NCLEX: Inflammatory & Structural Heart Disorders(Chapter 37 is for tests 1 & 2)

Assessment of an IV cocaine user with infective endocarditis should focus on which signs and symptoms (select all that apply) a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes d. Painless nodules over bony prominences e. painless erythematous macules on the palms and soles a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes e. painless erythematous macules on the palms and soles Rationale: Clinical manifestations of infective endocarditis may include hemorrhagic retinal lesions (Roth's spots), splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) on the palms and soles. The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition? a. fatigue b. peripheral edema c. jugular venous distention d. thickened pericardium on echocardiography c. jugular venous distention Rationale: Cardiac tamponade is a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling decreases cardiac output. Neck veins usually are markedly distended because of jugular venous pressure elevation. 00:29 00:53 A patient is admitted with myocarditis. While performing the initial assessment, which clinical signs and symptoms might the nurse find (select all that apply)? a. angina b. pleuritic chest pain c. splinter hemorrhages d. pericardial friction rub e. presence of Osler's nodes a. angina b. pleuritic chest pain d. pericardial friction rub Rationale: Clinical manifestations of myocarditis may include early systemic manifestations (i.e., fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and nausea and vomiting), early cardiac manifestations (i.e., pleuritic chest pain with a pericardial friction rub and effusion), and late cardiac signs (i.e., S3 heart sound, crackles, jugular venous distention [JVD], syncope, peripheral edema, and angina). Priority nursing management for a patient with myocarditis includes interventions related to a. meticulous skin care b. antibiotic prophylaxis c. tight glycemic control d. oxygenation and ventilation d. oxygenation and ventilation Rationale: General supportive measures for management of myocarditis include interventions to improve ventilation and oxygenation (i.e., oxygen therapy, bed rest, and restricted activity). When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of a. valvular heart disease b. pulmonary hypertension c. superior vena cava syndrome d. hypertrophy of the right ventricle a. valvular heart disease Rationale: Rheumatic heart disease is a chronic condition resulting from rheumatic fever that is characterized by scarring and deformity of the heart valves. Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? a. administration of antibiotics as ordered b. management of pain with opioid analgesics c. encouragement of fluid intake for hydration d. performance of frequent, active range-of motion exercises a. administration of antibiotics as ordered Rationale: The primary goal of managing a patient with acute rheumatic fever is to control and eradicate the infecting organism. The nurse should administer antibiotics as ordered to treat the streptococcal infection and teach the patient that completion of the full course of antibiotic therapy is essential for successful treatment. Which clinical finding would most likely indicate decreased cardiac output in a patient with aortic valve regurgitation? a. reduction in peripheral edema and weights b. carotid venous distention and new-onset atrial fibrillation c. significant pulses paradoxus and diminished peripheral pulses d. shortness of breath on minimal exertion and a diastolic murmur d. shortness of breath on minimal exertion and a diastolic murmur Rationale: Clinical manifestations of aortic regurgitation (AR) that indicate decreased cardiac output include severe dyspnea, chest pain, and hypotension. Other manifestations of chronic AR include water-hammer pulse (i.e., a strong, quick beat that collapses immediately), soft or absent S1, presence of S3 or S4, and soft, high-pitched diastolic murmur. A low-pitched diastolic murmur may be heard in severe AR. Early manifestations may include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to nursing assistant personnel (NAP) (select all that apply)? a. obtain and record daily weight b. determine apical-radial pulse rate c. observe for overt signs of bleeding d. obtain and record vital signs, including pulse oximetry e. teach the patient how to purchase a Medic Alert bracelet a. obtain and record daily weight c. observe for overt signs of bleeding d. obtain and record vital signs, including pulse oximetry Rationale: The nurse may delegate routine procedures such as obtaining weights and vital signs. The nurse may give specific directions to the nursing assistive personnel (NAP) to observe and report obvious signs of bleeding. The nurse cannot delegate teaching, assessment, or activities that require clinical judgment. Obtaining an apical-radial pulse rate is an assessment. Which of the following diagnostic study best differentiates the various types of cardiomyopathy? a. echocardiography b. arterial blood gases c. cardiac catheterization d. endomyocardial biopsy a. echocardiography Rationale: The echocardiogram is the primary diagnostic tool used to differentiate between the different types of cardiomyopathies and other structural cardiac abnormalities. The nurse is caring for a patient newly admitted with heart failure secondary to dilated cardiomyopathy. Which of the following interventions would be a priority? a. encourage caregivers to learn CPR b. consider a consultation with hospice for palliative care c. monitor the patient's response to prescribed medications d. arrange for the patient to enter a cardiac rehabilitation program c. monitor the patient's response to prescribed medications Rationale: Observing for signs and symptoms of worsening heart failure, dysrhythmias, and embolic formation in patients with dilated cardiomyopathy is essential, as is monitoring drug responsiveness. The goal of therapy is to keep the patient at an optimal level of functioning and out of the hospital. The priority intervention is to manage the acute symptoms with medications. The caregivers should learn cardiopulmonary resuscitation (CPR) before hospital discharge, and the patient may be referred to cardiac rehabilitation. Patients with dilated cardiomyopathy with progression to class IV stage D heart failure are candidates for palliative care. Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes? a. Endocarditis b. Acute renal failure c. Myocardial infarction d. Chronic thrombophlebitis a. Endocarditis Rationale: Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency. While admitting a patient with pericarditis, the nurse will assess for which of the following signs, symptoms, and complications of this disorder? a. Pulsus paradoxus b. Prolonged PR intervals c. Widened pulse pressure d. Clubbing of the fingers a. Pulsus paradoxus Rationale: Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus 10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis.