on exertion. In the assessment, the nurse notes a systolic murmur with a prominent S4 . What will the nurse suspect is occurring with this patient? a. Mitral valve stenosis b. Aortic valve stenosis c. Acute mitral valve regurgitation d. Chronic mitral valve regurgitation

b. Aortic valve stenosis is identified with the triad of angina, syncope, and dyspnea on exertion, as well as the systolic murmur and prominent S4 heart sound. Mitral valve stenosis manifests as exertional dyspnea, hemoptysis, fatigue, atrial fibrillation, and a diastolic murmur. Acute mitral valve regurgitation has a new systolic murmur with pulmonary edema and cardiogenic shock rapidly developing. Chronic mitral valve regurgitation is identified with weakness, fatigue, exertional dyspnea, palpitations, an S3 gallop, and holosystolic murmur.

25. Priority Decision: A patient with symptomatic mitral valve prolapse has atrial and ventricular dysrhythmias. In addition to monitoring for decreased cardiac output related to the dysrhythmias, what is an important nursing intervention related to the dysrhythmias identified by the nurse? a. Monitor breathing pattern related to hypervolemia. b. Encourage calling for assistance when getting out of bed. c. Give sleeping pills to decrease paroxysmal nocturnal dyspnea. d. Teach the patient exercises to prevent recurrence of dysrhythmias.

b. Dysrhythmias frequently cause palpitations, lightheadedness, and dizziness and the patient should be carefully attended to to prevent falls. Hypervolemia and paroxysmal nocturnal dyspnea (PND) would be apparent in the patient with heart failure. Exercises will not prevent dysrhythmias.

5. A patient with infective endocarditis of a prosthetic mitral valve develops a left hemiparesis and visual changes. What should the nurse expect to be included in collaborative management of the patient? a. Embolectomy b. Surgical valve replacement c. Administration of anticoagulants d. Higher than usual antibiotic dosages

b. Early valve replacement followed by prolonged antibiotic and anticoagulant therapy is recommended for these patients. Drug therapy for patients who develop endocarditis of prosthetic valves is often unsuccessful in eliminating the infection and preventing embolization.

24. Which drugs would the nurse expect to be included in those prescribed for patients with a mechanical valve replacement? a. Oral nitrates b. Anticoagulants c. Atrial antidysrhythmics d. β-adrenergic blocking agents

b. Patients with mechanical valves have an increased risk for thrombus formation. Therefore prophylactic anticoagulation therapy is used to prevent thrombus formation and systemic or pulmonary embolization. Nitrates are contraindicated for the patient with aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve. Antidysrhythmics are used only if dysrhythmias occur and β-adrenergic blocking drugs may be used to control the heart rate if needed.

12. The patient with acute pericarditis is having a pericardiocentesis. Postoperatively what complication should the nurse monitor the patient for? a. Pneumonia b. Pneumothorax c. Myocardial infarction (MI) d. Cerebrovascular accident (CVA)

b. Pneumothorax may occur as a needle is inserted into the pericardial space to remove fluid for analysis and relieve cardiac pressure with pericardiocentesis. Other complications could include dysrhythmias, further cardiac tamponade, myocardial laceration, and coronary artery laceration.

8. Xenographs, used for valve replacement, have a viability of about: a. 2 years. b. 4 years. c. 8 years. d. 12 years.

c

9. The nurse knows that a patient who is to receive a xenograft from a pig or cow will be receiving a (an): a. allograft. b. autograft. c. heterograft. d. homograft.

c

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

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

14. When obtaining a nursing history for a patient with myocarditis, what should the nurse specifically question the patient about? a. Prior use of digoxin for treatment of cardiac problems b. Recent symptoms of a viral illness, such as fever and malaise c. A history of coronary artery disease (CAD) with or without an MI d. A recent streptococcal infection requiring treatment with penicillin

b. Viruses are the most common cause of myocarditis in the United States and early manifestations of myocarditis are often those of systemic viral infections. Myocarditis may also be associated with systemic inflammatory and metabolic disorders as well as with other microorganisms, drugs, or toxins. The patient with myocarditis is predisposed to drug-related dysrhythmias and toxicity with digoxin, so it is used very cautiously, if at all, in treatment of the condition

18. A patient with rheumatic heart disease with carditis asks the nurse how long his activity will be restricted. What is the best answer by the nurse? a. "Full activity will be allowed as soon as acute symptoms have subsided." b. "Bed rest will be continued until symptoms of heart failure are controlled." c. "Nonstrenuous activities can be performed as soon as antibiotics are started." d. "Bed rest must be maintained until antiinflammatory therapy has been discontinued."

