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Lemone Chapter 31

Lemone Chapter 31

Lemone Chapter 31

Last updated 18 May 2022

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1439

PASSING GRADES FLASHCARDS
The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound should the nurse expect to auscultate?

1. expiratory wheezes
2. friction rub
3. harsh vesicular sounds
4. crackles
Correct Answer: 4

Fluid accumulates in the alveolar spaces in left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. Expiratory wheezes, friction rub, and harsh vesicular sounds are not associated with chronic heart failure.
 
The nurse is caring for a chronic heart failure patient with left-sided failure. Which documentation should the nurse expect to see in the medical record after this patient has a cardiac catheterization?

1. "Pressures in the left ventricle and atrium are increased."
2. "Pressures in the left ventricle and atrium are decreased."
3. "Pressures in the right ventricle and atrium match the ventricle pressures."
4. "Pressures in the right ventricle reflect functioning of all heart chambers."
Correct Answer: 1

As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume. This patient is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side.
 
The nurse is caring for a 
The nurse should recognize which finding as a sign of decreased cardiac output and tissue perfusion in a patient with heart failure?

1. reduced mental alertness
2. increased urine output
3. abdominal distention
4. strong peripheral pulses
Correct Answer: 1

A change in mentation is a common sign of decreased cardiac output and tissue perfusion. Urine output would decrease and pulses would weaken. Abdominal distention is a sign of right-sided failure, which is a problem with venous return, not cardiac output or tissue perfusion.
 
A patient is exhibiting dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. Which health problem should the nurse suspect is occurring in this patient?

1. chronic heart failure
2. pulmonary edema
3. endocarditis
4. angina
Correct Answer: 2

Dyspnea, orthopnea, cyanosis, clammy skin, crackles, and productive cough with pink frothy sputum are signs and symptoms of pulmonary edema, which is considered a medical emergency. Not all patients with chronic heart failure have pink, frothy sputum. The presence of this symptom differentiates pulmonary edema from chronic heart failure. Endocarditis would manifest with pain and potentially fever. Angina is chest pain.
 
A patient is diagnosed with pulmonary edema. What is a priority for this patient?

1. inserting a peripheral intravenous catheter
2. requesting a prescription to medicate the patient for comfort
3. monitoring the blood glucose level
4. placing a pulse oximeter and administering oxygen
Correct Answer: 4

Pulmonary edema is a medical emergency. Priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation. Inserting an IV catheter would follow, although often, if more than one caregiver is present, this action can be done simultaneously. Medication would not be given until the ABCs have been addressed. The blood glucose level is not related to pulmonary edema.
 
The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient?

1. Endocarditis does not pose a high risk of damage to affected heart valves.
2. Patients with this disorder can be treated with open heart surgery to clean the heart valves.
3. The condition is unrelated to fever, so patients can be medicated with the prescribed antipyretic and observed.
4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.
Correct Answer: 4

Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures. Endocarditis carries serious risks of damage to heart valves. Fever may be present in endocarditis. Open heart surgery is not an appropriate treatment for this condition.
 
The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.

1. pericardial friction rub
2. abdominal discomfort and nausea
3. chest pain
4. bradycardia
5. distended neck veins
Correct Answer: 1, 3

Pericardial friction rub and chest pain are hallmark signs of pericarditis. Abdominal discomfort, nausea, bradycardia, and distended neck veins are not associated with pericarditis.
 
A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient?

1. antidysrhythmic drugs and oxygen
2. oxygen and rest
3. pericardiocentesis
4. antibiotics
Correct Answer: 3

When cardiac tamponade occurs, it is considered a medical emergency. Pericardiocentesis is performed to removed fluid or blood that has collected around the heart and is preventing the heart from pumping effectively. Antidysrhythmic drugs, oxygen, rest, and antibiotics may be indicated after the pericardiocentesis is performed.
 
The nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. What should the nurse suspect is occurring in this patient?

1. valvular heart disease
2. pericarditis
3. cardiac tamponade
4. heart failure
Correct Answer: 1

Valvular heart disorders interfere with the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease. The heart sound characteristic of pericarditis is a pericardial friction rub. Distant and muffled heart sounds are typical of cardiac tamponade. Extra heart sounds S3 and S4 are heard in heart failure.
 
The nurse suspects that a patient is experiencing paroxysmal nocturnal dyspnea (PND). What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.

1. symptoms occurring at night
2. pulmonary congestion
3. improving cardiac reserve
4. voiding more than one time per night
5. daytime peripheral edema
Correct Answer: 1, 2, 4, 5

PND is a condition in which the patient is awakened at night by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night, causing pulmonary congestion. Nocturia, or voiding more than once a night, is associated with PND. Daytime peripheral edema contributes to the development of PND. PND is often a symptom of chronic heart failure, which is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses.
 
Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which patient statement indicates that the teaching has been effective?

1. "I will be sure to tell my dentist that I had rheumatic fever."
2. "I will try to focus on eating less protein and more fat so I will have more energy."
3. "I will avoid brushing my teeth so often and quit using mouth rinse because I have gingivitis."
4. "If my joints start to hurt again, I need to slow down, but I won't have to worry because I'm immune to rheumatic fever now."
Correct Answer: 1

Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever. Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue. Maintaining good oral hygiene and preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease. Rheumatic fever is manifested by joint pain. One episode of rheumatic fever does not confer immunity to future episodes.
 
The nurse is reviewing data collected on a group of patients. Which patient should the nurse realize is at risk for high-output heart failure?

1. a patient with chronic anemia
2. a person with untreated hypertension
3. an individual with untreated hypothyroidism
4. someone who abuses sedatives and analgesics
Correct Answer: 1

High-output heart failure occurs in patients in hypermetabolic states such as anemia or hyperthyroidism. Hypertension is typically associated with low-output heart failure. Sedatives and analgesics slow metabolic function.
 
 
The nurse is caring for an older patient. The nurse recognizes that which factors place older adults at higher risk for development of heart failure?
Standard Text: Select all that apply.

1. impaired diastolic filling
2. increased cardiac reserve
3. increased maximal heart rate
4. reduced ventricular compliance
5. high responsiveness to sympathetic nervous system stimulation
Correct Answer: 1, 4

Diastolic filling is impaired because of reduced ventricular compliance. With aging, cardiac function is less responsive to increased stress because cardiac reserve decreases, maximal heart rate is reduced, and the heart becomes less responsive to sympathetic nervous system stimulation.
 
An older patient with a history of heart failure is experiencing dyspnea, weight gain, chest pain, and increasing edema of the lower extremities. The patient's blood pressure is elevated. What should the nurse ask to help determine why the patient is currently having health problems?

1. "Are you married?"
2. "Have you been out of the country lately?"
3. "Do you have grandchildren that you babysit?"
4. "Have you attended any recent family or social gatherings?"
Correct Answer: 4

If the patient has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the patient anticipated. The other questions are not relevant to determining the reason for exacerbation of the patient's heart failure.
 
The nurse is reviewing information received in report for a group of patients. Which patient should the nurse assess first?

1. patient with occasional chest pain who has recently been diagnosed with gallbladder disease
2. older patient with heart failure who was admitted with increasing edema of the lower extremities
3. newly admitted patient complaining of substernal chest pain and whose father died recently from heart disease
4. patient complaining of chest pain and hyperventilating after a family member leaves the room following an argument
Correct Answer: 3

The nurse would want to assess the newly admitted patient with substernal chest pain and a family history of cardiac disease and initiate any interventions that are appropriate. This manifestation could indicate mitral valve prolapse. The patient who is hyperventilating could be having an anxiety attack but needs to be assessed as soon as possible. The patient with gallbladder disease may have chest pain that is not cardiac related. The older patient with increasing edema of the extremities would need evaluation, but after another patient in the group.
 
The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first?

1. patient with hypertrophic cardiomyopathy who is reporting dyspnea
2. patient who had a cardiac catheterization and will be ambulating for the first time
3. patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
4. patient recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101°F.
Correct Answer: 3

The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment; a temperature of 101°F requires further assessment; and the patient ambulating for the first time will be assessed by a nurse. However, the patient with a possible PE is the most emergent.
 
A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first?

1. notify the physician about these findings
2. elevate the leg above the level of the heart
3. wrap the extremity in a loose, warm blanket and apply a foot cradle
4. perform passive range of motion (PROM) exercises to stimulate circulation
Correct Answer: 3

The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. Elevating the leg above the heart could worsen the ischemia. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.
 
A patient newly diagnosed with heart failure is prescribed 40 mg of furosemide (Lasix) to be given IV push. Knowing that the patient is also prescribed digoxin (Lanoxin), the nurse should review which laboratory result?

