Preview Extract
Chapter 41
1. Cardiac tamponade is suspected in a client who has undergone a repair of a ventricular
aneurysm. What assessment data would assist the nurse in determining the presence of
cardiac tamponade?
1. The distance in mm's of Hg between the Korotkoff sounds during inspiration, while taking
the blood pressure
2. The rhythm of the pulse in relation to the client's inspiration and expiration
3. Arterial blood gases
4. A cardiac murmur that occurs during systole
Answer: The distance in mm's of Hg between the Korotkoff sounds during inspiration, while
taking the blood pressure
Rationale:
A pulse’s paradox is an important diagnostic clue when evaluating for the presence and
progression of cardiac tamponade. It is defined as a greater than 10-mm drop in systolic
blood pressure (BP) during inspiration. The BP normally decreases during inspiration, but it
is less than 10 mmHg. A paradox of greater than 10 mmHg is present when there is increased
thoracic pressure, which is due to pericardial swelling. There is normally no difference in the
rhythm of the pulse during inspiration and expiration. Arterial blood gases changes and the
presence of cardiac murmurs are not specific to cardiac tamponade.
2. The nurse implements the following measures for a client with rheumatic fever: turn,
cough, deep breath, elevate head of bed, instruct on use of incentive spirometry. Upon which
parameters would the nurse assess the effectiveness of the nursing interventions?
Select all that apply.
1. Arterial blood gases
2. Lung sounds
3. Orientation
4. Urine output
5. Potassium level
Answer: 1. Arterial blood gases
2. Lung sounds
3. Orientation
Rationale:
Arterial blood gases. The outcome of the nursing measures is adequate gas exchange. Arterial
blood gases are evaluation parameters used when assessing gas exchange. Lung sounds. The
outcome of the nursing measures is adequate gas exchange. Lung sound evaluation
parameters are used when assessing gas exchange. Orientation. The outcome of the nursing
measures is adequate gas exchange. The client’s orientation is an evaluation parameter used
when assessing gas exchange. Urine output. Urine output is not a gas exchange parameter.
Potassium level. Potassium level is not a gas exchange parameter.
3. Pain is associated with inflammatory heart disease. What interventions should be included
in the best management plan to keep the client pain-free?
Select all that apply.
1. Instruct client to inform nurse if pain is not relieved.
2. Provide a supportive environment where client is able to express pain level.
3. Instruct the client that there is a risk of addiction and overdose.
4. Medicate the client only when the pain is severe.
5. Have the family manage the client’s pain.
Answer: 1. Instruct client to inform nurse if pain is not relieved.
2. Provide a supportive environment where client is able to express pain level.
Rationale:
Instruct client to inform nurse if pain is not relieved. Pain relief is the nursing goal; therefore,
it is essential that the client communicates with the nurse about the effectiveness of the pain
control measures. Provide a supportive environment where client is able to express pain level.
The nurse must provide an environment where the client feels comfortable and supported in
order to have effective communication and attain the pain-free goal. Instruct the client that
there is a risk of addiction and overdose. The nurse needs to assure the client that the risk of
addiction is not a consideration with short-term narcotic use. Medicate the client only when
the pain is severe. An effective pain relief measure is to medicate as soon as the pain begins,
as it increases comfort and decreases need for medication. Have the family manage the
client’s pain. It is inappropriate to have the family manage the pain. It is the responsibility of
the health care provider and the nurse.
4. Clients with stenosed heart valves will have problems with __________ flow of blood, and
those with regurgitant incompetent heart valves will have problems with _________ flow of
blood.
1. Forward; backward
2. Forward; forward
3. Backward; forward
4. Backward; backward
Answer: Forward; backward
Rationale:
A stenotic valve has a narrowed orifice that does not allow blood to flow normally into the
next chamber. A regurgitant valve does not close properly; therefore blood backs up into the
previous chamber. Both conditions decrease cardiac output.
5. While caring for a client with severe aortic stenosis, the nurse understands that limited
activity is essential to prevent fatigue. Which of the following instructions is (are)
appropriate?
Select all that apply.
