PrepU chapter 27
Which disease is caused by calcified scar tissue that develops between the visceral and parietal layers of the serous pericardium?
constrictive pericarditis
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?
"The left ventricle is having problems pumping blood forward, and this is causing blood to back up into your lungs."
Cardiac reserve refers to which of the following events?
Ability to increase cardiac output during physical exercise
The nurse is preparing to auscultate for a mitral valve stenosis murmur. Where is the best location to place the stethoscope?
At the apex of the heart
What should the nurse teach the pregnant woman about congenital heart defects?
Congenital heart defects occur between the 3rd and 8th weeks of development before you know you are pregnant.
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.
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?
Hypertrophic cardiomyopathy
Increased cardiac workload with left-sided heart failure can result in which change to the myocardial cells?
Hypertrophy
A client has developed cardiogenic shock. The most frequent cause of this type of shock is:
Myocardial infarction
A client with heart failure tells the nurse that he is frustrated and is unable to get "a good night's rest." The client relates that he falls asleep and is suddenly awakened and feels as though he is having a hard time breathing and is suffocating. The nurse recognizes this assessment as:
Paroxysmal nocturnal dyspnea
Which serum biomarker is highly specific for myocardial tissue?
Troponin
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:
hypovolemic shock due to acute intravascular volume loss
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:
myocardial infarction
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?
pericarditis
A preventive measure to decrease the risk of developing rheumatic heart disease includes:
prompt diagnosis of streptococcal infections with a throat culture
The nurse should anticipate administering intravenous antibiotic therapy as a priority to a client experiencing which type of shock?
septic shock
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?
troponin assays
In an ICU setting, one assessment that would lead the nurse to suspect that shock has led to decreased blood flow to vital organs is:
urine output less than 20 mL/hour.
A client awaiting a heart transplant is experiencing decompensation of the left ventricle that will not respond to medications. The health care provider (HCP) suggests placing the client on a ventricular assist device (VAD). The client asks what this equipment will do. Which response most accurately describes the purpose of a VAD?
"Decreases the workload of the myocardium while maintaining cardiac output and systemic arterial pressure."
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?
Increased vascular stiffness
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?
Infective endocarditis
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?
Obstructive shock
A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing:
Onset of STEMI
A nurse is assessing a client diagnosed with severe mitral valve stenosis. The nurse anticipates which classic assessment finding?
Orthopnea
The nurse caring for a client 12 hours after a coronary bypass graft notes a sudden decrease in the amount of chest tube drainage, a rapidly narrowing pulse pressure, paradoxical pulse, and shortened amplitude of the QRS complex on the electrocardiogram monitor. Which action should the nurse take next?
Prepare for pericardiocentesis
A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF (40°C) in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this client most likely is experiencing which type of shock?
Septic
