Chapter 33 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 33

Question 1

Type: MCSA

Which information should the nurse consider when planning care for patients at risk for endocarditis?

1. Endocarditis does not pose a high risk for damage to affected heart valves.

2. The major treatment modality for endocarditis is open heart surgery to clean the heart valves.

3. Fever is a rare manifestation of endocarditis.

4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.

Correct Answer: 4

Rationale 1: Endocarditis carries a serious risk for damage to heart valves.

Rationale 2: Surgery to clean valves may be necessary, but it is not the major treatment modality.

Rationale 3: Fever occurs in about 90% of patients with endocarditis.

Rationale 4: Prophylactic antibiotic therapy can prevent endocarditis in those at risk for developing the disease.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-1

Question 2

Type: MCMA

Which assessment findings would increase the nurses suspicion that a patient may have pericarditis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

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

Rationale 1: Pericardial friction is a hallmark sign of pericarditis, in addition to fever.

Rationale 2: Abdominal discomfort and nausea are not associated with pericarditis.

Rationale 3: Chest pain is a hallmark sign of pericarditis, in addition to fever.

Rationale 4: Bradycardia is not associated with pericarditis.

Rationale 5: Distended neck veins are not associated with pericarditis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 3

Type: MCSA

The nurse, caring for a patient diagnosed with cardiac tamponade, prepares to participate in which initial treatment?

1. Antidysrhythmic drugs and oxygen

2. Oxygen and rest

3. Pericardiocentesis

4. Antibiotics

Correct Answer: 3

Rationale 1: Antidysrhythmic drugs may be necessary but are not the initial treatment.

Rationale 2: Oxygen and rest will be required but are not the initial treatment.

Rationale 3: When cardiac tamponade occurs, it is considered a medical emergency. Pericardiocentesis is performed to remove fluid or blood that has collected around the heart and is preventing the heart from pumping effectively.

Rationale 4: Antibiotic therapy may be necessary but is not the initial treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-1

Question 4

Type: MCSA

A nurse caring for a patient with coronary artery disease (CAD) hears a murmur during auscultation of the heart. The nurse suspects which complication of CAD?

1. Valvular heart disease

2. Pericarditis

3. Cardiac tamponade

4. Heart failure

Correct Answer: 1

Rationale 1: Valvular disorders interfere with the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease.

Rationale 2: The heart sound characteristic of pericarditis is a pericardial friction rub

Rationale 3: Distant and muffled heart sounds are typical of cardiac tamponade.

Rationale 4: Extra heart sounds S3 and S4 are heard in heart failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 5

Type: MCSA

Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which statement by the patient would indicate 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 eat less protein and more fat, so I will have more energy.

3. I am already at risk for increased bleeding, so I will avoid taking aspirin for pain.

4. I know that if my joints start to hurt again, I need to slow down, but I wont have to worry since Im immune to getting rheumatic fever again.

Correct Answer: 1

Rationale 1: Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever.

Rationale 2: Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue.

Rationale 3: Aspirin and NSAIDs are used to treat joint pain or fever. Rheumatic fever does not raise the risk of bleeding.

Rationale 4: Rheumatic fever is manifested by joint pain. Immunity is not conferred by having had an episode of rheumatic fever.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 33-1

Question 6

Type: MCSA

The nurse caring for patients on a cardiac unit should plan to see which assigned patient first?

1. A patient with hypertrophic cardiomyopathy who is reporting dyspnea

2. A patient who had a cardiac catheterization and will be ambulating for the first time

3. A patient receiving antibiotics for bacterial endocarditis who is reporting dyspnea and chest pain

4. A patient who is recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101F

Correct Answer: 3

Rationale 1: Dyspnea is a chronic symptom with hypertrophic cardiomyopathy and requires assessment. However, another patient is the priority.

Rationale 2: The patient ambulating for the first time will be assessed by a nurse. However, another patient is the priority.

Rationale 3: The patient with bacterial endocarditis is at risk for thrombus formation. Chest pain and dyspnea are signs of pulmonary embolism (PE), which is life threatening.

Rationale 4: A temperature of 101F requires further assessment. However, another patient is the priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-1

Question 7

Type: MCSA

A patient with endocarditis develops sudden leg pain with pallor, tingling, and a loss of peripheral pulses. What should be the initial nursing intervention?