1. Discontinue activity if chest pain or shortness of breath occurs.
2. Explore sedentary activities.
3. Maintain balanced nutrition to ensure adequate caloric intake.
4. Administer humidified oxygen as prescribed.
5. Follow a progressive activity schedule that increases activity level by 10% each week.
Answer: 1. Discontinue activity if chest pain or shortness of breath occurs.
2. Explore sedentary activities.
3. Maintain balanced nutrition to ensure adequate caloric intake.
Rationale:
Discontinue activity if chest pain or shortness of breath occurs. It is important to have an
activity plan that prevents fatigue. Teaching the client when to stop activities is essential in
preventing extra workload on the heart and fatigue. Explore sedentary activities. Exploring
sedentary activities that the client enjoys will help decrease cardiac workload. Maintain
balanced nutrition to ensure adequate caloric intake. Well-balanced nutrition will provide the
needed calories for energy expenditure. Administer humidified oxygen as prescribed. Activity
that would require oxygen is too strenuous. Follow a progressive activity schedule that
increases activity level by 10% each week. A progressive activity plan would not be feasible
with severe aortic stenosis.
6. Following valve replacement surgery, the client is taught that if fever, increased heart rate,
fatigue, malaise, anorexia, weight loss, headache, chills, and/or night sweats occur, the client
needs to notify the health care provider, as this is as a sign of:
1. Infective endocarditis.
2. Myocardial infarction.
3. Valve rejection.
4. Heart failure.
Answer: Infective endocarditis.
Rationale:
The clinical manifestations are a sign of postoperative infective endocarditis, which needs
immediate medical attention. Myocardial infarction is typically manifested with angina, ECG
changes, and an increase in cardiac laboratory tests. Replacement valves are not vascular;
therefore rejection does not occur. Heart failure is manifested with lung congestion and
shortness of breath.
7. As the nurse, you are developing a discharge plan for a client who has had valve
replacement surgery and is on warfarin. You know the client understands the plan when she
states:
1. “I need to report bruising, bleeding, epistaxis, and hemoptysis to my health care provider.”
2. “I need to eat large amounts of yellow and dark green vegetables.”
3. “I should take aspirin and anti-inflammatory drugs (NSAIDs) for pain.”
4. “I should avoid red meat.”
Answer: “I need to report bruising, bleeding, epistaxis, and hemoptysis to my health care
provider.”
Rationale:
Bruising, bleeding, epistaxis, and hemoptysis are all signs of abnormal bleeding, which may
indicate that a change is needed to the warfarin dosage. Yellow and green vegetables should
be avoided due to the vitamin K content, which counteracts the warfarin. Aspirin and
NSAIDs also cause bleeding and would be contraindicated while taking warfarin. Red meat
has no significance for this client.
8. The client with mitral regurgitation is instructed to report to the health care provider when
it is becoming too difficult to perform activities of daily living because this is an indication:
1. That it is time for valve replacement.
2. Of infective endocarditis.
3. Of a myocardial infarction.
4. Of acute respiratory distress.
Answer: That it is time for valve replacement.
Rationale:
The client’s ability to perform activities of daily living is used 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. Since valves wear out over time, it is essential to wait as long as
possible. Ability to perform activities of daily living is not used when assessing for
myocardial infarction, infective endocarditis, or respiratory distress.
9. The nurse is admitting a client with a sudden onset of dyspnea and a blowing high-pitched
murmur. The nurse understands that these are typical clinical manifestations of:
1. Acute mitral valve regurgitation.
2. Acute mitral valve stenosis.
3. Aortic stenosis.
4. Mitral valve prolapse.
Answer: Acute mitral valve regurgitation.
Rationale:
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. Chronic
valve disorders have a gradual onset of symptoms. Mitral valve stenosis has a low-pitched,
rumbling, crescendo-decrescendo diastolic murmur. Aortic stenosis has a harsh crescendodecrescendo systolic murmur. Mitral valve prolapse has a mid-systolic to late-systolic click
heard between S1 and S2.
10. The nurse is admitting a client who is scheduled for a valvular annuloplasty. The client
asks why she needs her valve replaced. What are the most appropriate responses?
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. “Have you asked your surgeon this question?”
3. “You are having your valve replaced because it is diseased.”
4. “Due to valve stenosis, the valve leaflets must be separated.”
5. “Your family has been informed of the procedure.”
