Chapter 25Heart Failure and Inflammatory Dysfunction: Nursing Management My Nursing Test Banks

Chapter 25Heart Failure and Inflammatory Dysfunction: Nursing Management

MULTIPLE CHOICE

1.The nurse suspects a clients heart is failing when which of the following heart sounds is assessed?

1.

S1

2.

S2

3.

S3

4.

S4

ANS: 3

An auscultated S3 is a sign that increased blood volume remains in the ventricle with each beat and that the heart is beginning to fail. S1 and S2 sounds are the first and second sounds heard when auscultating the heart. An S4 sound may indicate increased resistance to ventricular filling.

PTS: 1 DIF: Analyze REF: Assessment with Clinical Manifestations

2.A client is diagnosed with heart failure. Which of the following diagnostic tests is useful to determine the degree of the failure?

1.

Brain natriuretic peptide level

2.

Blood cultures

3.

Sedimentation rate

4.

Arterial blood gas

ANS: 1

Brain natriuretic peptide is a hormone found in the left ventricle; it is used to help diagnose and grade the severity of heart failure. Blood cultures are used to diagnose carditis. Sedimentation rate is used to diagnose pericarditis. Arterial blood gasses are not used to determine the degree of heart failure.

PTS: 1 DIF: Analyze REF: Heart Failure: Diagnostic Tests

3.A nurse is instructing a client regarding medications and substances contraindicated for the client with heart failure. Which of the following would not be contraindicated?

1.

Alcohol

2.

Furosemide

3.

Metformin

4.

Pioglitazone

ANS: 2

Loop diuretics (e.g., furosemide) are part of the recommended medications for heart failure. Alcohol, metformin, and pioglitazone (a thiazolidinedione) are contraindicated.

PTS:1DIF:Apply

REF: Table 25-1 Recommended and Contraindicated Medications in Heart Failure

4.The nurse is determining nursing diagnoses appropriate for a client demonstrating productive cough with pink frothy sputum, shortness of breath, and crackles. Which of the following nursing diagnoses is of the most importance?

1.

Activity intolerance

2.

Anxiety

3.

Impaired gas exchange

4.

Risk for ineffective respiratory function

ANS: 3

The first priority is to maintain adequate oxygenation. The next diagnoses in priority would be risk for ineffective respiratory function. Activity intolerance would be the third diagnosis. Anxiety would be the last diagnosis in order of priority.

PTS: 1 DIF: Apply REF: Heart Failure: Nursing Diagnoses

5.In planning the care for a client diagnosed with heart failure, which of the following would be an appropriate goal?

1.

Reduce myocardial contractility.

2.

Increase cardiac workload.

3.

Decrease ejection fraction.

4.

Increase activity levels.

ANS: 4

An increase in activity levels would be an appropriate goal for the client diagnosed with heart failure. The other options would be a decrease in ability, function, or management of the heart failure patient.

PTS: 1 DIF: Analyze REF: Heart Failure: Collaborative Management

6.The nurse is instructing a client diagnosed with mild heart failure on dietary modifications. Which of the following client statements indicates that the instruction has been effective?

1.

I will avoid green beans.

2.

I will avoid orange juice.

3.

I will avoid soy sauce.

4.

I will avoid apple sauce.

ANS: 3

Soy sauce is a high-sodium food choice; all the other choices are low sodium. Treatment for mild symptoms of heart failure includes dietary restriction of salt.

PTS: 1 DIF: Analyze REF: Heart Failure: Planning and Implementation

7.A client is undergoing diagnostic testing for infective endocarditis. Which of the following laboratory tests would be most useful in diagnosis?

1.

Basic metabolic panel

2.

Blood cultures

3.

Reticulocyte count

4.

Prothrombin time

ANS: 2

Blood cultures identify the causative organisms. A basic metabolic panel gives the current status of the clients acid/base balance and electrolytes. The reticulocyte count determines bone marrow function and evaluates erythropoietic activity. The prothrombin time is useful in monitoring anticoagulant therapy.

PTS: 1 DIF: Analyze REF: Infective Endocarditis: Diagnostic Tests

8.Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure?

1.

Distended neck veins

2.

Oliguria

3.

Cough with frothy blood-tinged sputum

4.

Syncope

ANS: 1

An assessment finding in a client diagnosed with right-sided heart failure is distended neck veins. Oliguria, cough with frothy blood-tinged sputum, and syncope are all clinical manifestations of left-sided heart failure.

PTS: 1 DIF: Apply REF: Box 25-2 Heart Failure Clinical Manifestations

9.Which of the following diagnostic tests is useful to diagnose mitral valve prolapse?

1.

Electrocardiogram

2.

Echocardiogram

3.

Cardiac angiography

4.

Transesophageal echocardiography

ANS: 4

Transesophageal echocardiography is useful in the assessment of cardiac murmurs, stenosis, and regurgitation of all four cardiac valves. An electrocardiogram, echocardiogram, and cardiac angiography may or may not be useful when diagnosing mitral valve prolapse.

PTS:1DIF:Analyze

REF:Mitral Valve Prolapse: Assessment with Clinical Manifestations

10.A client diagnosed with mitral valve prolapse is experiencing palpitations. Which of the following should the nurse instruct this client?

1.

Avoid tobacco

2.

Ingest alcohol in moderation

3.

Avoid weight loss

4.

Limit caffeine intake

ANS: 1

Clients with palpitations associated with mitral valve prolapse should be instructed to avoid caffeine, alcohol, and tobacco. Weight loss should be encouraged in overweight clients.