1. Notify the physician about these findings.

2. Elevate the leg above the level of the heart.

3. Administer prn analgesia.

4. Perform passive range-of-motion (PROM) exercises to stimulate circulation.

Correct Answer: 1

Rationale 1: The physician should be notified of these finding immediately.

Rationale 2: Elevating the leg above the heart can worsen the ischemia.

Rationale 3: The patient may require analgesia, but this is not the priority intervention.

Rationale 4: Passive range-of-motion exercises will increase tissue demand for oxygen and increase ischemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-1

Question 8

Type: MCSA

A patient is admitted with acute pericarditis. When auscultating heart sounds, the nurse should ask the patient to assume which position?

1. Sit leaning forward

2. Lie supine

3. Sit upright

4. Lie on the left side

Correct Answer: 1

Rationale 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.

Rationale 2: The supine position does not enhance the nurses ability to hear a pericardial friction rub, the characteristic sign of pericarditis.

Rationale 3: The upright position does not enhance the nurses ability to hear a pericardial friction rub, the characteristic sign of pericarditis.

Rationale 4: Positioning the patient on the left side does not enhance the nurses ability to hear a pericardial friction rub, the characteristic sign of pericarditis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 9

Type: MCSA

A patient is being discharged from the health care 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 nurses 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 at your office visit.

3. You will need to take it until the valve covers over with tissue.

4. Your surgeon will help wean you off the warfarin in about 3 months.

Correct Answer: 1

Rationale 1: Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve.

Rationale 2: This statement gives false reassurance to the patient and does not answer the question.

Rationale 3: There is no expectation that the valve will cover over with tissue.

Rationale 4: The patient will not be taken off anticoagulants in 3 months. There is no reason to wean the patient from warfarin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-4

Question 10

Type: MCMA

A nurse is caring for a patient diagnosed with pericarditis. Due to this patients risk for cardiac tamponade, the nurse is vigilant about assessing for which findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart sounds that are more difficult to auscultate

2. A palpable lift at the third intercostal space just left of the midclavicular line

3. Decreased systolic blood pressure

4. Visible distention of jugular veins

5. Patient report of headache

Correct Answer: 1,3,4

Rationale 1: Muffling of heart sounds is one component of Becks triad, the classic assessment findings of cardiac tamponade.

Rationale 2: Cardiac tamponade compresses the heart, which would decrease wall motion. Lifts are caused by increased force of contraction.

Rationale 3: Decreased blood pressure is one component of Becks triad, the classic assessment findings of cardiac tamponade.

Rationale 4: Jugular venous distention is one component of Becks triad, the classic assessment findings of cardiac tamponade.

Rationale 5: Headache is not associated with cardiac tamponade.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 11

Type: MCSA

Cardiac tamponade is suspected in a patient diagnosed with pericarditis. What assessment data would assist the nurse in determining the presence of this complication?

1. Changes in systolic blood pressure during inspiration

2. Arterial blood gases

3. The rhythm of the pulse in relation to inspiration and expiration

4. A cardiac murmur that occurs during systole

Correct Answer: 1

Rationale 1: A pulsus paradoxus is an important diagnostic clue when evaluating for the presence and progression of cardiac tamponade. It is defined as a drop greater than 10 mmHg in systolic blood pressure (BP) during inspiration. The BP normally decreases during inspiration, but by less than 10 mmHg. A drop of greater than 10 mmHg occurs when there is increased thoracic pressure due to pericardial swelling.

Rationale 2: Arterial blood gas measurement is not specific to cardiac tamponade.

Rationale 3: As tamponade increases, there are changes in cardiac rate and rhythm, but they are not associated with inspiration and expiration.

Rationale 4: The presence of a systolic murmur is not specific to cardiac tamponade.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 12

Type: MCMA

The nurse implements the following measures for a patient with rheumatic fever: turn, cough, deep breathe, elevate head of bed, instruct on use of incentive spirometry. On which parameters would the nurse assess the effectiveness of the nursing interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Urine output

2. Arterial blood gases

3. Potassium level

4. Lung sounds

5. Orientation

Correct Answer: 2,4,5

Rationale 1: Urine output is not a gas exchange parameter.

Rationale 2: The outcome of the nursing measures is adequate gas exchange. Arterial blood gases are evaluation parameters used when assessing gas exchange.