Answer: 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. “Have you asked your surgeon this question?”
Rationale:
“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.” An annuloplasty is a repair procedure, not a
valve replacement surgery, that is for valve regurgitation, not stenosis. “Have you asked your
surgeon this question?” The client needs to talk to the surgeon in order to have informed
consent before surgery. “You are having your valve replaced because it is diseased.” Telling
the client that the valve is being replaced is inaccurate. “Due to valve stenosis, the valve
leaflets must be separated.” This client does not have valve stenosis, she has regurgitation.
“Your family has been informed of the procedure.” This is inappropriate because in order for
the client to sign for the surgery, she must understand the procedure in order to have informed
consent.
11. Due to the chronic and progressive nature of cardiac valve disease, a collaborative care
approach is optimal for client management. What member of the team would be essential to a
holistic approach to client care?
Select all that apply.
1. Nurses and health care providers
2. Physical and occupational therapists
3. Psychologists/psychiatrists
4. Dieticians
5. Pharmacists
Answer: 1. Nurses and health care providers
2. Physical and occupational therapists
3. Psychologists/psychiatrists
4. Dieticians
5. Pharmacists
Rationale:
Nurses and health care providers. 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. Physical
and occupational therapists. The occupational therapist helps facilitate realistic occupational
goals, while the physical therapist assists in the maintenance of optimum conditioning given
the activity restrictions. Psychologists/psychiatrists. Psychiatric counseling may be necessary
to assist in lifestyle adjustments necessitated by a chronic disease process. Dieticians. When
cardiac valve disease is complicated by the presence of heart failure symptoms of congestion,
diet and fluid restriction counseling are necessary. The dietician can educate the client/family
about salt restrictions and assist them to have satisfying meals that do not increase the risk of
fluid retention. Pharmacists. Since medication is an essential part of the management of valve
disorders, the role of the pharmacist is crucial in educating the client about how to manage
the medications and their side effects.
12. While teaching a client about her pending valve replacement surgery, the nurse explains
that the main differences between biological valves and mechanical valves are that:
Select all that apply.
1. Biological valves have a decreased incidence of clot formation as opposed to mechanical
valves.
2. Biological valves wear out faster than mechanical valves.
3. Biological valves have an increased incidence of clot formation as opposed to mechanical
valves.
4. Mechanical valves wear out faster than biological valves.
Answer: 1. Biological valves have a decreased incidence of clot formation as opposed to
mechanical valves.
2. Biological valves wear out faster than mechanical valves.
Rationale:
Biological valves have a decreased incidence of clot formation as opposed to mechanical
valves. Mechanical valves have an increased incidence of clot formation as opposed to
biological valves. Biological valves wear out faster than mechanical valves. Mechanical
valves wear out more slowly than biological valves. Biological valves have an increased
incidence of clot formation as opposed to mechanical valves. Biological valves have a
decreased incidence of clot formation as opposed to mechanical valves. Mechanical valves
wear out faster than biological valves. Biological valves wear out faster than mechanical
valves.
13. While taking a nursing history of a client recently diagnosed with restrictive
cardiomyopathy, which information does the nurse recognize as significant to his health
problem?
1. A history of living in Europe
2. A family history of cardiomyopathy
3. Excessive alcohol use
4. History of depression
Answer: A history of living in Europe
Rationale:
The most common cause of restrictive cardiomyopathy is from a parasitic infection that is
seen primarily in Africa, Europe, and India. A family history of cardiomyopathy is most
common with hypertrophic obstructive cardiomyopathy. Excessive alcohol use is associated
with dilated cardiomyopathy. Depression is not related to the cause of cardiomyopathy.
14. When assessing a client with dilated cardiomyopathy, the nurse understands that the most
common clinical manifestation is___________ due to______________.
1. Dyspnea; bronchial compression
2. Cyanosis; decreased oxygenation
3. Peripheral edema; decreased renal perfusion
4. Confusion; decreased cerebral perfusion
Answer: Dyspnea/bronchial compression
Rationale:
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 that is common to dilated cardiomyopathy. Cyanosis, peripheral edema,
and confusion may be present, but they are not the most common clinical manifestation.
