Preview Extract
Chapter 42
1. A client with heart failure is given discharge instructions by the nurse. As the client leaves
the hospital, the nurse recognizes that, statistically, this client has a _______ likelihood of
readmission within 6 months.
1. 30% to 50%
2. 50% to 75%
3. 0% to 20%
4. 20% to 30%
Answer: 30% to 50%
Rationale:
The likelihood of readmission for a client with heart failure within 6 months is between 30%
and 50%. The other answer choices are therefore not correct.
2. The nurse knows that the client who is diagnosed with heart failure has a higher mortality
rate. The best way to help decrease the incidence of heart failure is to:
1. Teach clients about modifiable risk factors.
2. Teach clients about the higher incidence of sudden cardiac death.
3. Discuss the higher mortality with the health care provider.
4. Discuss heart failure statistics at a nursing meeting.
Answer: Teach clients about modifiable risk factors.
Rationale:
Modifying a client’s risk factors may help to decrease the client’s susceptibility to heart
failure. Limiting smoking and cardiotoxic substances, decreasing the likelihood of cardiac
disease, and increasing activity may all help to decrease the soaring incidence of heart failure
in the United States. Discussion with the client about higher incidence of sudden cardiac
death will not impact the incidence of heart failure unless it scares a client into taking action.
Discussion with the health care provider and nurses about heart failure may help promote
awareness of the problem, but will not impact the client directly.
3. A 68-year-old male client is seen in the clinic complaining of fatigue and other nonspecific,
vague symptoms that the nurse believes may be related to heart failure. The nurse questions
the client regarding risk factors for heart disease. Which of the following could be modifiable
risk factors for this client regarding heart failure?
1. Hemoglobin A1C 9.0%
2. Male
3. Father-in-law died from heart disease a year ago
4. Blood pressure 119/78
Answer: Hemoglobin A1C 9.0%
Rationale:
Hemoglobin A1C of 9.0% indicates an average blood sugar of 240 mg/dL. Therefore the
client is likely to have undiagnosed diabetes, which is a modifiable risk factor for heart
failure. Being male is a risk factor, but is not modifiable. An in-law’s death from cardiac
disease is unrelated to the client’s risk factors. Hypertension is a modifiable risk factor, but
the blood pressure of 119/78 is not hypertensive.
4. The nurse is performing an admission assessment on a client who presents to the
emergency department (ED) complaining of poor appetite, bloated abdomen, and peripheral
edema. The nurse recognizes these symptoms as:
1. Right-sided failure.
2. Left-sided failure.
3. Diastolic dysfunction.
4. A myocardial infarction.
Answer: Right-sided failure.
Rationale:
Right-sided failure includes symptoms of poor appetite, nausea, vomiting, bloated abdomen,
ascites, and peripheral edema. Left-sided failure symptoms include a cough, shortness of air,
orthopnea, and activity intolerance. Diastolic dysfunction symptoms are often similar to
systolic dysfunction symptoms. A myocardial infarction (MI) may initially cause the insult to
the cardiac system that results in heart failure.
5. An elderly female client has a left ventricular ejection fraction (LVEF) of 60%. She
complains of activity intolerance, shortness of air, and peripheral edema. The nurse knows
that this client’s diagnosis differs from that of another client who has systolic dysfunction
because this client’s:
1. LVEF is within normal limits.
2. LVEF is low.
3. Symptoms are unique to diastolic dysfunction.
4. Symptoms are unique to systolic dysfunction.
Answer: LVEF is within normal limits.
Rationale:
Diastolic dysfunction is diagnosed based upon a client’s LVEF being normal and the client
exhibiting clinical symptoms of heart failure. This client is an elderly female, which is typical
of diastolic dysfunction. In systolic dysfunction, the LVEF is low, with the client exhibiting
clinical symptoms of heart failure. Systolic and diastolic dysfunctions tend to have similar
symptoms.
6. A client has been diagnosed with left-sided heart failure. The nurse collects the following
data: peripheral edema, abdominal bloating, bradycardia, bilateral crackles, weight loss, and a
cough. Which of the data would be indicative of left-sided heart failure?