1. sodium level
2. digoxin level
3. creatinine level
4. potassium level
Correct Answer: 4

Serum potassium level is measured in the patient receiving digoxin and furosemide. Heightened digoxin effect can occur in the patient with hypokalemia. Hypokalemia also predisposes the patient to ventricular dysrhythmias. There is no data indicating renal insufficiency; therefore creatinine level is not relevant. Furosemide can cause hyponatremia, but the risk of hypokalemia has more severe consequences in this situation.
 
A patient is admitted with acute pericarditis. When auscultating heart sounds, the nurse should ask the patient to perform which action?

1. sit and lean forward while the nurse auscultates at the left lower sternal border
2. lie supine and breathe quietly while the nurse auscultates for expiratory wheezes
3. sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds
4. sit and lean forward while the nurse auscultates at the second right intercostal space, near the sternal border
Correct Answer: 1

Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heard on expiration and may be constant or intermittent. Auscultating lung sounds for expiratory wheezes and vesicular breath sounds is done but does not focus on the pericardial friction rub. Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub.
 
A patient is being discharged from the healthcare facility following surgical replacement of a mitral valve with a mechanical valve. The patient asks the nurse how much longer he will need to take warfarin (Coumadin). What is the nurse's best response?

1. "You will be on it for the rest of your life because you have a mechanical valve."
2. "That will depend on your surgeon. Ask her when you go to your office visit."
3. "You will be on it for the rest of your life because you have a biologic tissue valve."
4. "You will be told when to stop, usually when your mechanical prosthetic valve is healed and there is a minimal risk of clots."
Correct Answer: 1

Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve. Biologic tissue valves have a low risk of thrombus formation and long-term anticoagulation is rarely necessary. The nurse should address the patient's question.
 
A patient is being started on enalapril (Vasotec). Which common adverse effect should the nurse review with the patient?

1. increased thirst
2. reduced urine output
3. persistent cough
4. loss of appetite
Correct Answer: 3

A primary adverse effect of an ACE inhibitor is a persistent cough. Thirst, reduced urine output, and loss of appetite are not primary adverse effects of this medication.
 
The nurse suspects that a patient is experiencing a neuroendocrine response from low cardiac output in heart failure. What manifestations did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.

1. irregular heart rhythm
2. gastrointestinal bleeding
3. blood pressure 188/94 mmHg
4. nausea, vomiting, and diarrhea
5. heart rate 112 beats per minute
Correct Answer: 3, 5

A neuroendocrine response to low cardiac output is stimulation of the sympathetic nervous system and catecholamine release, leading to an increase in heart rate or tachycardia. A neuroendocrine response to low cardiac output and decreased renal perfusion is the stimulation of the renin-angiotensin system, which leads to vasoconstriction and increased blood pressure. Dysrhythmias, gastrointestinal bleeding, nausea, vomiting, and diarrhea are not neuroendocrine responses to low cardiac output.
 
 
A male patient of African-American descent is prescribed hydralazine and isosorbide (BiDil) as treatment for heart failure. What should the nurse instruct the patient about this medication?
Standard Text: Select all that apply.

1. "Change positions slowly."
2. "Dizziness and fainting are expected adverse effects of this medication."
3. "You may have a headache when starting this medication, but it will subside."
4. "Notify the healthcare provider if you have chest pain while taking this medication."
5. "Do not take medications to treat erectile dysfunction while taking this medication."
Correct Answer: 1, 3, 4, 5

This drug can cause a drop in blood pressure, particularly when changing positions from lying to sitting or sitting to standing. The patient should change positions slowly and use caution to prevent falls. Headache is a common adverse effect of this drug, particularly when first starting therapy. Headaches tend to subside with continued treatment. The doctor should be notified if chest pain develops while taking this medication. Drugs such as sildenafil (Viagra, Revatio), vardenafil (Levitra), or tadalafil (Cialis) are not to be taken while taking this medication because the combination may cause an extreme drop in blood pressure, leading to fainting, chest pain, or a heart attack. Dizziness and fainting should be reported to the healthcare provider as they may indicate a significant drop in blood pressure.
 
During a home visit the nurse suspects that a patient with heart failure needs additional teaching. What did the nurse observe to make this decision?
Standard Text: Select all that apply.

