Lewis Ch 36: Inflammatory and Structural Heart Disorders

Question 1

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?

a. “Do you have a history of a heart attack?”
b. “Is there a family history of endocarditis?”
c. “Have you had any recent immunizations?”
d. “Have you had dental work done recently?”

Answer 1

ANS: D
Dental procedures place the patient with a prosthetic mitral valve at risk for IE. Myocardial infarction, immunizations, and a family history of endocarditis are not risk factors for IE.

Question 2

What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)?

a. Substernal chest pressure
b. A new regurgitant murmur
c. A pruritic rash on the chest
d. Involuntary muscle movement

Answer 2

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

Question 3

Which assessment finding(s) indicate to the nurse that a patient with infective endocarditis has decreased cardiac output?

a. Fever, chills, and diaphoresis
b. Urine production of 25 mL/hr
c. Increase in heart rate of 15 beats/min with walking
d. Petechiae on the inside of the mouth and conjunctiva

Answer 3

ANS: B
Decreased renal perfusion caused by inadequate cardiac output will lead to decreased 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/min is normal with exercise.

Question 4

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is appropriate for the nurse to include?

a. Arrange for placement of a long-term IV catheter.
b. Monitor labs for levels of streptococcal antibodies.
c. Teach the importance of completing all oral antibiotics.
d. Encourage the patient to begin regular aerobic exercise.

Answer 4

ANS: A
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy 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.

Question 5

A patient is admitted to the hospital with possible acute pericarditis. What diagnostic test would the nurse expect the patient to undergo?

a. Blood cultures
b. Echocardiography
c. Cardiac catheterization
d. 24-hour Holter monitor

Answer 5

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 and 24-hour Holter monitor are not diagnostic procedures for pericarditis.

Question 6

How should the nurse assess the patient with pericarditis for evidence of a pericardial friction rub?
a. Listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.
b. Auscultate with the diaphragm of the stethoscope on the lower left sternal border.
c. Ask the patient to cough during auscultation to distinguish the sound from a
pleural friction rub.
d. Feel the precordial area with the palm of the hand to detect vibrations with cardiac
contraction.

Answer 6

ANS: B
Pericardial friction rubs are best heard with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

Question 7

The nurse suspects cardiac tamponade in a patient who has acute pericarditis. How should the nurse assess for the presence of pulsus paradoxus?

a. Subtract the diastolic blood pressure from the systolic blood pressure.
b. Note when Korotkoff sounds are heard during both inspiration and expiration.
c. Check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.
d. Listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

Answer 7

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. The difference between the diastolic blood pressure and the systolic blood pressure is known as the pulse pressure.

Question 8

A patient has pain due to acute pericarditis. What is an appropriate nursing intervention for this problem?

a. Teach the patient to take deep, slow breaths to control the pain.
b. Force fluids to 3000 mL/day to decrease fever and inflammation.
c. Place the patient in Fowler’s position, leaning forward on the table.
d. Provide a fresh ice bag every hour for the patient to place on the chest.

Answer 8

ANS: C
Sitting upright and leaning forward often will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Ice does not decrease this type of inflammation and pain.

Question 9

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever?

a. “Do you use any illegal IV drugs?”
b. “Have you ever injured your chest?”
c. “Have you had a recent sore throat?”
d. “Do you have a family history of heart disease?”

Answer 9

ANS: C
Rheumatic fever occurs because of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and it 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.

Question 10

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that joint discomfort prevents favorite activities such as taking a daily walk and sewing. What problem should be the focus of nursing interventions?

a. Social isolation
b. General anxiety
c. Activity intolerance
d. Altered body image

Answer 10

ANS: C
The patient’s joint pain will lead to difficulty with activity. 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. This patient did not provide any data to support a problem with social isolation, anxiety, or altered body image.

