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Monahan: Phipps' Medical-Surgical Nursing: Health and Illness
Perspectives, 8th Edition
Test Bank
Chapter 30: Heart Failure, Valvular Problems, and Inflammatory Problems of the
Heart
MULTIPLE CHOICE
1.
1.
2.
3.
4.
Which objective finding strongly supports the presence of acute pericarditis?
Dysphagia
Left shoulder pain
Bilateral lung crackles
Pericardial friction rub
ANS: 4
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
2. Prior to discharge, the patient who has undergone treatment for infective endocarditis is
taught to:
1. Avoid crowds
2. Monitor daily weight
3. Take antibiotics as prescribed
4. Use only aspirin for chest discomfort
ANS: 2
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
3. Following endomyocardial biopsy to confirm the presence of myocarditis, the nurse will
monitor for which immediate postprocedural complications?
1. Hematoma, hemorrhage, and infection
2. Edema, dysrhythmias, and pulmonary emboli
3. Bleeding, cardiac tamponade, and pneumothorax
4. Shock, confusion, and adult respiratory distress syndrome
ANS: 3
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Safe Effective Care Environment
4. The body attempts to compensate for heart failure by:
1. Decreasing afterload and decreasing heart rate
2. Increasing heart rate and dilating ventricular chambers
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3. Increasing blood pressure and decreasing cardiac preload
4. Inhibiting epinephrine and maintaining minimal venous return
ANS: 2
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Analysis/Nursing Diagnosis
MSC: Client Needs: Physiological Integrity
5.
1.
2.
3.
4.
Which clinical manifestations are suggestive of left ventricular heart failure?
Dyspnea, orthopnea, and cough
Hemoptysis, ascites, and friction rub
Distended neck veins, fatigue, and lung crackles
Angina, Cheyne-Stokes respiration, and pitting edema
ANS: 1
PTS: 1
TOP: Nursing Process: Assessment
6.
1.
2.
3.
4.
Which organs are most adversely affected when heart failure occurs?
Brain and spleen
Liver and kidneys
Adrenal glands and lungs
Pancreas and gastrointestinal tract
ANS: 2
PTS: 1
TOP: Nursing Process: Evaluation
7.
1.
2.
3.
4.
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
Which findings are consistent with digitalis toxicity?
Cardiac dysrhythmia, confusion, and nausea and vomiting
Bradycardia, blurred vision, and increased blood pressure
Constipation, irritability, and gastric pain
Nausea, vomiting, and headache
ANS: 4
PTS: 1
TOP: Nursing Process: Assessment
8.
1.
2.
3.
4.
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
DIF: Category: Drug-related responses
MSC: Client Needs: Physiological Integrity
Which potentially life-threatening complication can occur from digitalis therapy?
Hypokalemia
Hypocalcemia
Hyponatremia
Hypermagnesemia
ANS: 1
PTS: 1
DIF: Category: Drug-related responses
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TOP: Nursing Process: Assessment
9.
1.
2.
3.
4.
MSC: Client Needs: Physiological Integrity
Which side effects are associated with vasodilator drug therapy?
Nausea, vomiting, or memory loss
Constipation, impotence, or confusion
Fatigue, muscle weakness, or blurred vision
Lightheadedness, palpitations, or feeling faint
ANS: 4
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Drug-related responses
MSC: Client Needs: Physiological Integrity
10. Which nursing diagnosis is appropriate for the person experiencing acute heart failure?
1. Acute chest pain related to inadequate cardiac perfusion
2. Deficient fluid volume related to chronic heart failure
3. Ineffective tissue perfusion related to ineffective pump
4. Increased cardiac output related to fluid volume overload
ANS: 3
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Analysis/Nursing Diagnosis
MSC: Client Needs: Physiological Integrity
11. Which patient outcome can be expected when acute congestive heart failure is successfully
treated?
1. Weight fluctuates by less than 2 kg/day
2. Requests medication for anxiety only at night
3. Heart rate increases by 50 beats/min with mild exercise
4. Able to dress and feed self without experiencing dyspnea
ANS: 4
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
12. Which nursing action is essential for the patient experiencing severe pitting edema
secondary to heart failure?
1. Place in Sims’ position for meals.
2. Administer oxygen at 6 L/min via nasal cannula.
3. Turn patient frequently to prevent skin breakdown.
4. Maintain strict bed rest with lower extremities elevated.
ANS: 3
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Safe Effective Care Environment
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13. When caring for a patient suffering from heart failure who is on a 1000-ml fluid restriction
diet, the nurse will:
1. Provide 400 ml of fluid during the day and evening hours and 200 ml during the
night
2. Weigh the patient daily before breakfast and every 4 hours thereafter using a bed
scale
3. Place a fluid restriction sign on the front of the patient’s medical record
4. Enforce fluid restriction, monitor output, and weigh all served foods
ANS: 1
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Safe Effective Care Environment
14. Patients with heart failure are taught to avoid the Valsalva maneuver because it causes:
1. Reduced afterload, resulting in increased atrial tension
2. Increased afterload, resulting in reduced stroke volume
3. Reduced preload, resulting in increased cardiac output
4. Increased preload, resulting in increased cardiac workload
ANS: 4
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
15. Approximately how much fluid is retained when a patient with heart failure gains 4 pounds
within a 24-hour period?
1. 1 L
2. 2 L
3. 3 L
4. 4 L
ANS: 2
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
16. Which diet promotes nutritional health in a patient with congestive heart failure? A diet that
is:
1. Low in potassium
2. High in calories
3. High in protein
4. Low in sodium
ANS: 4
PTS: 1
TOP: Nursing Process: Planning
DIF: Category: Cardiovascular
MSC: Client Needs: Health Promotion and Maintenance
17. Which clinical manifestations help confirm the presence of pulmonary edema?
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1.
2.
3.
4.
5
Absent breath sounds on the left, severe dyspnea, and tachycardia
Bilateral lung crackles, complaint of headache, and confusion
Severe dyspnea, blood-tinged sputum, and audible wheezing
Pain on inspiration, bronchiolar wheezing, and pulse deficit
ANS: 3
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
18. Which drug is administered during the initial treatment of acute pulmonary edema because it
blunts the sympathetic response?
1. Morphine sulfate
2. Furosemide
3. Dopamine
4. Digoxin
ANS: 1
PTS: 1
DIF: Category: Drug-related responses
TOP: Nursing Process: Implementation MSC: Client Needs: Safe Effective Care Environment
19. Which is the primary reason why patients with cardiomyopathy are at increased risk for
injury? They are:
1. Taking anticoagulants to prevent the formation of emboli
2. Suffer increased side effects from heart medications
3. Are on numerous drugs that sometimes interact
4. Experience orthostatic blood pressure changes
ANS: 4
PTS: 1
TOP: Nursing Process: Planning
DIF: Category: Cardiovascular
MSC: Client Needs: Safe Effective Care Environment
20. Which information in the history best correlates with a suspected medical diagnosis of mitral
stenosis?
1. Acute myocardial infarction
2. Rheumatic fever
3. Chest trauma
4. Malaria
ANS: 2
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
21. Which dysrhythmia is commonly associated with mitral stenosis?
1. Ventricular tachycardia
2. Ventricular fibrillation
3. Atrial tachycardia
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4. Atrial fibrillation
ANS: 4
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
22. Which nursing diagnoses is appropriate for the patient with mitral stenosis?
1. Ineffective breathing pattern
2. Ineffective coping
3. Deficient fluid volume
4. Chronic chest pain
ANS: 1
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Analysis/Nursing Diagnosis
MSC: Client Needs: Physiological Integrity
23. The development of which problem suggests that the condition of the patient with mitral
regurgitation may be deteriorating?
