Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders

Test Bank

MULTIPLE CHOICE

1. The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?

a.

Have you been to the dentist lately?

b.

Do you have a history of a heart attack?

c.

Is there a family history of endocarditis?

d.

Have you had any recent immunizations?

ANS: A

Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

DIF: Cognitive Level: Application REF: 844 | 845-846

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. During the assessment of a patient with infective endocarditis (IE), the nurse would expect to find

a.

a new regurgitant murmur.

b.

a pruritic rash on the trunk.

c.

involuntary muscle movement.

d.

substernal chest pain and pressure.

ANS: A

New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

DIF: Cognitive Level: Comprehension REF: 842-843

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on the assessment finding of

a.

fever, chills, and diaphoresis.

b.

urine output less than 30 mL/hr.

c.

petechiae of the buccal mucosa and conjunctiva.

d.

increase in pulse rate of 15 beats/minute with activity.

ANS: B

Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise

DIF: Cognitive Level: Application REF: 845-846 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention will the nurse include?

a.

Monitor labs for streptococcal antibodies.

b.

Arrange for insertion of a long-term IV catheter.

c.

Encourage the patient to get regular aerobic exercise.

d.

Teach the importance of completing all oral antibiotics.

ANS: B

Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

DIF: Cognitive Level: Application REF: 844-845 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

5. A patient is admitted to the hospital with possible acute pericarditis. The nurse will plan to teach the patient about the purpose of

a.

electrolyte levels.

b.

echocardiography.

c.

daily blood cultures.

d.

cardiac catheterization.

ANS: B

Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization is not a diagnostic procedure for pericarditis. Electrolyte levels are not helpful in making a diagnosis of pericarditis.

DIF: Cognitive Level: Application REF: 847-848 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

6. To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should

a.

auscultate with the stethoscope diaphragm at the lower left sternal border.

b.

listen for a rumbling, low-pitched, systolic sound over the left anterior chest.

c.

feel the precordial area with the palm of the hand to detect vibration with cardiac contraction.

d.

ask the patient to stop breathing during auscultation to distinguish the sound from a pleural friction rub.

ANS: A

Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. Because dyspnea is one clinical manifestation of pericarditis, the nurse should time the friction rub with the pulse rather than ask the patient to stop breathing during auscultation. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

DIF: Cognitive Level: Comprehension REF: 847

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

a.

check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration.

b.

note when Korotkoff sounds are audible during both inspiration and expiration.

c.

auscultate for a pericardial friction rub that increases in volume during inspiration.

d.

subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

ANS: B

Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

DIF: Cognitive Level: Comprehension REF: 847

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The most appropriate intervention by the nurse for this problem is to

a.

force fluids to 3000 mL/day to decrease fever and inflammation.

b.

teach the patient to take deep, slow respirations to control the pain.

c.

remind the patient to ask for the opioid pain medication every 4 hours.

d.

position the patient in Fowlers position, leaning forward on the overbed table.

ANS: D

Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID).

DIF: Cognitive Level: Application REF: 848-849

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. While obtaining an admission health history from a patient with possible rheumatic fever, which question will be most pertinent to ask?

a.

Have you had a recent sore throat?

b.

Are you using any illegal IV drugs?

c.

Do you have any family history of congenital heart disease?

d.

Can you recall having any chest injuries in the last few weeks?

ANS: A

Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit intravenous (IV) drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

DIF: Cognitive Level: Application REF: 850

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An appropriate nursing diagnosis based on these findings is

a.

activity intolerance related to arthralgia.

b.

risk for infection related to open skin lesions.

c.

chronic pain related to permanent joint fixation.

d.

risk for impaired skin integrity related to pruritus.

ANS: A

The patients joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.

DIF: Cognitive Level: Application REF: 850-853 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever says,

a.

I will need to have monthly antibiotic injections for 10 years or longer.

b.

I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain.

c.

I will call the doctor if I develop excessive fatigue or difficulty breathing.

d.

I will be immune to further episodes of rheumatic fever after this infection.

ANS: D

Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.

DIF: Cognitive Level: Application REF: 852 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

12. Which action will the community health nurse include when planning ways to decrease the incidence of rheumatic fever?

a.

Immunize susceptible groups in the community with streptococcal vaccine.

b.

Teach community members to seek treatment for streptococcal pharyngitis.

c.

Educate about the importance of monitoring temperature when infections occur.

d.

Provide prophylactic antibiotics to people with a family history of rheumatic fever.

ANS: B

The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever.

DIF: Cognitive Level: Application REF: 852 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for

a.

diastolic murmur.

b.

peripheral edema.

c.

right upper quadrant tenderness.

d.

complaints of shortness of breath.

ANS: D

The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease, but are not indicators of possible hypoxemia.

DIF: Cognitive Level: Application REF: 853

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty instead of valve replacement to the patient, which information will the nurse include?

a.

Biologic replacement valves require the use of immunosuppressive drugs.

b.

Mechanical mitral valves require replacement approximately every 5 years.

c.

Lifelong anticoagulant therapy is needed after mechanical valve replacement.

d.

Ongoing cardiac care by a health care provider is unnecessary after valvuloplasty.

ANS: C

Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than 5 years. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.

DIF: Cognitive Level: Application REF: 856-857 | 859

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. While caring for a patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to

a.

plan to take antibiotics before any dental appointments.

b.

limit physical activity to avoid stressing the heart valves.

c.

take 1 aspirin a day to prevent embolization from the valve.

d.

avoid use of over-the-counter (OTC) medications that contain stimulant drugs.

ANS: D

Use of stimulant medications should be avoided by patients with MVP since these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

DIF: Cognitive Level: Application REF: 854-855 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

16. While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to

a.

promote rest to decrease myocardial oxygen demand.

b.

educate the patient about the need for anticoagulant therapy.

c.

teach the patient to use sublingual nitroglycerin for chest pain.

d.

elevate the head of the bed 60 degrees to decrease venous return.

ANS: A

Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

DIF: Cognitive Level: Application REF: 855

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding the

a.

use of daily aspirin for anticoagulation.

b.

correct method for taking the radial pulse.

c.

need for frequent laboratory blood testing.

d.

possibility of valve replacement in 7 to 10 years.

ANS: C

Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing risk for clots on the valve. Mechanical valves are durable and would last longer than 7 to 10 years. Monitoring of the radial pulse is not necessary after valve replacement.

DIF: Cognitive Level: Application REF: 857 | 859

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. A patient who has had recent cardiac surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which of these ordered PRN medications will be the most appropriate for the nurse to administer?

a.

Fentanyl 2 mg IV

b.

IV morphine sulfate 6 mg

c.

Oral ibuprofen (Motrin) 800 mg

d.

Oral acetaminophen (Tylenol) 650 mg

ANS: C

The pain associated with pericarditis is caused by inflammation, so nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.

DIF: Cognitive Level: Application REF: 847-848

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for

a.

dyspnea.

b.

flank pain.

c.

hemiparesis.

d.

splenomegaly.

ANS: A

Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.

DIF: Cognitive Level: Application REF: 842-843 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. A patient admitted with acute dyspnea is diagnosed with dilated cardiomyopathy. Which information will the nurse include when teaching the patient about management of this disorder?

a.

Elevating the legs above the heart will help relieve angina.

b.

No more than two alcoholic drinks daily are recommended.

c.

Careful compliance with diet and medications will prevent heart failure.

d.

Notify the doctor about any symptoms of heart failure such as shortness of breath.

ANS: D

The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy).

DIF: Cognitive Level: Application REF: 863 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

21. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most relevant?

a.

The patient reports using cocaine once at age 16.

b.

The patient has a history of a recent upper respiratory infection.

c.

The patients 29-year-old brother has had a sudden cardiac arrest.

d.

The patient has a family history of coronary artery disease (CAD).

ANS: C

About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people; the information about the patients brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC.

DIF: Cognitive Level: Application REF: 861-862

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for the patient who

a.

was admitted with a large acute myocardial infarction.

b.

is being discharged after an exacerbation of heart failure.

c.

has had a mitral valve replacement with a mechanical valve.

d.

has been treated for rheumatic fever after a streptococcal infection.

ANS: C

Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

DIF: Cognitive Level: Application REF: 842 | 844 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

23. Which of these prescriptions written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever should the nurse implement first?

a.

Order blood cultures drawn from two sites.

b.

Give acetaminophen (Tylenol) PRN for fever.

c.

Administer ceftriaxone (Rocephin) 1 g IV.

d.

Obtain a transesophageal echocardiogram.

ANS: A

Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and Tylenol administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

DIF: Cognitive Level: Application REF: 843-845

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

24. Which assessment finding in a patient who is hospitalized with infective endocarditis (IE) is most important to communicate to the health care provider?

a.

Generalized muscle aching

b.

Sudden onset left flank pain

c.

Janeways lesions on the palms

d.

Temperature 100.5 F (38.1 C)

ANS: B

Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions.

DIF: Cognitive Level: Application REF: 842-844

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

25. Which of the following assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?

a.

Pulsus paradoxus 8 mm Hg

b.

Blood pressure (BP) of 166/96

c.

Jugular vein distention (JVD) to the level of the jaw

d.

Level 6 (0 to 10 scale) chest pain with deep inspiration

ANS: C

The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.

DIF: Cognitive Level: Application REF: 847

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

26. Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider?

a.

The patient complains of chest pain associated with ambulation.

b.

A loud systolic murmur is audible along the right sternal border.

c.

A thrill is palpable at the 2nd intercostal space, right sternal border.

d.

The point of maximum impulse (PMI) is at the left midclavicular line.

ANS: A

Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

DIF: Cognitive Level: Application REF: 853 | 855

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

27. A few days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first?

a.

Auscultate the heart sounds.

b.

Check the patients oral temperature.

c.

Notify the patients health care provider.

d.

Give the ordered acetaminophen (Tylenol).

ANS: A

The patients clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen (Tylenol), and notifying the health care provider also are appropriate actions but would not be done before listening for a rub.

DIF: Cognitive Level: Application REF: 846-847

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

28. Which information obtained by the nurse when assessing a patient admitted with mitral valve regurgitation should be communicated to the health care provider immediately?

a.

The patient has 4+ peripheral edema in both legs.

b.

The patient has crackles audible to the lung apices.

c.

The patient has a palpable thrill felt over the left anterior chest.

d.

The patient has a loud systolic murmur all across the precordium.

ANS: B

Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

DIF: Cognitive Level: Application REF: 853-854

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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