The nurse would assess closely for which sign of right-sided...

The nurse would assess closely for which sign of right-sided heart failure?

A. cough.
B. increasing abdominal girth.
C. shortness of breath.
D. edema of feet and ankles.
E. distended jugular veins.
F. orthopnea.

Correct Answer: B,D,E

Rationale: Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles.

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The nurse would reinforce teaching for a patient with Raynaud disease to include which teaching point?

A. Warming hands and feet with a heating pad
B. Using mittens in cold weather
C. Practicing stress-reducing techniques
D. Complete smoking cessation
E. Using caution when cleaning the refrigerator or freezer

Correct Answer: B,C,D,E

Rationale: Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.

Which patient teaching would help to prevent venous stasis?

A. Dangle legs when sitting.
B. Avoid crossing the legs at the knee.
C. Elevate legs when lying in bed or sitting.
D. Massage extremities to help maintain blood flow.
E. Wear elastic stockings when ambulating.

Correct Answer: B,C,E

Rationale: Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus).

The nurse outlines which as a condition that would disqualify a candidate for a heart transplant?

A. Recent malignancy
B. Dilated cardiomyopathy
C. Peptic ulcer disease
D. Diabetes type 2
E. Severe obesity
F. Inoperable coronary artery disease

Correct Answer: A,C,E

Rationale: Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant.

Which intervention is appropriate for a patient who is experiencing an acute attack of Raynaud's disease?

A. Vigorously rub both the hands in ice or snow.
B. Place the hands in ice water to observe for pallor.
C. Apply hot water over both the hands to rapidly warm the hands.
D. Place mittens on the hands and encourage the patient to move fingers.

Correct Answer: D

Rationale: For an acute attack, the patient should wear layers such as mittens, and move the fingers and hands to improve circulation. Placing the hands in ice, snow or ice water would worsen the arterial constriction. Applying hot water would cause serious burns.

The patient, age 26, is hospitalized with cardiomyopathy. While assisting with data collection from the patient, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor?

A. Cocaine use
B. Viral infection
C. Vitamin B1 deficiency
D. Pregnancy

Correct Answer: A

Rationale: Cardiomyopathy caused by cocaine abuse triggers intense vasoconstriction of the coronary arteries and peripheral vasoconstriction. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues.