Chapter 25 - Complications from Heart Disease Flashcards
The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem? A. Pericarditis B. Cardiomyopathy C. Pulmonary edema D. Right ventricular hypertrophy
C. Pulmonary edema
Rationale: As a result of decreased cerebral oxygenation, the client with pulmonary edema becomes increasingly restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the client’s hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum. Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client’s risk for heart failure?
A. The client takes furosemide 20 mg/day.
B. The client’s potassium level is 4.7 mEq/L.
C. The client is white.
D. The client’s age is greater than 65
D. The client’s age is greater than 65
Rationale: Heart failure is the most common reason for hospitalization of people older than 65 years of age and is the second-most common reason for visits to a physician’s office. A potassium level of 4.7 mEq/L is within reference range and does not indicate an increased risk for heart failure. The fact that the client takes furosemide 20 mg/day does not indicate an increased risk for heart failure, although this drug is often used in the treatment of heart failure. The client being white indicates a decreased risk for heart failure compared with Black and Hispanic clients
The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential PRIMARY cause of the client's heart failure? A. Endocarditis B. Pleural effusion C. Atherosclerosis D. Atrial septal defect
C. Atherosclerosis
Rationale: Atherosclerosis of the coronary arteries is the primary cause of heart failure. Pleural effusion, endocarditis, and an atrial-septal defect are not health problems that contribute to the etiology of heart failure
The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? A. Monitoring liver function studies B. Blood pressure C. Vitamin D intake D. Monitoring potassium levels
B. Blood pressure
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the client at risk of hypotension. Clients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant
The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is MOST consistent with this client's diagnosis? A. Pulmonary edema B. Distended neck veins C. Dry cough D. Orthopnea
B. Distended neck veins
Rationale: Right-sided heart failure may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers are not characteristic signs of right-sided heart failure
A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela? A. Stroke B. Myocardial infarction (MI) C. Hemorrhage D. Peripheral edema
A. Stroke
Rationale: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of MI, hemorrhage, or peripheral edema
The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information? A. Skin turgor B. Potassium level C. White blood cell count D. Peripheral pulses
B. Potassium level
Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take FIRST? A. Check for a carotid pulse. B. Apply supplemental oxygen. C. Give two full breaths. D. Gently shake and shout, "Are you OK?"
D. Gently shake and shout, “Are you OK?”
Rationale: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A. Right-sided heart failure B. Acute pulmonary edema C. Pneumonia D. Cardiogenic shock
B. Acute pulmonary edema
Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia
A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse BEST position the client? A. In a high Fowler position B. On the left side-lying position C. In a flat, supine position D. In the Trendelenburg position
A. In a high Fowler position
Rationale: Proper positioning can help reduce venous return to the heart. The client is positioned upright. If the client is unable to sit with the lower extremities dependent, the client may be placed in an upright position in bed. The supine and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying position does not promote circulation
The nurse has entered a client’s room and found the client unresponsive and not breathing. What is the nurse’s NEXT appropriate action?
A. Palpate the client’s carotid pulse.
B. Illuminate the client’s call light.
C. Begin performing chest compressions.
D. Activate the Emergency Response System (ERS).
Activate the Emergency Response System (ERS).
Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?
A. Monitor and record blood pressure daily.
B. Monitor and record radial pulses daily.
C. Monitor weight daily.
D. Monitor bowel movements
C. Monitor weight daily.
Rationale: To assess fluid balance at home, the client should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance
The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for? A. Jugular vein distention B. Right upper quadrant pain C. Bibasilar fine crackles D. Dependent edema
C. Bibasilar fine crackles
Rationale: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse’s nutritional teaching plan has been effective?
A. “I will have a ham and cheese sandwich for lunch.”
B. “I will have a baked potato with broiled chicken for dinner.”
C. “I will have a tossed salad with cheese and croutons for lunch.”
D. “I will have chicken noodle soup with crackers and an apple for lunch.”
B. “I will have a baked potato with broiled chicken for dinner.”
Rationale: The client’s choice of a baked potato with broiled chicken indicates that the teaching plan has been effective. Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
The nurse’s comprehensive assessment of a client who has heart failure includes evaluation of the client’s hepatojugular reflux. What action should the nurse perform during this assessment?
A. Elevate the client’s head to 90 degrees.
B. Press the right upper abdomen.
C. Press above the client’s symphysis pubis.
D. Lay the client flat in bed
B. Press the right upper abdomen.
Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux
The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at GREATEST risk for the development of cardiogenic shock?
A. The client admitted with acute renal failure
B. The client admitted following an MI
C. The client admitted with malignant hypertension
D. The client admitted following a stroke
B. The client admitted following an MI
Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While clients with acute kidney injury are at risk for dysrhythmias and clients experiencing a stroke are at risk for thrombus formation, the client admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
A. A diastolic blood pressure that is lower during exhalation
B. A diastolic blood pressure that is higher during inhalation
C. A systolic blood pressure that is higher during exhalation
D. A systolic blood pressure that is lower during inhalation
D. A systolic blood pressure that is lower during inhalation
Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal
The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm? A. Pulseless electrical activity (PEA) B. Ventricular fibrillation C. Ventricular tachycardia D. Asystole
D. Asystole
Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm
The nurse is reviewing a newly admitted client’s electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?
A. Teach the client deep breathing and coughing exercises.
B. Administer supplemental oxygen at all times.
C. Limit the client’s activity level.
D. Avoid positioning the client supine
D. Avoid positioning the client supine.
Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of heart failure and, consequently, the nurse should avoid positioning the client supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.
The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply. A. Improve functional status B. Prevent endocarditis. C. Extend survival. D. Limit physical activity. E. Relieve client symptoms
A. Improve functional status
C. Extend survival.
E. Relieve client symptoms
Rationale: The overall goals of management of heart failure are to relieve the client’s symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of heart failure and preventing it is not a major goal of care.
A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment? A. Blood pressure B. Level of consciousness (LOC) C. Nausea D. Oxygen saturation
A. Blood pressure
Rationale: Clients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in clients with heart failure, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client?
A. A beta-adrenergic blocker
B. An antiplatelet aggregator
C. A calcium channel blocker
D. A nonsteroidal anti-inflammatory drug (NSAID)
A. A beta-adrenergic blocker
Rationale: Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed
The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs?
A. Loop diuretic and antiplatelet aggregator
B. Loop diuretic and calcium channel blocker
C. Combination of hydralazine and isosorbide dinitrate
D. Combination of digoxin and normal saline
C. Combination of hydralazine and isosorbide dinitrate
Rationale: A combination of hydralazine and isosorbide dinitrate may be an alternative for clients who cannot take ACE inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
A client with a diagnosis of heart failure is started on a beta-blocker. What is the nurse’s priority role during gradual increases in the client’s dose?
A. Educating the client that symptom relief may not occur for several weeks
B. Stressing that symptom relief may take up to 4 months to occur
C. Making adjustments to each day’s dose based on the blood pressure trends
D. Educating the client about the potential changes in LOC that may result from the drug
A. Educating the client that symptom relief may not occur for several weeks
Rationale: An important nursing role during titration is educating the client about the potential worsening of symptoms during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4 months, however. The nurse monitors blood pressure, but changes are not made based on short-term assessment results. Beta-blockers rarely affect LOC.