1. The patient lifted an 18-month-old child off the floor.
2. The patient's lunch was a small salad and half a sandwich.
3. The patient drank from a pitcher of water on the coffee table.
4. The patient documented the frequency and amount of walking completed.
5. Working in the kitchen, the patient was obviously sweating and short of breath.
Correct Answer: 1, 5

Home activity guidelines for the patient with heart failure include no heavy lifting. An 18-month-old child would be considered heavy. The patient should also stop any activity that causes sweating or shortness of breath. Other guidelines include eating up to six small meals per day, drinking water to prevent constipation, and participating in a graded exercise program.
 
The nurse is reviewing medication orders for a patient with myocarditis caused by diphtheria. Which medications should the nurse question before administering them to the patient?
Standard Text: Select all that apply.

1. antibiotic
2. anticoagulant
3. cardiac glycoside
4. proton pump inhibitor
5. antidysrhythmic agent
Correct Answer: 3, 4

Patients with myocarditis often are particularly sensitive to the effects of digitalis, which is a cardiac glycoside, so it is used with caution. Proton pump inhibitors are used for gastrointestinal disorders. The nurse should question this medication as well. Myocarditis is an infection of the heart muscle. Antibiotics are indicated in the treatment of this condition. Emboli can occur with myocarditis and would be treated with anticoagulants. Dysrhythmias can occur with myocarditis and would be treated with antidysrhythmic agents.
 
The nurse auscultates a heart murmur that is continuous and rumbling and increases in sound toward the end. Which conditions should the nurse suspect this patient might be experiencing?
Standard Text: Select all that apply.

1. mitral stenosis
2. tricuspid stenosis
3. mitral regurgitation
4. aortic regurgitation
5. tricuspid regurgitation
Correct Answer: 1, 2

The murmurs associated with mitral and tricuspid stenosis are continuous and rumbling and increase in sound towards the end. The murmurs associated with mitral and tricuspid regurgitation are continuous and occur throughout systole. The murmur associated with aortic regurgitation is decrescendo and continuous.
 
A patient is undergoing diagnostic tests for aortic regurgitation. Which findings should the nurse expect to assess in this patient?
Standard Text: Select all that apply.

1. dizziness
2. head bobbing
3. peripheral edema
4. throbbing neck pulse
5. palpitations in the supine position
Correct Answer: 1, 2, 4, 5

Dizziness, head bobbing, throbbing neck pulse, and palpitations are common manifestations of aortic regurgitation. Peripheral edema is not a manifestation of aortic regurgitation.
 
A patient is scheduled for surgery to replace the mitral valve with a biologic heterograft valve. What should the nurse include when instructing the patient about this surgery?
Standard Text: Select all that apply.

1. There will be an audible click with this valve.
2. The valve will not need to be replaced.
3. Long-term anticoagulation therapy is not necessary.
4. The valve will likely need to be replaced in 15 years.
5. Long-term antibiotic therapy is needed after the surgery.
Correct Answer: 3, 4

Long-term anticoagulation therapy is not needed with a biologic valve. Biologic valves are less durable than mechanical valves; up to 50% must be replaced within 15 years. An audible click is associated with a mechanical valve. Mechanical valves do not necessarily need to be replaced. Long-term antibiotic therapy is not needed after valve replacement surgery.
 
The nurse is completing an assessment of a patient with hypertrophic cardiomyopathy. What interventions should the nurse identify to help this patient with feelings of fatigue?
Standard Text: Select all that apply.

1. organizing care to allow for rest periods
2. restricting fluids and measuring abdominal girth
3. reviewing dietary restrictions for sodium intake
4. assisting with activities of daily living as needed
5. consulting with physical therapy for an activity plan
Correct Answer: 1, 4, 5

The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should organize care to allow for rest periods, assist with activities of daily living as needed, and consult with physical therapy for an activity plan. Restricting fluids, measuring abdominal girth, and reviewing dietary restrictions would be appropriate to help manage fluid balance.
 
A patient with rheumatic heart disease is being discharged. What should the nurse include in the patient's discharge instructions?
Standard Text: Select all that apply.

1. "Perform dental hygiene several times a day."
2. "Complete the full course of prescribed antibiotics."
3. "Take antibiotics as prescribed before dental work."
4. "Restrict fluids and limit activity while taking medication."
5. "Notify the physician if you develop a sore throat or other infection."
Correct Answer: 1, 2, 3, 5

The patient with rheumatic heart disease should be instructed to perform dental hygiene to avoid gingival infections. The complete course of antibiotics should be taken as prescribed. Antibiotics may be prescribed before dental work. The physician should be notified if a sore throat or any other signs of infection develop. There is no need to restrict fluids or limit activity while taking medication.
 
 

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