Rationale 3: Potassium level is not a gas exchange parameter.

Rationale 4: The outcome of the nursing measures is adequate gas exchange. Lung sounds are used as evaluation parameters when assessing gas exchange.

Rationale 5: The outcome of the nursing measures is adequate gas exchange. The patients orientation is an evaluation parameter used when assessing gas exchange.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 33-1

Question 13

Type: MCMA

Pain is associated with inflammatory heart disease. What interventions should be included in an effective management plan to keep the patient pain-free?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Instruct the patient to inform the nurse if pain is not relieved.

2. Have the family manage the patients pain.

3. Medicate the patient only when the pain is severe.

4. Instruct the patient that there is a risk of addiction and overdose.

5. Provide a supportive environment in which the patient is able to express his or her pain level.

Correct Answer: 1,5

Rationale 1: Relief is the patient goal; therefore, it is essential that the patient communicate with the nurse about the effectiveness of pain control measures.

Rationale 2: It is inappropriate to have the family manage the pain. It is the responsibility of the health care provider and the nurse.

Rationale 3: An effective pain relief measure is to medicate as soon as the pain begins, as it increases comfort and reduces the need for medication.

Rationale 4: The nurse needs to assure the patient that the risk of addiction is not a consideration with short-term narcotic use.

Rationale 5: The nurse must provide an environment in which the patient feels comfortable and supported to facilitate effective communication and attain relief from pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-1

Question 14

Type: MCSA

Diagnostic testing reveals that an adult patient has a stenotic mitral valve. How would the nurse explain this diagnosis to the patient?

1. One of the valves of your heart does not open well enough.

2. You have a leaky valve in your heart.

3. The valves in your heart were not formed correctly before you were born.

4. One of the valves in your heart is stuck in the open position.

Correct Answer: 1

Rationale 1: A stenotic valve has a narrowed orifice that does not allow blood to flow normally into the next chamber.

Rationale 2: A regurgitant valve does not close properly; therefore blood backs up into the previous chamber. This can be described as a leaky valve.

Rationale 3: The adult patient is more likely to have acquired valvular disease than congenital valvular disease. In any case, there is not enough information in the question for the nurse to discuss etiology.

Rationale 4: Stenosis is a narrowing of the valve, not a condition in which the valve is stuck open.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 15

Type: MCMA

The nurse is providing discharge instructions to a patient diagnosed with severe aortic stenosis. What should the nurse teach the patient about returning to activity?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A balanced diet will provide the calories you need for activity.

2. Plan to increase your activity level by about 10% each week.

3. If you have chest pain or shortness of breath, sit down and rest immediately.

4. You will be able to exercise more if you wear oxygen.

5. Find sedentary activities you enjoy.

Correct Answer: 1,3,5

Rationale 1: The patient should consume a balanced diet that provides the calories and nutrients to support activity.

Rationale 2: A progressive activity plan would not be feasible with severe aortic stenosis.

Rationale 3: It is important to have an activity plan that prevents fatigue. Teaching the patient when to stop activities is essential in preventing extra workload on the heart and fatigue.

Rationale 4: Activity that would require oxygen is too strenuous.

Rationale 5: Exploring sedentary activities that the patient enjoys will help reduce cardiac workload.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-3

Question 16

Type: MCSA

Following valve replacement surgery, the patient is instructed to notify the health care provider if fever, increased heart rate, fatigue, malaise, anorexia, weight loss, headache, chills, and/or night sweats occur. What is the nurses rationale for this instruction?

1. These are manifestation of valve rejection.

2. These are manifestations of the type of heart failure associated with valve replacement.

3. These findings suggest that the patient is having a myocardial infarction.

4. These findings are manifestations of infective endocarditis.

Correct Answer: 4

Rationale 1: Replacement valves are not vascular; therefore rejection does not occur.

Rationale 2: Heart failure is manifested with lung congestion and shortness of breath.

Rationale 3: Myocardial infarction (MI) is manifested by chest pain and can result in fatigue with increased heart rate. The other manifestation of fever, anorexia, malaise, and chills are not associated with MI.

Rationale 4: The clinical manifestations are a sign of postoperative infective endocarditis, which needs immediate medical attention.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-4

Question 17

Type: MCSA

The nurse has provided discharge education for a patient who had valve replacement surgery and is on warfarin. Which statement by the patient would indicate understanding of the nurses instruction?