PTS:1DIF:Apply

REF: Mitral Valve Prolapse: Planning and Implementation

11.A client tells the nurse that she had rheumatic heart disease as a child. For which of the following valvular disorders should this client be assessed?

1.

Mitral valve prolapse

2.

Mitral stenosis

3.

Aortic regurgitation

4.

Aortic stenosis

ANS: 2

Mitral stenosis is most commonly caused by rheumatic heart disease. Rheumatic heart disease has not been linked to mitral valve prolapse, aortic regurgitation, or aortic stenosis.

PTS:1DIF:AnalyzeREF:Mitral Stenosis

12.A client, recovering from surgery to replace a calcified aortic valve with a mechanical valve, should be instructed that which of the following medications will be needed long term?

1.

ACE inhibitor

2.

Beta-blocker

3.

Antibiotic

4.

Anticoagulant

ANS: 4

The mechanical valve requires long-term anticoagulation therapy to prevent the risk of thromboembolism. ACE inhibitors, beta-blockers, and antibiotics are not indicated as long-term therapy for this surgery.

PTS:1DIF:ApplyREF:Valvular Surgery

13.A client is scheduled for annuloplasty surgery to the aortic valve. Which of the following will most likely occur during this clients procedure?

1.

A catheter will be inserted through the femoral vein.

2.

A heart bypass machine will be used.

3.

Local anesthesia will be provided.

4.

A balloon will inflate and stretch the valve open.

ANS: 2

For an annuloplasty, the client will receive general anesthesia and a heart bypass machine will be used. A balloon valvuloplasty is done by inserting a catheter through the femoral vein or artery and stretching the valve open with a balloon. The client needs general anesthesia for an annuloplasty and not a local anesthetic.

PTS:1DIF:ApplyREF:Valvular Surgery

MULTIPLE RESPONSE

1.The nurse suspects a client is experiencing left-sided heart failure when which of the following is assessed? (Select all that apply.)

1.

Decreased basilar lung sounds

2.

Distended neck veins

3.

Extra heart sounds

4.

Lung crackles

5.

Tachycardia

6.

Weight gain

ANS: 1, 3, 4, 5

Signs of left-sided heart failure are dysrhythmic heart rate, tachycardia, heart murmurs, extra heart sounds, lung crackles, and decreased basilar lung sounds. Distended neck veins and weight gain are symptoms of right-sided heart failure.

PTS: 1 DIF: Analyze REF: Box 25-2 Heart Failure Clinical Manifestations

2.A client diagnosed with heart failure is prescribed furosemide (Lasix). Which of the following should this client be monitored for because of this medication? (Select all that apply.)

1.

Dehydration

2.

Rebound fluid volume overload

3.

Hyponatremia

4.

Hypokalemia

5.

Hypernatremia

6.

Hyperkalemia

ANS: 1, 3, 4

Any client prescribed diuretics should be monitored for dehydration, hyponatremia, and hypokalemia. Rebound fluid volume overload is not possible with diuretic therapy. Hypernatremia and hyperkalemia are also not possible with diuretic therapy.

PTS: 1 DIF: Apply REF: Heart Failure: Pharmacology

3.The nurse is reviewing the medications prescribed for a client diagnosed with dilated cardiomyopathy. Which of the following medications are commonly prescribed for this disease process? (Select all that apply.)

1.

ACE Inhibitor

2.

Beta-blocker

3.

Diuretic

4.

Anticoagulant

5.

Antiarrhythmic

6.

Antibiotic

ANS: 1, 2, 3, 4, 5

Pharmacological management of dilated cardiomyopathy includes ACE inhibitor to prevent further dilation of the heart, beta-blocker to reduce the strain that heart failure produces on the heart muscle, diuretics to decrease the amount of circulating fluid, anticoagulants to decrease blood clots, and antiarrhythmics to maintain the normal electrical stimulation of the heart. Antibiotics are not routinely prescribed for a client diagnosed with dilated cardiomyopathy.

PTS: 1 DIF: Analyze REF: Dilated Cardiomyopathy: Pharmacology

4.Which of the following should the nurse instruct a client diagnosed with hypertrophic cardiomyopathy? (Select all that apply.)

1.

Follow recommended activity level

2.

Avoid all alcohol

3.

Take hot tub baths routinely

4.

Avoid overexertion

5.

Avoid dehydration

6.

Unexplained breathlessness is a common symptom

ANS: 1, 4, 5

The nurse should instruct the client diagnosed with hypertrophic cardiomyopathy to follow the recommended activity level, avoid overexertion, and avoid dehydration. The client should be instructed to use alcohol in moderation, to avoid hot tub baths or showers, and to report unexplained breathlessness to a health care provider.

PTS:1DIF:Apply

REF:Hypertrophic Cardiomyopathy: Planning and Implementation

5.The nurse determines that a client diagnosed with pericarditis is demonstrating the classic signs of the Beck triad. What are the signs of the Beck triad? (Select all that apply.)

1.

Fever

2.

Dyspnea

3.

Muffled heart sounds

4.

Elevated jugular vein pressure

5.

Hypotension

6.

Abdominal pain

ANS: 3, 4, 5

The symptoms of Beck triad include muffled heart sounds, elevated jugular vein pressure, and hypotension. Fever, dyspnea, and abdominal pain are not considered findings within the Beck triad.

PTS:1DIF:Analyze

REF: Pericarditis: Assessment with Clinical Manifestations

One comment

Leave a Reply