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

11. Probably the most helpful diagnostic test to identify cardiomyopathy is: a. serial enzyme studies. b. cardiac catheterization. c. the echocardiogram. d. the phonocardiogram.

c

3. The pathophysiology of mitral stenosis is consistent with: a. aortic stenosis. b. left ventricular failure. c. left atrial hypertrophy. d. all of the above.

c

28. In which patient would a mechanical prosthetic valve be preferred over a biologic valve for valve replacement? a. 41-year-old man with peptic ulcer disease b. 22-year-old woman who desires to have children c. 35-year-old man with a history of seasonal asthma d. 62-year-old woman with early Alzheimer's disease

c. Mechanical prosthetic valves require long-term anticoagulation and this is a factor in making a decision about the type of valve to use for replacement. Patients who cannot take anticoagulant therapy, such as women of childbearing age, patients at risk for hemorrhage, patients who may not be compliant with anticoagulation therapy, and patients over age 65 may be candidates for the less durable biologic valves.

21. What accurately describes mitral valve prolapse? a. Rapid onset prevents left chamber dilation b. May be caused by pulmonary hypertension c. Ballooning of valve into left atrium during ventricular systole d. Rapid development of pulmonary edema and cardiogenic shock

c. Mitral valve prolapse is the ballooning of the valve leaflets into the left atrium during ventricular systole. The rapid onset that prevents left chamber dilation and the rapid development of pulmonary edema and cardiogenic shock occur with acute mitral regurgitation. Pulmonary hypertension may contribute to tricuspid valve disease.

20. Delegation Decision: An RN is working with a licensed practical nurse (LPN) in caring for a group of patients on a cardiac telemetry unit. A patient with aortic stenosis has the nursing diagnosis of activity intolerance related to fatigue and exertional dyspnea. Which nursing activity could be delegated to the LPN? a. Explain the reason for planning frequent periods of rest. b. Evaluate the patient's understanding of his disease process. c. Monitor BP, HR, RR, and SpO2 before, during, and after ambulation. d. Teach the patient which activities to choose that will gradually increase endurance.

c. Monitoring vital signs before and after ambulation is the collection of data. Instructions should be provided to the licensed practical nurse (LPN) regarding what changes in these vital signs should be reported to the RN. The other actions listed are RN responsibilities

32. When planning care for the patient with hypertrophic CMP, what should the nurse include? a. Ventricular pacing b. Administration of vasodilators c. Teach the patient to avoid strenuous activity and dehydration d. Surgery for cardiac transplantation will need to be done soon

c. Nursing interventions for the patient with hypertrophic CMP are to improve ventricular filling by reducing ventricular contractility and relieving left ventricular outflow obstruction to relieve symptoms and prevent complications. Strenuous activity and dehydration will increase systemic vascular resistance and should be avoided. Atrioventricular pacing will allow the septum to move away from the left ventricular wall and reduce the degree of outflow obstruction. Vasodilators may decrease venous return and further increase obstruction of blood flow from the heart. The surgery that could be done involves cutting into the thickened septal wall and removing some of the ventricular muscle

27. A patient is scheduled for an open surgical valvuloplasty of the mitral valve. In preparing the patient for surgery, what should the nurse know about this surgery? a. Cardiopulmonary bypass is not required with this procedure. b. Valve repair is a palliative measure, whereas valve replacement is curative. c. The operative mortality rate is lower in valve repair than in valve replacement. d. Patients with valve repair do not require postoperative anticoagulation as do those who have valve replacement.

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

6. A patient with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. What should the nurse suspect that the patient is experiencing? a. Pulmonary embolization from valve vegetations b. Vegetative embolization to the coronary arteries c. Valvular incompetence with resulting heart failure d. Nonspecific manifestations that accompany infectious diseases

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

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

c. The stethoscope diaphragm at the left sternal border with the patient leaning forward is the best method to use to hear the high-pitched, grating sound of a pericardial friction rub. The sound does not radiate widely and occurs with the heartbeat. To differentiate a pericardial friction rub from a pleural friction rub, have the patient hold his or her breath. The rub will still be heard if it is cardiac in nature.

26. A patient is scheduled for a percutaneous transluminal balloon valvuloplasty. The nurse understands that this procedure is indicated for which patient? a. Any patient with aortic regurgitation b. Older patients with aortic regurgitation c. Older patients with stenosis of any valve d. Young adult patients with mild mitral valve stenosis

c. This procedure has been used for repair of mitral, tricuspid, and pulmonic stenosis and less often for aortic stenosis. It is usually used for older patients and for those patients who are poor surgical risks because it is relatively easy and has good results and few complications.

1. Incomplete closure of the tricuspid valve results in a backward flow of blood from the: a. aorta to the left ventricle. b. left atrium to the left ventricle. c. right atrium to the right ventricle. d. right ventricle to the right atrium.

d

15. Clinical manifestations of infective endocarditis may include: a. embolization. b. focal neurologic lesions. c. heart murmurs. d. all of the above.

d

3. Initial nursing intervention includes maintenance of bed rest until the following symptom disappears: a. fever. b. friction rub. c. pain. d. all of the above.

d

7. Mr. Fontana needs to be advised that prophylactic antibiotic therapy is also recommended for: a. tooth extraction. b. bronchoscopy. c. cystoscopy. d. all of the above

d

7. The most common valvuloplasty procedure is the: a. balloon valvuloplasty. b. annuloplasty. c. chordoplasty. d. commissurotomy

d

31. What accurately describes dilated CMP (select all that apply)? a. Characterized by ventricular stiffness b. The least common type of cardiomyopathy c. The hyperdynamic systolic function creates a diastolic failure d. Echocardiogram reveals cardiomegaly with thin ventricular walls e. Often follows an infective myocarditis or exposure to toxins or drugs f. Differs from chronic heart failure in that there is no ventricular hypertrophy

d, e, f. Dilated CMP, the most common type of CMP, reveals cardiomegaly with thin ventricular walls on echocardiogram, as there is no ventricular hypertrophy, and may follow an infective myocarditis. As well, stasis of blood in the ventricles may contribute to systemic embolization. Restrictive CMP is the least common type and is characterized by ventricular stiffness. Hypertrophic CMP has hyperdynamic systolic function creating a diastolic failure, is characterized by massive thickening of intraventricular septum and ventricular wall, and may result in syncope during increased activity resulting from an obstructed aortic valve outflow

22. What causes a sudden onset of cardiovascular collapse? a. Mitral stenosis b. Tricuspid valve disease c. Pulmonic valve stenosis d. Acute aortic regurgitation

d. Acute aortic regurgitation causes a sudden cardiovascular collapse. With mitral valve stenosis dyspnea is a prominent symptom and embolization may result from chronic atrial fibrillation. With tricuspid and pulmonic valve diseases, stenosis occurs more often than regurgitation. Tricuspid valve stenosis results in right atrial enlargement and elevated systemic venous pressures. Pulmonic valve stenosis results in right ventricular hypertension and hypertrophy.

15. Priority Decision: What is the most important role of the nurse in preventing rheumatic fever? a. Teach patients with infective endocarditis to adhere to antibiotic prophylaxis. b. Identify patients with valvular heart disease who are at risk for rheumatic fever. c. Encourage the use of antibiotics for treatment of all infections involving a sore throat. d. Promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis

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

4. What describes Janeway's lesions that are manifestations of infective endocarditis? a. Hemorrhagic retinal lesions b. Black longitudinal streaks in nail beds c. Painful red or purple lesions on fingers or toes d. Flat, red, painless spots on the palms of hands and soles of feet

d. Janeway's lesions are flat, painless, small red spots found on the palms of the hands and the soles of the feet. Black streaks on the nails are splinter hemorrhages. Hemorrhagic retinal lesions are Roth's spots. Painful lesions on the fingers and toes are Osler's nodes.

8. When instructing a patient with endocarditis how to prevent recurrence of the infection, what should the nurse teach the patient? a. Start on antibiotic therapy when exposed to persons with infections. b. Take one aspirin a day to prevent vegetative lesions from forming around the valves. c. Always maintain continuous antibiotic therapy to prevent the development of any systemic infection. d. Obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures (e.g., dental cleaning).

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

13. Priority Decision: A patient with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. What is the best nursing intervention for the patient? a. Administer opioids as prescribed on an around-the-clock schedule. b. Promote progressive relaxation exercises with the use of deep, slow breathing. c. Position the patient on the right side with the head of the bed elevated 15 degrees. d. Position the patient in Fowler's position with a padded over-the-bed table for the patient to lean on.

d. Relief from pericardial pain is often obtained by sitting up and leaning forward. Pain is increased by lying flat. The pain has a sharp, pleuritic quality that changes with respiration and patients take shallow breaths. Antiinflammatory medications may also be used to help control pain but opioids are not usually indicated.

29. When performing discharge teaching for the patient following a mechanical valve replacement, the nurse determines that further instruction is needed when the patient says which statement? a. "I may begin an exercise program to gradually increase my cardiac tolerance." b. "I will always need to have my blood checked once a month for its clotting function." c. "I should take prophylactic antibiotics before I have dental or invasive medical procedures." d. "The biggest risk I have during invasive health procedures is bleeding because of my anticoagulants."

d. The greatest risk to a patient who has an artificial valve is the development of endocarditis with invasive medical or dental procedures. Before any of these procedures, antibiotic prophylaxis is necessary to prevent infection. Planning of an exercise program and monitoring anticoagulant therapy will be done.

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

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

19. What is an effect of valvular regurgitation? a. It causes a pressure gradient difference across an open valve. b. A pericardial friction rub is heard on the right sternal border of the chest. c. It leads to decreased flow of blood and hypertrophy of the preceding chamber. d. There is a backward flow of blood and volume overload in the preceding chamber.

d. Valvular regurgitation causes a backward flow of blood and volume overload in the preceding chamber. Without treatment, eventually hypertrophy of that chamber occurs. Stenosis causes a pressure gradient difference and decreased blood flow and hypertrophy of the preceding chamber. A pericardial friction rub is not related to valvular regurgitation but would be heard at the lower left sternal border of the chest