15. You are admitting a 22-year-old client who is experiencing palpitations, light-headedness,
and fatigue. She has congested lungs and frothy sputum, consistent with heart failure. Her
health care provider has diagnosed her with cardiomyopathy. Which type of cardiomyopathy
is she most likely experiencing?
1. Arrhythmogenic right ventricular cardiomyopathy
2. Idiopathic hypertrophic subaortic stenosis
3. Dilated cardiomyopathy
4. Restrictive cardiomyopathy
Answer: Arrhythmogenic right ventricular cardiomyopathy
Rationale:
Due to her age and clinical manifestations, this client has arrhythmogenic right
ventricular cardiomyopathy. Idiopathic hypertrophic subaortic stenosis is most frequently
manifested with sudden cardiac death. She is too young for dilated cardiomyopathy and does
not have the risk factors for restrictive cardiomyopathy.
16. You are caring for a client with infective endocarditis who is experiencing fear and
anxiety related to changes in her health status. What nursing measures are appropriate to help
decrease the fear and anxiety?
Select all that apply.
1. Provide factual information concerning diagnosis, treatment, disfigurement, disabilities,
and prognosis.
2. Explain all procedures and allow time for mental preparation.
3. Tell the client not to worry, that everything will be fine.
4. Explain to the client that it is better not to be informed prior to procedures, as this increases
anxiety.
5. Tell the client that it is not your job to inform her about the procedure.
Answer: 1. Provide factual information concerning diagnosis, treatment, disfigurement,
disabilities, and prognosis.
2. Explain all procedures and allow time for mental preparation.
Rationale:
Provide factual information concerning diagnosis, treatment, disfigurement, disabilities, and
prognosis. Truthful explanations increase trust and potentially decrease anxiety, fear, and
anxiety of the unknown. Explain all procedures and allow time for mental preparation. It is
important to give the client time to process the information to be sure it is clearly understood.
Often there are more questions after the initial explanation. Tell the client not to worry, that
everything will be fine. Telling the client not to worry is dismissive ,and fear of the unknown
potentially increases anxiety. Explain to the client that it is better not to be informed prior to
procedures, as this increases anxiety. Truthful explanations increase trust and potentially
decrease anxiety, fear, and anxiety of the unknown. Tell the client that it is not your job to
inform her about the procedure. This is an unprofessional, inappropriate response. It is the
nurse’s job to help decrease the client’s anxiety. Accomplishing this goal may be
multifaceted. The nurse must verify the client’s understanding and then notify the surgeon
that she needs to discuss the procedure so there is informed consent.
17. The primary goals when treating clients with hypertrophic obstructive cardiomyopathy
are:
Select all that apply.
1. Preventing sudden cardiac death.
2. Preventing heart failure.
3. Preventing renal failure.
4. Preventing liver failure.
5. Preventing pulmonary damage.
Answer: 1. Preventing sudden cardiac death.
2. Preventing heart failure.
Rationale:
Preventing sudden cardiac death. Preventing heart failure and sudden cardiac death are the
primary goals of treatment for clients with hypertrophic obstructive cardiomyopathy.
Preventing heart failure. Preventing heart failure and sudden cardiac death are the primary
goals of treatment for clients with hypertrophic obstructive cardiomyopathy. Preventing renal
failure. Renal failure is not directly related to hypertrophic obstructive cardiomyopathy.
Preventing liver failure. Liver failure is not directly related to hypertrophic obstructive
cardiomyopathy. Preventing pulmonary damage. Pulmonary damage is not directly related to
hypertrophic obstructive cardiomyopathy.
18. When developing a teaching plan for a patient with any type of cardiomyopathy, the nurse
understands that compliance is an essential factor for this progressive disease. What factor
must the nurse determine to help ensure compliance?
1. Determine motivation factors for individual patients and create a plan that utilizes these
factors.
2. Comply with follow up health care provider visits.
3. Stop working and go on general assistance.
4. Move to an assisted living facility.
Answer: Determine motivation factors for individual patients and create a plan that utilizes
these factors.
Rationale:
Compliance is dependent on the client’s motivating factors. Once the nurse identifies them,
the plan can be tailored to use them. Complying with health care provider visits is only one
portion of the entire plan. It may not be necessary to stop working or move to assisted living.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