1. I need to report bruising, bleeding, epistaxis, and hemoptysis to my health care provider.

2. I should take aspirin and anti-inflammatory drugs (NSAIDs) for pain.

3. I should avoid red meat.

4. I need to eat large amounts of yellow and dark green vegetables.

Correct Answer: 1

Rationale 1: Bruising, bleeding, epistaxis, and hemoptysis are all signs of abnormal bleeding, which may indicate that a change is needed in the warfarin dosage.

Rationale 2: Aspirin and NSAIDs cause bleeding and would be contraindicated while taking warfarin.

Rationale 3: Avoiding red meat is not necessary.

Rationale 4: Yellow and green vegetables should be avoided due to their high vitamin K content, which counteracts the warfarin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 33-4

Question 18

Type: MCSA

A patient with mitral regurgitation is instructed to report to the health care provider if it becomes too difficult to perform activities of daily living. What is the nurses rationale for providing this instruction?

1. Activity intolerance indicates acute respiratory distress.

2. The patient may have experienced a myocardial infarction.

3. These changes indicate that it is time to consider valve replacement.

4. Infective endocarditis is developing.

Correct Answer: 3

Rationale 1: Acute respiratory distress will result in activity intolerance, but this is not the reason this assessment is important to this patient.

Rationale 2: A slowly progressive reduction in activity tolerance is not typically associated with MI.

Rationale 3: The patients ability to perform activities of daily living serves as the indicator of when it is time to replace the valve. The goal is to replace the valve before there is permanent left ventricular damage.

Rationale 4: Infective endocarditis can result in these assessment findings, but this is not the primary reason the assessment is crucial for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-4

Question 19

Type: MCSA

The nurse is admitting a patient with a sudden onset of dyspnea and a blowing high-pitched murmur. The nurse is most concerned about which condition?

1. Aortic stenosis

2. Acute mitral valve stenosis

3. Acute mitral valve regurgitation

4. Mitral valve prolapse

Correct Answer: 3

Rationale 1: Aortic stenosis has a harsh crescendo-decrescendo systolic murmur.

Rationale 2: Mitral valve stenosis has a low-pitched, rumbling, crescendo-decrescendo diastolic murmur.

Rationale 3: The sudden onset of symptoms indicates it is an acute problem. The dyspnea and blowing high-pitched murmur are classic clinical manifestations of mitral valve regurgitation.

Rationale 4: Mitral valve prolapse is characterized by a mid-systolic to late-systolic click heard between S1 and S2.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 20

Type: MCMA

A patient being admitted for valvular annuloplasty says, I still dont understand why I need my valve replaced now. Ive had this floppy valve for years. How should the nurse respond?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You are not having the valve replaced; you are having the fibrous ring at the junction of the valve leaflets and the muscular wall repaired.

2. You are having your valve replaced because it is diseased.

3. Due to valve stenosis, the valve leaflets must be separated.

4. Your family has been informed of the procedure.

5. What did your surgeon tell you about the procedure?

Correct Answer: 1,5

Rationale 1: An annuloplasty is a valve repair procedure, not a valve replacement surgery.

Rationale 2: Telling the patient that the valve is being replaced is inaccurate.

Rationale 3: This patient does not have valve stenosis but regurgitation, as evidenced by the description of a floppy valve.

Rationale 4: The patient must understand the procedure to give informed consent.

Rationale 5: The patient should discuss the surgery in detail with the surgeon before giving consent. The nurse should assess what information was provided and reinforce the teaching.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-4

Question 21

Type: MCMA

The nurse is developing a program to support patients with cardiac valve disease, both before and after surgical intervention. For this program to be holistic, members from which disciplines should be included on the planning committee?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Dieticians

2. Nurses and health care providers

3. Laboratory technicians

4. Psychologists/psychiatrists

5. Pharmacists

Correct Answer: 1,2,4,5

Rationale 1: When cardiac valve disease is complicated by congestion, a symptom of heart failure, counseling on diet and fluid restriction is necessary. The dietician can provide education about salt restriction and assist in developing satisfying meals that do not increase the risk of fluid retention.