1. Cough
2. Bradycardia
3. Abdominal bloating
4. Weight loss
Answer: Cough
Rationale:
A cough and bilateral crackles would be indicative of left-sided heart failure. Peripheral
edema and abdominal bloating would be indicators of right-sided heart failure. Tachycardia
would be a symptom of heart failure, not bradycardia. Weight loss could be a symptom of
right-sided heart failure, since these clients report loss of appetite. However, there is usually
enough fluid gain to mask any actual nutritional deficits.
7. A client with heart failure has orthopnea, tachycardia, fatigue, and activity intolerance. The
nurse instructs the client that these symptoms are a result of the client’s:
1. Inherent compensatory mechanisms trying to maintain a good blood pressure and
oxygenation.
2. Inability to cope with the body’s changing health.
3. Inability to follow instructions.
4. Inherent compensatory mechanisms that are malfunctioning.
Answer: Inherent compensatory mechanisms trying to maintain a good blood pressure and
oxygenation.
Rationale:
The client’s compensatory mechanisms attempt initially to compensate for the failing blood
pressure and oxygen levels. At the outset, these mechanisms are able to keep up with the
body’s demands. However, long term, they create bigger problems. The client’s symptoms are
not a result of the client’s inability to cope with the body’s changing health or to follow
instructions, since the client has no power over the compensatory mechanisms. The client’s
inherent compensatory mechanisms are not malfunctioning, but instead continue to attempt to
maintain homeostasis.
8. The nurse notes that one of her clients is more anxious than usual. The client states, “I
don’t understand how I can still be alive when my heart has failed.” The nurse’s most
appropriate response is:
1. “It must be very confusing. Heart failure doesn’t mean your heart has quit, just that it no
longer is as efficient as it once was. You have internal mechanisms that work to try to keep
your blood pressure from falling, but eventually these mechanisms work against the heart’s
ability to pump blood easily.”
2. “It seems like you are upset. Would you like for me to call the health care provider to
explain this to you?”
3. “Heart failure is pretty complicated. It means the heart is failing to work.”
4. “Heart failure is a common problem in the United States. Many people have it. They all
have problems such as yours.”
Answer: “It must be very confusing. Heart failure doesn’t mean your heart has quit, just that
it no longer is as efficient as it once was. You have internal mechanisms that work to try to
keep your blood pressure from falling, but eventually these mechanisms work against the
heart’s ability to pump blood easily.”
Rationale:
An explanation that helps alleviate the client’s concerns may be helpful. Contacting the health
care provider is not necessary, since the nurse should know how to respond to this question.
Answering with “Heart failure is pretty complicated. It means the heart is failing to work”
does not provide the client with enough information. Sharing with the client that heart failure
is a common problem doesn’t help the client understand the heart issue any better.
9. Which of the following nursing diagnoses is most appropriate for the client with acute
systolic heart failure?
1. Excess Fluid Volume
2. Disturbed Body Image
3. Imbalanced Nutrition: more than body requirements
4. Ineffective Airway Clearance
Answer: Excess Fluid Volume
Rationale:
The client with acute systolic heart failure will have excess fluid volume. If there is an
imbalance in nutrition, it is more likely to be less than body requirements. Ineffective airway
clearance is not applicable, since these clients do not have issues with clearing the airway as
much as issues with impaired gas exchange. It is not common for the client to have disturbed
body image related to heart failure.
10. Reflecting upon the client’s other symptoms and past history, the nurse determines the
client likely has right-sided heart failure when the client:
1. Consumes 5% of meals and complains of nausea.
2. Admits to anxiety over learning the new medication regimen.
3. Has trouble concentrating on the conversation.
4. Is dyspneic with activity.
Answer: Consumes 5% of meals and complains of nausea.
Rationale:
Poor appetite and complaints of nausea and vomiting correspond to right-sided heart failure.
Dyspnea with activity is more commonly associated with left-sided heart failure. Anxiety
over new medications and difficulty concentrating on the conversation are not likely related
to heart failure, but could be symptoms of depression.