Question 11

The home health nurse is visiting a 30-yr-old patient recovering from rheumatic fever without carditis. Which statement by the patient indicates a need for further teaching?

a. “I will need prophylactic antibiotic therapy for 5 years.”
b. “I can take aspirin or ibuprofen to relieve my joint pain.”
c. “I will be immune to future episodes of rheumatic fever after this infection.”
d. “I should call the health care provider if I am fatigued or have difficulty
breathing. ”

Answer 11

ANS: C
Patients with a history of rheumatic fever are more susceptible to a second episode. Patients
with rheumatic fever without carditis require prophylaxis until age 20 years and for a minimum of 5 years. The other patient statements are correct.

Question 12

Which action should the nurse include in a community health program to decrease the incidence of rheumatic fever?
a. Vaccinate high-risk groups in the community with streptococcal vaccine.
b. Teach community members to seek treatment for streptococcal pharyngitis.
c. Teach about the importance of monitoring temperature when sore throats occur.
d. Teach about prophylactic antibiotics to those with a family history of rheumatic
fever.

Answer 12

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. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.

Question 13

Which finding for a patient with mitral valve stenosis would be of most concern to the nurse?

a. Diastolic murmur
b. Peripheral edema
c. Shortness of breath on exertion
d. Right upper quadrant tenderness

Answer 13

ANS: C
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 hypoxemia, which is a priority.

Question 14

A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?

a. Biologic valves will require immunosuppressive drugs after surgery.
b. Mechanical mitral valves need to be replaced sooner than biologic valves.
c. Lifelong anticoagulant therapy is needed after mechanical valve replacement.
d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

Answer 14

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 biologic valves. 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.

Question 15

Which statement by a 23-yr-old patient who has mitral valve prolapse (MVP) without valvular regurgitation indicates that discharge teaching has been effective?

a. “I will take antibiotics before any dental appointments.”
b. “I will limit physical activity to avoid stressing the heart.”
c. “I should avoid over-the-counter drugs that contain stimulants.”
d. “I should take an aspirin a day to prevent clots from forming on the valve.”

Answer 15

ANS: C
Patients with MVP should avoid using stimulant drugs because they 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.

Question 16

A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?

a. Promote rest to decrease myocardial oxygen demand.
b. Teach the patient about the need for anticoagulant therapy.
c. Teach the patient to use sublingual nitroglycerin for chest pain.
d. Raise the head of the bed 60 degrees to decrease venous return.

Answer 16

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.

Question 17

An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching?

a. Use of daily aspirin for anticoagulation.
b. Correct method for taking the radial pulse.
c. Need for frequent laboratory blood testing.
d. Plan to avoid any physical activity for 1 month.

Answer 17

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 testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

Question 18

A patient recovering from heart surgery develops pericarditis and reports level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give?

a. Fentanyl 1 mg IV
b. IV morphine sulfate 4 mg
c. Oral ibuprofen (Motrin) 600 mg
d. Oral acetaminophen (Tylenol) 650 mg

Answer 18

ANS: C
The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (e.g., ibuprofen) are most effective. Opioid analgesics and acetaminophen are not very effective for the pain associated with pericarditis.

Question 19

What nursing assessment finding for a patient with infective endocarditis would be consistent with embolized vegetations from the tricuspid valve?

a. Flank pain
b. Splenomegaly
c. Shortness of breath
d. Mental status changes

Answer 19

ANS: C
Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves.

Question 20

A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient?

a. A heart transplant should be scheduled as soon as possible.
b. Elevating the legs above the heart will help relieve dyspnea.
c. Careful compliance with diet and medications will prevent heart failure.
d. Notify the health care provider about symptoms such as shortness of breath.

Answer 20

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. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation.

Question 21

The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important in planning care?

a. The patient had a recent upper respiratory infection.
b. The patient has a family history of coronary artery disease.
c. The patient reports using cocaine “a few times” as a teenager.
d. The patient’s 29-yr-old brother died from a sudden cardiac arrest.

Answer 21

ANS: D
About half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient’s brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP.

Question 22

Which patient will need the nurse to plan discharge teaching about prophylactic antibiotics before dental procedures?

a. Patient admitted with a large acute myocardial infarction
b. Patient being discharged after an exacerbation of heart failure
c. Patient who had a mitral valve replacement with a mechanical valve
d. Patient being treated for rheumatic fever after a streptococcal infection

Answer 22

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.

Question 23

Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?

a. Administer ceftriaxone 1 gram IV.
b. Order blood cultures from two sites.
c. Schedule a transesophageal echocardiogram.
d. Give acetaminophen (Tylenol) PRN for fever.

Answer 23

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

Question 24

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

a. Muscle aching
b. Right flank pain
c. Janeway’s lesions on the palms
d. Temperature 100.7° F (38.1° C)

Answer 24

ANS: B
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.

Question 25

Which finding by the nurse 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 168/94 mm Hg
c. Jugular venous distention (JVD) to jaw level
d. Level 6 (0 to 10 scale) chest pain with a deep breath

Answer 25

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. 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.

Question 26

The nurse is caring for a patient with aortic stenosis. Which assessment data would be most important to report to the health care provider?

a. The patient reports chest pressure when ambulating.
b. A loud systolic murmur is heard along the right sternal border.
c. A thrill is palpated at the second intercostal space, right sternal border.
d. The point of maximum impulse (PMI) is at the left midclavicular line.

Answer 26

ANS: A 
Chest pressure (or 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.

Question 27

Two days after an acute myocardial infarction (MI), a patient reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first?

a. Auscultate the heart sounds.
b. Check the patient’s temperature.
c. Give PRN acetaminophen (Tylenol).
d. Notify the patient’s health care provider.

Answer 27

ANS: A
The patient’s 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 and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. Acetaminophen (Tylenol) is not effective for pericarditis pain. An analgesic would not be given before assessment of a new symptom.

Question 28

The nurse is caring for a patient admitted with mitral valve regurgitation. Which information obtained by the nurse should be reported to the health care provider immediately?

a. The patient has 4+ peripheral edema.
b. The patient has diffuse bilateral crackles.
c. The patient has a loud systolic murmur across the precordium.
d. The patient has a palpable thrill felt over the left anterior chest.

Answer 28

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.

Question 29

Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?

a. Assess for the presence of a paradoxical pulse.
b. Monitor for changes in the patient’s sedimentation rate.
c. Assess for the presence of jugular venous distention (JVD).
d. Check the electrocardiogram (ECG) for ST segment changes.

Answer 29

ANS: C
Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis.

Question 30

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse’s discharge teaching about self-management has been effective?

a. “I will avoid taking aspirin or other antiinflammatory drugs.”
b. “I can restart my exercise program that includes hiking and biking.”
c. “I will need to limit my intake of salt and fluids even in hot weather.”
d. “I will take antibiotics before my teeth are cleaned at the dental office.”

Answer 30

ANS: D
Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs.

Question 31

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?

a. Fatigue
b. Leukocytosis
c. Irregular pulse
d. Generalized myalgia

Answer 31

ANS: C
Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.

Question 32

After receiving change-of-shift report on four patients, which patient should the nurse assess first?

a. Patient with rheumatic fever who has sharp chest pain with a deep breath.
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg.
c. Patient with infective endocarditis who has a murmur and splinter hemorrhages.
d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases.

Answer 32

ANS: B
Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

Question 33

After receiving information about four patients during change-of-shift report, which patient should the nurse assess first?

a. Patient with acute pericarditis who has a pericardial friction rub.
b. Patient who has just returned to the unit after balloon valvuloplasty.
c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116.
d. Patient with a mitral valve replacement who has an anticoagulant scheduled.

Answer 33

ANS: B
The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention.

Question 34

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit?
a. Select the best lead for monitoring a patient with an admission diagnosis of
Dressler syndrome.
b. Obtain a list of herbal medications used at home while admitting a new patient
with pericarditis.
c. Teach about the need to monitor the weight daily for a patient who has
hypertrophic cardiomyopathy.
d. Watch the heart monitor for changes in rhythm while a patient who had a valve
replacement ambulates.

Answer 34

ANS: D
Under the supervision of registered nurses (RNs), UAPs check the patient’s cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

Question 35

The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation?

a. 1
b. 2
c. 3
d. 4

Answer 35

ANS: D
Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line.