Chapter 36 Inflammatory and Structural Heart Disorders PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter36:InflammatoryandStructuralHeartDisorders TestBank MULTIPLECHOICE 1.Thenurseobtainsahealthhistoryfroma65-year-oldpatientwithaprostheticmitralvalvewhohas symptomsofinfectiveendocarditis(IE).Whichquestionbythenurseismostappropriate? 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?

ANS:D 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:Apply(application)REF:782 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 2.Duringtheassessmentofa25-year-oldpatientwithinfectiveendocarditis(IE),thenursewouldexpectto find a.

substernalchestpressure.

b.

anewregurgitantmurmur.

c.

apruriticrashonthechest.

d.

involuntarymusclemovement.

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. DIF:CognitiveLevel:Understand(comprehension)REF:781 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whichassessmentfinding(s)? a.

Fever,chills,anddiaphoresis

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b.

Urineoutputlessthan30mL/hr

c.

Petechiaeontheinsideofthemouthandconjunctiva

d.

Increaseinheartrateof15beats/minutewithwalking

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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/minuteisnormalwithexercise. DIF:CognitiveLevel:Apply(application)REF:782 TOP:NursingProcess:DiagnosisMSC:NCLEX:PhysiologicalIntegrity 4.Whenplanningcareforapatienthospitalizedwithastreptococcalinfectiveendocarditis(IE),which interventionisapriorityforthenursetoinclude? a.

Monitorlabsforstreptococcalantibodies.

b.

Arrangeforplacementofalong-termIVcatheter.

c.

Teachtheimportanceofcompletingalloralantibiotics.

d.

Encouragethepatienttobeginregularaerobicexercise.

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:Apply(application)REF:784 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 5.Apatientisadmittedtothehospitalwithpossibleacutepericarditis.Thenurseshouldplantoteachthe patientaboutthepurposeof a.

echocardiography.

b.

dailybloodcultures.

c.

cardiaccatheterization.

d.

24-hourHoltermonitor.

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ANS:A 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isnotadiagnosticprocedureforpericarditis. DIF:CognitiveLevel:Apply(application)REF:786 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 6.Toassessthepatientwithpericarditisforevidenceofapericardialfrictionrub,thenurseshould a.

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

b.

auscultatebyplacing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.

ANS:B Pericardialfrictionrubsareheardbest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. DIF:CognitiveLevel:Understand(comprehension)REF:785 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 7.Thenursesuspectscardiactamponadeinapatientwhohasacutepericarditis.Toassessforthepresenceof pulsusparadoxus,thenurseshould a.

notewhenKorotkoffsoundsareauscultatedduringbothinspirationandexpiration.

b.

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

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.

ANS:A 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:Understand(comprehension)REF:786 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity

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

remindthepatienttorequestopioidpainmedicationevery4hours.

d.

place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breathswilltend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antiinflammatorydrug(NSAID). DIF:CognitiveLevel:Apply(application)REF:787 OBJ:SpecialQuestions:PrioritizationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 9.Thenurseisadmittingapatientwithpossiblerheumaticfever.Whichquestionontheadmissionhealth historywillbemostpertinenttoask? a.

DoyouuseanyillegalIVdrugs?

b.

Haveyouhadarecentsorethroat?

c.

Haveyouinjuredyourchestinthelastfewweeks?

d.

Doyouhaveafamilyhistoryofcongenitalheartdisease?

ANS:B Rheumaticfeveroccursasaresult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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:Apply(application)REF:789 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity 10.Apatientwithrheumaticfeverhassubcutaneousnodules,erythemamarginatum,andpolyarthritis.Based onthesefindings,whichnursingdiagnosiswouldbemostappropriate? a.

Painrelatedtopermanentjointfixation

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

b.

Activityintolerancerelatedtoarthralgia

c.

Riskforinfectionrelatedtoopenskinlesions

d.