11. The client has been diagnosed with heart failure. The nurse is asked if the client’s
symptoms are more likely right or left heart failure. Which of the following symptoms would
indicate left-sided heart failure?
1. Respiration of 36 per minute
2. Right upper quadrant pain
3. Dependent edema
4. Anasarca
Answer: Respirations of 36 per minute
Rationale:
The client with left-sided heart failure has pulmonary involvement and therefore will be
tachypneic. Right upper quadrant pain, dependent edema, and anasarca are all symptoms of
right-sided heart failure.
12. A client with left-sided heart failure is admitted to the unit. Which item is a priority
assessment upon arrival?
1. Airway and oxygenation status
2. Neurological status
3. Abdominal assessment
4. Presence of peripheral edema
Answer: Airway and oxygenation status
Rationale:
The client with left-sided failure will exhibit symptoms of a respiratory nature. The priority
assessment for this client would be the airway and oxygenation status. The neurological
status will decline as the lack of oxygenation progresses. An abdominal assessment and
presence of peripheral edema will be included in the assessment, but are more common in
right-sided failure than in left-sided failure.
13. The nurse is assessing a client who has been admitted with heart failure. The nurse
anticipates which of the following lab tests to be ordered to validate the severity of the
diagnosis?
1. BNP
2. CBC
3. Troponin
4. Lipid panel
Answer: BNP
Rationale:
A BNP, renal function, and liver function studies may provide an indication of the severity of
the heart failure. CBC, troponin, and lipid panel may give an indication of the etiology of this
client’s heart failure.
14. A client is admitted with heart failure. The nurse establishes a nursing diagnosis of
decreased cardiac output related to ventricular dysfunction. Which one of the following
parameters might the nurse establish to measure the client’s outcome?
1. PCWP 6−12 mmHg
2. CO 2−3 L/min
3. BP 100/48
4. Daily weight same as the day before
Answer: PCWP 6−12 mmHg
Rationale:
The overall desired outcome is to achieve an adequate cardiac output. The only parameter
that is within normal limits is the PCWP of 6−12 mmHg. The CO and BP are both low, which
would indicate the cardiac output is still low. The daily weight would need to be lower than
the previous day to show continued weight loss.
15. The client may have several diagnostic tests completed to assist with the diagnosis of
heart failure. Which of the following diagnostic studies would rule out heart failure being
present?
1. BNP 50 pg/mL
2. Hemoglobin 10g/dl
3. Sodium 148 mEq/L
4. Normal EKG
Answer: BNP 50pg/mL
Rationale:
A BNP within normal limits will rule out heart failure. An elevated BNP is indicative of heart
failure, but will often only be one indicator of heart failure. Hemoglobin of 10 gm/dl is low,
and heart failure clients will often have anemia. Sodium level is slightly high. The EKG
results are normal. However, the low hemoglobin, a sodium slightly high, and a normal EKG
cannot rule heart failure in or out.
16. A client with heart failure will be undergoing the insertion of a pacemaker. The nurse is
providing instructions preoperatively regarding the client’s length of stay following the
procedure. On which of the following will the nurse instruct the client?
1. Following the procedure and recovery, the client may expect to stay at the hospital up to 24
hours, but often the stay is less.
2. Following the procedure, the client may expect to go home immediately.
3. Following the procedure, the client will be required to stay in the hospital up to 2 days.
4. Following the procedure, the client will be required to stay in the hospital up to a week.
Answer: Following the procedure and recovery, the client may expect to stay at the hospital
up to 24 hours, but often the stay is less.
Rationale:
The client is usually kept in the facility overnight and released pending follow-up tests to
ensure the leads and pacemaker are functioning. Only the client who experiences unforeseen
complications could expect a longer length of stay.
17. A client is sent home on lisinopril (Zestril). The nurse has educated the heart failure client
on the actions of this medication. Which of the following best describes what the nurse
instructed?
1. Lisinopril is an ACE inhibitor medication. This medication will lower the blood pressure
and decrease the fluid in the body. The client may notice a cough.
2. Lisinopril is an ACE inhibitor medication that will lower the client’s heart rate and blood
pressure. The client should observe closely for angioedema.
