Nokea
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?
- A. An S3 heart sound
- B. Pleural friction rub
- C. Faint breath sounds
- D. A heart murmur
Correct Answer: A
Rationale: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.
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The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient?
- A. Insertion of an implantable cardioverter defibrillator
- B. Insertion of an implantable pacemaker
- C. Administration of a calcium channel blocker
- D. Administration of a beta-blocker
Correct Answer: A
Rationale: In patients with severe left ventricular dysfunction and the possibility of life-threatening dysrhythmias, placement of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a calcium channel blocker, and a beta-blocker are not medical interventions that may extend the survival of the patient with left ventricular dysfunction.
The nurse is reviewing a newly admitted patients electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated?
- A. Teach the patient deep breathing and coughing exercises
- B. Administer supplemental oxygen at all times
- C. Limit the patients activity level
- D. Avoid positioning the patient supine
Correct Answer: D
Rationale: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF?
- A. HF ultimately affects oxygen transportation to the brain
- B. Patients with HF are susceptible to overstimulation of the sympathetic nervous system
- C. Decreased LOC causes an exacerbation of the signs and symptoms of HF
- D. The most significant adverse effect of medications used for HF treatment is altered LOC
Correct Answer: A
Rationale: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?
- A. A diastolic blood pressure that is lower during exhalation
- B. A diastolic blood pressure that is higher during inhalation
- C. A systolic blood pressure that is higher during exhalation
- D. A systolic blood pressure that is lower during inhalation
Correct Answer: D
Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?
- A. Right-sided heart failure
- B. Acute pulmonary edema
- C. Pneumonia
- D. Cardiogenic shock
Correct Answer: B
Rationale: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described. In right-sided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.