Riskforimpairedskinintegrityrelatedtopruritus

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ANS:B 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:Apply(application)REF:789 TOP:NursingProcess:DiagnosisMSC:NCLEX:PhysiologicalIntegrity 11.Thenurseestablishesthenursingdiagnosisofineffectivehealthmaintenancerelatedtolackofknowledge regardinglong-termmanagementofrheumaticfeverwhena30-year-oldrecoveringfromrheumaticfever withoutcarditissayswhichofthefollowing? a.

Iwillneedprophylacticantibiotictherapyfor5years.

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.Patientswithrheumatic feverwithoutcarditisrequireprophylaxisuntilage20andforaminimumof5years.Theotherpatient statementsarecorrectandwouldnotsupportthenursingdiagnosisofineffectivehealthmaintenance. DIF:CognitiveLevel:Apply(application)REF:790 TOP:NursingProcess:DiagnosisMSC:NCLEX:PhysiologicalIntegrity 12.Whendevelopingacommunityhealthprogramtodecreasetheincidenceofrheumaticfever,whichaction wouldbemostimportantforthecommunityhealthnursetoinclude? 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.

ANS:B

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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. DIF:CognitiveLevel:Apply(application)REF:790 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.

shortnessofbreathonexertion.

d.

rightupperquadranttenderness.

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possible hypoxemia. DIF:CognitiveLevel:Apply(application)REF:791 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.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willbeneededaftermechanicalvalvereplacement.

d.

Ongoingcardiaccarebyahealthcareproviderisnotnecessary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 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. DIF:CognitiveLevel:Apply(application)REF:794 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity

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15.Whilecaringfora23-year-old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.

takeantibioticsbeforeanydentalappointments.

b.

limitphysicalactivitytoavoidstressingtheheart.

c.

takeanaspirinadaytopreventclotsfromformingon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because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:Apply(application)REF:792 TOP:NursingProcess:EvaluationMSC:NCLEX:PhysiologicalIntegrity 16.Whilecaringforapatientwithaorticstenosis,thenurseidentifiesanursingdiagnosisofacutepainrelated todecreasedcoronarybloodflow.Aprioritynursinginterventionforthispatientwouldbeto 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.

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:Apply(application)REF:793 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 17.Duringdischargeteachingwitha68-year-oldpatientwhohadamitralvalvereplacementwitha mechanicalvalve,thenurseinstructsthepatientonthe a.

useofdailyaspirinforanticoagulation.

b.

correctmethodfortakingtheradialpulse.

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c.

needforfrequentlaboratorybloodtesting.

d.

needtoavoidanyphysicalactivityfor1month.

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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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. DIF:CognitiveLevel:Apply(application)REF:796 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 18.Apatientrecoveringfromheartsurgerydevelopspericarditisandcomplainsoflevel6(0to10scale)chest painwithdeepbreathing.Whichordered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

ANS:C Thepainassociatedwithpericarditisiscausedbyinflammation,sononsteroidalantiinflammatorydrugs (NSAIDs)(e.g.,ibuprofen)aremosteffective.Opioidanalgesicsareusuallynotusedforthepainassociated withpericarditis. DIF:CognitiveLevel:Apply(application)REF:786 TOP:NursingProcess:ImplementationMSC:NCLEX:PhysiologicalIntegrity 19.Whencaringforapatientwithinfectiveendocarditisofthetricuspidvalve,thenurseshouldmonitorthe patientforthedevelopmentof a.

flankpain.

b.

splenomegaly.

c.

shortnessofbreath.

d.

mentalstatuschanges.

ANS:C Embolizationfromthetricuspidvalvewouldcausesymptomsofpulmonaryembolus.Flankpain,changesin

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mentalstatus,andsplenomegalywouldbeassociatedwithembolizationfromtheleft-sidedvalves. DIF:CognitiveLevel:Apply(application)REF:782 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity 20.Apatientadmittedwithacutedyspneaisnewlydiagnosedwithdilatedcardiomyopathy.Which informationwillthenurseplantoteachthepatientaboutmanagingthisdisorder? 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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.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. DIF:CognitiveLevel:Apply(application)R...