Nokea
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
- A. Pulmonary edema
- B. Congestive failure
- C. Thrombophlebitis
- D. Cardiogenic shock
Correct Answer: A
Rationale: A cough with productive, pink, frothy sputum and crackles in the bases of the lungs are signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive failure, thrombophlebitis, or cardiogenic shock.
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The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?
- A. Prone
- B. Supine
- C. Left lateral
- D. Right lateral
Correct Answer: C
Rationale: Changes in heart sounds may be the earliest indication of mitral valve stenosis. S1 may be extremely loud if the cusps are fused or muffled or absent if the cusps have calcified and are immobile. A murmur, described as sounding like a rumbling underground train, can be heard at the heart's apex, especially when the client assumes a left lateral position. The other positions are not supported by evidence-based practice guidelines as appropriate positions in which to place the client to monitor a murmur.
A client reports a family history of aortic stenosis. Which assessment finding would the nurse identify as a likely contributing factor?
- A. High blood pressure
- B. Missing aortic cusp
- C. Unidirectional blood flow
- D. Chest pain
Correct Answer: B
Rationale: In young adults, aortic stenosis usually is a consequence of a congenital defect in which the valve has two instead of three cusps. High blood pressure and chest pain are symptoms that can be exhibited in aortic stenosis. Unidirectional blood flow is the normal flow of blood through the heart.
The nurse is caring for a client diagnosed with mitral stenosis. Which client symptom change would most likely indicate to the nurse, a progression of this condition?
- A. Decreased systolic pressure
- B. Increased systolic pressure
- C. Widening pulse pressure
- D. Normal diastolic pressure
Correct Answer: A
Rationale: As mitral stenosis progresses, the systolic blood pressure will decrease due to the reduction of the cardiac output. Widening pulse pressure with normal diastolic pressure is associated more with aortic regurgitation.
A client with progressive mitral valve prolapse is experiencing sympathetic nervous system symptoms in addition to prolapse symptoms. Which teaching point should be stressed by the nurse to minimize these effects?
- A. Antibiotic therapy before invasive procedures
- B. Low-dose aspirin daily
- C. Avoid caffeine.
- D. Decrease fluid and sodium intake.
Correct Answer: C
Rationale: The symptoms associated with sympathetic nervous response (anxiety, agitation, nervousness, and palpitations) are often managed with antianxiety medications and advisement to avoid caffeine and over-the-counter medications that contain stimulants. Periodic antibiotic therapy use before an invasive procedure is not associated with sympathetic nervous system symptoms. Low-dose aspirin is used to prevent thrombus formation. Decreasing fluid and sodium intake is indicated for the control of congestive failure.
Before an invasive procedure, a client is prescribed antibiotics. The nurse understands the reason for this preventative action is to avoid which complication?
- A. Cardiogenic shock
- B. Infective endocarditis
- C. Congestive heart failure
- D. Rheumatic heart disease
Correct Answer: B
Rationale: Infective endocarditis can compound valvular damage but can be minimized with the preventative use of antibiotics before invasive procedures and dental work. Rheumatic heart disease is associated with the original cause of valve disease and is not prevented with prophylactic antibiotic use. Although congestive heart failure is a complication associated with valvular disease, prophylactic antibiotic therapy is not prescribed for prevention. One type of valvular disease is mitral valve regurgitation. When this occurs rapidly, the heart is less able to compensate, causing the client to develop signs of cardiogenic shock leading to pulmonary congestion. The use of antibiotics is not meant to avoid this complication.