Rationale 2: Nurses are pivotal in the coordination of the health care team and nursing management. It is essential that the health care provider monitor the progress of the valve disease and determine when surgical intervention is necessary.

Rationale 3: Laboratory technicians are involved in care only at the direction of other practitioners who are already represented on the committee.

Rationale 4: Psychiatric counseling may be necessary to assist in lifestyle adjustments necessitated by a chronic disease process.

Rationale 5: Because medication is an essential part of the management of valve disorders, the role of the pharmacist is crucial in educating the patient about how to manage the medications and their side effects.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-6

Question 22

Type: MCMA

A patient is considering valve replacement surgery. The nurse would explain which main differences between biological and mechanical valves?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Biological valves have a higher incidence of clot formation than do mechanical valves.

2. Biological valves wear out faster than mechanical valves.

3. Mechanical valves sometimes have an audible click.

4. Infections are harder to treat in mechanical valves.

5. There is a higher risk of hemorrhage in the years after surgery if a biologic valve is used.

Correct Answer: 2,3,4

Rationale 1: The incidence of clot formation is higher in mechanical vales than in biological valves.

Rationale 2: Mechanical valves wear out more slowly than biological valves.

Rationale 3: Mechanical valves may make an audible clicking noise with each beat.

Rationale 4: Should an infection occur in a mechanical valve, it can be difficult to treat. Infections in biological valves are easier to treat.

Rationale 5: The risk of hemorrhage is related to anticoagulation, which is not necessary with biologic valves.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-4

Question 23

Type: MCSA

While taking a nursing history of a patient recently diagnosed with restrictive cardiomyopathy, which information does the nurse recognize as significant to this health problem?

1. A history of cocaine abuse

2. A family history of cardiomyopathy

3. History of depression

4. History of excessive alcohol use

Correct Answer: 1

Rationale 1: The incidence of cocaine-related restrictive cardiomyopathy is increasing in the United States.

Rationale 2: A family history of cardiomyopathy is most common with hypertrophic obstructive cardiomyopathy.

Rationale 3: Depression is not related to the causes of cardiomyopathy.

Rationale 4: Excessive alcohol use is associated with dilated cardiomyopathy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-5

Question 24

Type: MCSA

The nurse is assessing a patient diagnosed with dilated cardiomyopathy for progression of the disease. The nurse would focus questioning on which most common symptom?

1. Confusion

2. Cyanosis

3. Dyspnea

4. Peripheral edema

Correct Answer: 3

Rationale 1: Confusion may be present but is not the most common clinical manifestation.

Rationale 2: Cyanosis may be present but is not the most common manifestation.

Rationale 3: Dyspnea occurs because the enlarged heart compresses the bronchioles, thus diminishing the amount of oxygen entering and leaving the lungs. Additionally, blood backs up into the lungs due to heart failure, which is common in dilated cardiomyopathy.

Rationale 4: Peripheral edema may occur but is not the most common clinical manifestation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-5

Question 25

Type: MCSA

The nurse is admitting a 22-year-old patient who is experiencing palpitations, light-headedness, and fatigue. The health care provider has diagnosed cardiomyopathy. The nurse would ask additional questions about which most likely form of cardiomyopathy?

1. Restrictive

2. Arrhythmogenic right ventricular cardiomyopathy

3. Dilated cardiomyopathy

4. Hypertrophic cardiomyopathy

Correct Answer: 2

Rationale 1: No risk factors for restrictive cardiomyopathy are described.

Rationale 2: Because of the patients age and clinical manifestations, arrhythmogenic right ventricular cardiomyopathy is most likely. The nurse would ask about family history of cardiomyopathy, syncopal episodes, and symptoms of heart failure.

Rationale 3: Dilated cardiomyopathy is not common at this age. Symptoms of dilated cardiomyopathy include dyspnea and activity intolerance.

Rationale 4: The patient is not reporting dyspnea, so it would be unlikely that the cardiomyopathy is hypertrophic.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-5

Question 26

Type: MCMA

A patient with infective endocarditis is expressing fear and anxiety related to changes in health status and anticipated procedures. What interventions would the nurse include in this patients care plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected..

Standard Text: Select all that apply.

1. Provide factual information concerning diagnosis, treatment, disfigurement, disabilities, and prognosis.

2. State that the physician will have to be the one who talks to the patient about the procedure.

3. Explain to the patient that it is better not to be informed prior to procedures, as information increases anxiety.

4. Tell the patient not to worry and that everything will be fine.

5. Explain all procedures and allow the patient time for mental preparation.

Correct Answer: 1,5

Rationale 1: Truthful explanations increase trust and potentially reduce anxiety and fear of the unknown.

Rationale 2: This is an unprofessional, inappropriate response. It is the nurses job to help reduce the patients anxiety. Accomplishing this goal may require a multifaceted strategy. The nurse must verify the patients understanding and then notify the surgeon that the patient needs to discuss the procedure before providing informed consent.

Rationale 3: Truthful explanations increase trust and potentially reduce anxiety and fear of the unknown.

Rationale 4: Telling the patient not to worry is dismissive, and fear of the unknown potentially increases anxiety.

Rationale 5: It is important to give the patient time to process the information to be sure it is clearly understood. Often the patient has more questions after the initial explanation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-6

Question 27

Type: MCMA

A patient is diagnosed with hypertrophic obstructive cardiomyopathy. The nurse would design interventions to meet which primary collaborative treatment goals for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Preventing sudden cardiac death

2. Preventing renal failure

3. Preventing pulmonary damage

4. Preventing heart failure

5. Preventing liver failure

Correct Answer: 1,4

Rationale 1: Preventing sudden cardiac death is a primary goal of treatment for patients with hypertrophic obstructive cardiomyopathy.

Rationale 2: Renal failure is not directly related to hypertrophic obstructive cardiomyopathy.

Rationale 3: Pulmonary damage is not directly related to hypertrophic obstructive cardiomyopathy.

Rationale 4: Preventing heart failure is a primary goal of treatment for patients with hypertrophic obstructive cardiomyopathy.

Rationale 5: Liver failure is not directly related to hypertrophic obstructive cardiomyopathy.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-6

Question 28

Type: MCMA

The nurse is evaluating activity tolerance in a patient with mitral valve stenosis. Which finding would the nurse evaluate as indicating the patient tolerated ambulating in the hall?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The heart rate, measured 3 minutes after the patient returned to bed, was at the patients normal level.

2. Blood pressure taken at the halfway point of ambulation was not significantly different from the preambulation level.

3. The patient does not complain of being tired when ambulating.

4. The patients pulse oximetry reading goes up slightly right after ambulation.

5. The patients respiratory rate is at normal level at the end of the walk.

Correct Answer: 1,2,5

Rationale 1: If vital signs (HR, respirations, and BP) return to normal within 3 minutes of the end of activity, the patient has tolerated the activity.

Rationale 2: If blood pressure does not change with activity, the patient is tolerating ambulation.

Rationale 3: Physiological measures are more reliable indicators of the patients tolerance to activity.

Rationale 4: The nurse would be concerned if the pulse oximetry reading dropped as a result of ambulation.

Rationale 5: The patients respiratory rate is a good indicator of activity tolerance. If it is normal, the patient is tolerating activity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 33-3

Question 29

Type: MCMA

A patient who requires a valve replacement says, The surgeon wants to use a mechanical valve, but I think I would rather have a human valve. What information should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Human valves are not used for valve replacements.

2. Cadaver valves are more durable than mechanical valves.

3. Human valves are very expensive.

4. Anticoagulation is rarely needed with human valve transplant.

5. The patient should talk with the surgeon about the use of allograft valves.

Correct Answer: 3,4,5

Rationale 1: Human valves are used for valve replacements, but they are not readily available.

Rationale 2: Cadaver valves have limited durability.

Rationale 3: The expenses associated with the retrieval and storage of human valves make them very expensive.

Rationale 4: Anticoagulation is not an issue with natural tissue valves.

Rationale 5: Human cadaver valves are called homograft or allograft valves.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-3

Question 30

Type: MCSA

The nurse calls a patient 2 days before an outpatient procedure to discuss preprocedure preparation. The procedure is being done to track the progression of the patients valvular disease. Which testing is likely scheduled?

1. Chest x-ray

2. An electrocardiogram

3. Transesophageal echocardiography (TEE)

4. Cardiac catheterization

Correct Answer: 3

Rationale 1: A chest x-ray does not require preprocedure preparation and is not likely to give much information about the progression of valvular disease.

