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The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.
- A. Facilitate the presence of friends and family whenever possible
- B. Teach the patient about the harmful effects of anxiety on cardiac function
- C. Provide supplemental oxygen, as needed
- D. Provide validation of the patients expressions of anxiety
- E. Administer benzodiazepines two to three times daily
Correct Answer: A,C,D
Rationale: The nurse should empathically validate the patients sensations of anxiety. The presence of friends and family are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
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The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock?
- A. The patient admitted with acute renal failure
- B. The patient admitted following an MI
- C. The patient admitted with malignant hypertension
- D. The patient admitted following a stroke
Correct Answer: B
Rationale: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply.
- A. Platelet level
- B. Fluid status
- C. Cardiac rhythm
- D. Action of medications
- E. Sputum volume
Correct Answer: B,C,D
Rationale: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
- A. Monitor liver function studies
- B. Monitor for hypotension
- C. Assess the patients vitamin D intake
- D. Assess the patient for hyperkalemia
Correct Answer: B
Rationale: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake is not relevant.
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?
- A. Blood pressure
- B. Level of consciousness (LOC)
- C. Assessment for nausea
- D. Oxygen saturation
Correct Answer: A
Rationale: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patients subsequent care, what nursing diagnosis should be identified?
- A. Risk for ineffective tissue perfusion related to dysrhythmia
- B. Risk for fluid volume excess related to medication regimen
- C. Risk for ineffective breathing pattern related to hypoxia
- D. Risk for falls related to hypotension
Correct Answer: D
Rationale: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patients medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.