3. Lisinopril is a beta-blocking drug that will lower the client’s heart rate and blood pressure.
The client should observe closely for symptoms of worsening heart failure.
4. Lisinopril is a beta-blocker drug that will increase the pumping ability of the heart. The
client should observe closely for orthostatic hypotension.
Answer: Lisinopril is an ACE inhibitor medication. This medication will lower the blood
pressure and decrease the fluid in the body. The client may notice a cough.
Rationale:
ACE inhibitor medications act by preventing vasoconstriction, thus allowing vasodilation.
Since ACE inhibitors also interrupt the body’s ability to conserve sodium, the net result is
fluid loss. Lisinopril does not impact the heart rate. Angioedema and a cough are side effects
of ACE inhibitors. Angioedema should be reported to the health care provider immediately.
Lisinopril is not a beta-blocker drug and does not impact the pumping ability of the heart.
Lisinopril will not create worsening heart failure symptoms as beta blocker can. Lisinopril
can create orthostatic hypotension, so the client should be advised to rise slowly.
18. A client preparing for discharge asks the nurse about an appropriate diet. Which of the
following replies is best?
1. “I will be reviewing your discharge plans with you, but I would also like to ask the
dietitian to come visit with you to help finalize your diet.”
2. “I am glad you asked. The health care provider will be discussing the diet with you.”
3. “A special diet is important for you. Let me tell you about it in detail.”
4. “The pharmacist will be talking with the physician. They will let the dietitian know what is
best for you.”
Answer: “I will be reviewing your discharge plans with you, but I would also like to ask the
dietitian to come visit with you to help finalize your diet.”
Rationale:
Each client has special needs for discharge planning. A multidisciplinary team approach is
important for the success of the client in managing the disease process at home. The client
should be referred to a dietitian for any special instructions related to heart failure. While the
physician is important in the health care team, the most appropriate person to discuss the
details of the diet is the dietitian, not the physician.
19. The client has been instructed in the MAWDS system. Which one of the following
instructions is not included in the MAWDS method?
1. Avoid large crowds.
2. Check your pulse before taking digoxin (Lanoxin) each day.
3. You should rest periodically throughout the day.
4. Check your weight daily.
Answer: Avoid large crowds.
Rationale:
MAWDS stands for medication, activity, weight, diet, and symptoms. Avoiding large crowds
is not a typical instruction for a heart failure client and does not fit with the MAWDS
acronym. Checking a pulse before digoxin (medication), resting periodically throughout the
day (activity), and checking daily weights (weights) are all part of the MAWDS method.
20. The nurse recognizes that the heart failure client does not understand discharge
instructions when the client states:
1. “I will have my spouse pick up my new medications in a few days.”
2. “I will eat a low-sodium diet.”
3. “I will contact the health care provider if I begin gaining weight.”
4. “I will increase my activity a little every day.”
Answer: “I will have my spouse pick up my new medications in a few days.”
Rationale:
It is important that the client has the medication each and every day. Waiting for a few days to
pick up the medication will not be effective and could demonstrate a misunderstanding of
discharge instructions. Eating a low-sodium diet, increasing activity slowly, and notification
of a health care provider should there be weight gain all indicate understanding.
21. A client with heart failure does not have a scale to weigh on at home. What other methods
might the client be instructed to use until a scale can be purchased?
1. Instruct the client to see if his or her same belt or shoes are tighter every day.
2. Have the client observe if he or she feels heavier while wearing the same clothing every
day.
3. Suggest the client come to the health department every other week to weigh.
4. Have the client notice if his or her rings are tighter.
Answer: Instruct the client to see if his or her same belt or shoes are tighter every day.
Rationale:
A heart failure client who is gaining fluid will have his or her belt or shoes get tighter.
However, the best method of measuring fluid build-up is with a scale, and the client should
be so instructed. A client will not be able to gauge “feeling” heavier. Weighing at the health
department every other week is not frequent enough. A client should be advised to weigh
daily and at the same time each day. A client’s rings may get tighter, but this can also be
impacted by other activities and temperature.