Rationale 2: Electrocardiograms do not require preprocedure preparation and are not likely to give much information about the progression of valvular disease.

Rationale 3: TEE is particularly useful for tracking the progression of valvular disease. The patient does have to be NPO for this test.

Rationale 4: While cardiac catheterization may provide some information about heart function, it is an invasive test. Another, less invasive test is more likely to be performed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-3

Question 31

Type: MCSA

A young male athlete is admitted to the hospital after collapsing at football practice. The medical diagnosis is hypertrophic obstructive cardiomyopathy. The nurse expects that which activity recommendation will be necessary?

1. The patient should limit fluid intake while exercising.

2. The patient should stop playing football and other strenuous sports.

3. The patient will need to gradually return to previous levels of exercise.

4. Exercise is not related to hypertrophic cardiomyopathy symptomology.

Correct Answer: 2

Rationale 1: This patient should maintain hydration.

Rationale 2: The patient with hypertrophic obstructive cardiomyopathy should avoid strenuous exercise.

Rationale 3: Strenuous exercise is contraindicated in patients with hypertrophic obstructive cardiomyopathy.

Rationale 4: Exercise increases heart rate and the metabolic demand for oxygen. Exercise tends to precipitate symptoms.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-5

Question 32

Type: MCSA

Which nursing diagnosis will the nurse include as the priority in the care plan of a patient diagnosed with hypertrophic cardiomyopathy (HCM)?

1. Risk for Activity Intolerance

2. Ineffective Airway Clearance

3. Imbalanced Nutrition: More than Body Requirements

4. Ineffective Individual Coping

Correct Answer: 1

Rationale 1: Patients with HCM do not tolerate activity.

Rationale 2: Airway clearance is not typically a problem in patients with HCM.

Rationale 3: It would be more likely that the patient uses more energy than is provided by the diet.

Rationale 4: Additional assessment would be necessary to diagnose difficulty coping. This is not the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 33-6

Question 33

Type: MCMA

A patient has been admitted for treatment of acute pericarditis. The nurse would include which nursing diagnoses in this patients plan of care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Anxiety

2. Decreased Cardiac Output

3. Risk for Impaired Skin Integrity

4. Ineffective Tissue Perfusion

5. Activity Intolerance

Correct Answer: 1,2,4,5

Rationale 1: Anxiety is produced when the patient has a serious disease and the future is unknown.

Rationale 2: Many of the manifestations of pericarditis are related to a decrease in cardiac output.

Rationale 3: Pericarditis is not associated with impaired skin integrity.

Rationale 4: The patient with pericarditis has the potential for ineffective tissue perfusion because the heart is not pumping efficiently.

Rationale 5: Because the heart cannot deliver sufficient oxygen to the muscles, the patient will have activity intolerance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 33-6

Question 34

Type: MCMA

The nurse is reviewing physician orders for a patient who has been admitted for the treatment of myocarditis. The nurse would contact the prescriber regarding which medication orders?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ibuprofen

2. Digoxin

3. An antibiotic

4. An ACE inhibitor

5. Antidysrhythmic

Correct Answer: 1,2,5

Rationale 1: The use of NSAIDs with myocarditis is contraindicated because they appear to increase cardiac damage.

Rationale 2: Patients with myocarditis are sensitive to the effects of digoxin. If this drug is used, the patient must be monitored very closely.

Rationale 3: If the myocarditis is bacterial, an antibiotic will be ordered.

Rationale 4: An ACE inhibitor may be used to treat left heart failure.

Rationale 5: The patient may require an antidysrhythmic, as dysrhythmias commonly occur with myocarditis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-1

Question 35

Type: MCSA

The medical record states that a patient with infective endocarditis has Oslers nodes. The nurse would assess the patient for which finding?

1. Enlarged lymph nodes in the axilla

2. Painful mobile enlargement of the posterior lymph node chain in the neck

3. Painful red or purple lesions on the fingertips or toes

4. Round white spots on the retina

Correct Answer: 3

Rationale 1: Oslers nodes are not located in the axilla.

Rationale 2: Oslers nodes are not located in the neck.

Rationale 3: Oslers nodes are painful, red or purple, pea-sized lesions found on the fingertips or toes.

Rationale 4: Round white spots on the retina surrounded by hemorrhage are Roths spots.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-5

 

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