1. Conduction deficit dysrhythmia
2. Right-sided heart failure
3. Left-sided heart failure
4. Renal failure
ANS: 2
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
24. Discharge teaching for the patient with mitral regurgitation includes the need for:
1. Eventual implantation of a ventricular pacemaker
2. Increasing fluid intake to prevent fluid volume deficits
3. Prophylactic use of antibiotics before dental procedures
4. Limiting activities to those that are essential for personal hygiene
ANS: 3
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
25. Mitral valve prolapse has been linked to which risk factor?
1. Hyperthyroidism
2. Diabetes mellitus
3. Alcoholism
4. Smoking
ANS: 1
PTS: 1
DIF: Category: Cardiovascular
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TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
26. Which manifestations are associated with severe aortic stenosis?
1. Jugular vein distention, shortness of breath, and enlarged liver
2. Cyanosis, paroxysmal atrial tachycardia, and hypotension
3. Pitting edema, ascites, and decreased capillary refill
4. Dyspnea, exertional angina, and syncope
ANS: 4
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
27. Assessment of the patient with aortic regurgitation reveals a:
1. Systolic murmur that is loudest over the aortic area
2. Diastolic murmur that is loudest over the aortic area
3. Systolic murmur that is loudest over the pulmonic area
4. Narrowed pulse pressure and increased diastolic pressure
ANS: 2
PTS: 1
TOP: Nursing Process: Assessment
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
28. Patients with tricuspid or pulmonary valve disorders differ from patients with other valvular
defects in that they do not experience:
1. Dyspnea or pulmonary problems
2. Systemic venous congestion
3. Right-sided heart failure
4. Right atrial enlargement
ANS: 1
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
29. Which prosthetic valve carries the highest risk for thrombus formation as a complication?
1. Caged-ball valve
2. Caged-disk valve
3. Tilting-disk valve
4. Zenograft valve
ANS: 3
PTS: 1
TOP: Nursing Process: Planning
DIF: Category: Cardiovascular
MSC: Client Needs: Safe Effective Care Environment
30. Patients undergo long-term therapy with which medication following mechanical valve
replacement?
1. Antihypertensives
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2. Anticoagulants
3. Antibiotics
4. Analgesics
ANS: 2
PTS: 1
TOP: Nursing Process: Planning
DIF: Category: Drug-related responses
MSC: Client Needs: Safe Effective Care Environment
31. Induced hypothermia during cardiac surgery:
1. Protects and preserves myocardial tissues
2. Constricts arteries, thereby minimizing blood loss
3. Enhances flow of blood through the bypass machine
4. Decreases blood flow to the heart during the actual surgery
ANS: 1
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Analysis/Nursing Diagnosis
MSC: Client Needs: Physiological Integrity
32. The nurse must be alert for which complication of cardiopulmonary bypass in the period
immediately following cardiac surgery?
1. Cerebrovascular accident
2. Myocardial infarction
3. Acute renal failure
4. Hypoglycemia
ANS: 3
PTS: 1
TOP: Nursing Process: Planning
DIF: Category: Cardiovascular
MSC: Client Needs: Safe Effective Care Environment
33. Which finding indicates that intraaortic balloon counterpulsation is effective?
1. Skin warm and dry, alert sensorium
2. Urine output 20 ml/hr, blood pressure 100/70 mm Hg
3. Blood pressure 90/60 mm Hg, respirations 26 breaths/min, pulse 120 beats/min
4. Lungs with bilateral crackles limited to bases, oxygen saturation of 85%
ANS: 1
PTS: 1
TOP: Nursing Process: Evaluation
DIF: Category: Cardiovascular
MSC: Client Needs: Physiological Integrity
34. Which is most important to teach the cardiac patient prior to the scheduled surgery?
1. Use of a urinal
2. How to splint the abdomen
3. Ways to decrease pain when turning
4. Coughing and deep-breathing exercises
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ANS: 4
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
35. Four hours after cardiac surgery a patient’s blood pressure steadily trends downward to
90/60 mm Hg. The nurse will:
1. Administer 400 ml of lactated Ringer’s solution over 30 minutes
2. Obtain a rectal temperature to determine if hypothermia exists
3. Notify the physician and prepare to administer serum albumin
4. Prepare to insert an intraarterial catheter for monitoring
ANS: 2
PTS: 1
DIF: Category: Cardiovascular
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
36. Which instruction is included in discharge teaching for patients following cardiac surgery?
1. “It may be up to 6 months before you experience the maximum benefits of your
surgery.”
2. “Your family members need to continue helping you dress and eat for the next
month or so.”
3. “You should try to climb one flight of stairs without stopping at least once daily.”
4. “You may begin sexual activity after you have been home for 3 months.”
ANS: 1
PTS: 1
DIF: Category: Emotional needs related to health problems
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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