Chapter 27 Prep U
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?
"I'm trying to think of ways that I can cut down the amount of salt that I usually eat."
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?
"Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water."
In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which level indicates inadequate renal perfusion?
20 mL/hour
Four clients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which client most likely experienced myocardial infarction?
80-year-old woman whose pain was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose
A child's history of a recurrent sore throat followed by severe knee and ankle pain has resulted in a diagnostic workup and a diagnosis of rheumatic fever. What are the treatment priorities for this child?
Antibiotics and anti-inflammatory drugs
Which manifestation of left-sided heart failure can be diagnosed by examination of the lips and mucous membranes?
Cyanosis
A client who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which manifestation alerts the nurse to a developing complication?
Decreased level of consciousness
What is the primary physiologic result of obstructive shock?
Elevated right heart pressure
Neurogenic shock, or spinal shock, is a phenomenon caused by the inability of the vasomotor center in the brain stem to control blood vessel tone through the sympathetic outflow to the blood vessels. In neurogenic shock, what happens to the heart rate and the skin?
Heart rate slower than normal; skin warm and dry
A 20-year-old college student has a pelvic fracture and a severed leg from a motorcycle accident. She lost several units of blood. When the student arrived in the emergency department, her blood pressure was very low, her pulse was high, and her skin was pale. The nurse knows that this client has developed which type of shock?
Hypovolemic
While discussing the heart, the nursing instructor teaches about pericarditis. Which statement does the instructor state best defines this disease?
It is an inflammatory process.
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 myodardial 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?
Morphine
A nurse is assessing a client diagnosed with severe mitral valve stenosis. The nurse anticipates which classic assessment finding?
Orthopnea
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?
The disabling effects that result from involvement of heart valves
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?
Raising the head of the bed to a high Fowler's position
A client has been diagnosed with aortic stenosis and asks the nurse what this means. The mostappropriate response would be:
The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta.
Which serum biomarker is highly specific for myocardial tissue?
Troponin
A client comes to the emergency room with all the symptoms of a myodardial 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?
Troponin assays
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:
Valvular regurgitation
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?
anaphylatic shock
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?
have the client sit up and lean forward
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?
right-sided heart failure
A client who is experiencing angina at rest that has been increasing in intensity should be instructed to:
see the doctor for evaluation immediately.
Anaphylactic shock is directly associated with:
type I hypersensitivity response.