22. A diabetic client received instructions from the nurse discussing ways to minimize the any
further damage to the heart from heart failure. The client understands the instructions when
the client states the following:
1. “I will keep my hemoglobin A1C less than 6.4.”
2. “I will take a daily walk.”
3. “I will follow a diet.”
4. “I will weight myself every day.”
Answer: “I will keep my hemoglobin A1C less than 6.4.”
Rationale:
Keeping the blood sugar under control is the best way for a diabetic client with heart failure
to minimize any further damage to the heart. The other answer options are all instructions to
decrease exacerbation of heart failure.
23. The client who has hypertension and heart failure might expect to be discharged on which
of the following medications?
1. ACE inhibitors
2. Digoxin (Lanoxin)
3. Antidysrhythmics
4. Anticoagulants
Answer: ACE inhibitors
Rationale:
The client who has both hypertension and heart failure can expect to be taking ACE
inhibitors, which impact both diseases. Digoxin is not a first-line option for a client with both
hypertension and heart failure, but is often used for heart failure alone. Antidysrhythmics and
anticoagulants are not used to treat heart failure or hypertension unless there are other
underlying comorbidities.
24. A client with diabetes and heart failure can expect better outcomes from heart failure in
which of the following situations?
1. Hemoglobin A1C is 5.8%.
2. Fingerstick blood sugar is 155.
3. Hemoglobin is 14 g/dl.
4. Creatinine is 2.2 mg/dl.
Answer: Hemoglobin A1C is 5.8%.
Rationale:
The client who maintains strict glycemic control as evidenced by the hemoglobin A1C being
< 6% will have better heart failure outcomes. A fingerstick blood sugar of 155 is not glycemic
control and is a one-time result, whereas the hemoglobin A1C is an average of the blood
sugar over a 3-month time frame. The hemoglobin plays no role in long-term mortality of
heart failure. A creatinine of 2.2 mg/dl is high and could indicate renal involvement.
25. A client is on hospice with a diagnosis of end-stage heart failure. The family wants to
know what the goals of treatment will be. The hospice nurse relates to them that the primary
goal of treatment is tp:
1. Provide comfort and reduce any distressing respiratory symptoms.
2. Provide significant pain medications.
3. Keep the client out of the hospital.
4. Provide information to the family.
Answer: To provide comfort and reduce any distressing respiratory symptoms.
Rationale:
The goals of care are to provide comfort measures and reduce or eliminate any primary
symptoms that may be distressing, such as respiratory distress. The treatment plan is not to
cure the illness. Pain medications may be provided in the course of this plan. Attempts to
keep the client out of the hospital will be a goal if the client desires to stay at home.
Communication with the family and client is important to the overall plan of care.
26. The nurse has explained the seriousness of a client’s condition to the family. The family
understands that which one of the following problems most increases the mortality for their
loved one with terminal heart failure?
1. Other serious comorbidities
2. Age
3. Positive mental attitude
4. Taking ACE inhibitors
Answer: 1Other serious comorbidities
Rationale:
Many corresponding factors impact the poor prognosis of the heart failure client. Among
them are other serious comorbidities. Age, positive mental attitude, and on the use of ACE
inhibitors do not add to the poor prognosis.
27. A client who has heart failure is asking about end of life. The priority for the nurse’s
discussion with the client is to:
1. Be as honest as possible about the progression of the disease and the support needed.
2. Tell the client that nursing staff might be available if needed, but that family will need to
help provide client support.
3. Have the health care provider discuss end-of-life topics with the client.
4. Reassure the client that the chances for survival are good.
Answer: Be as honest as possible about the progression of the disease and the support needed.
Rationale:
The heart failure client who is nearing the end of life will need honest discussions regarding
the progression of the disease and the support needed and available. Telling the client that
nursing staff might be available, but family will need to provide support is not completely
honest and likely is not helpful. The health care provider will be involved in end-of-life
discussions, but the nurse as a client advocate can certainly discuss the end-of-life options
with the client. Reassuring the client of survival is not honest, especially given that the
survival rate for heart failure clients is not good.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
