A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure?
Orthopnea Cough Crackles
RATIONALES: Left-sided heart failure produces p
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A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure?
Orthopnea Cough Crackles
RATIONALES: Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly.
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
RATIONALES: In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, in turn causing sodium and water retention and arterial vasoconstriction.
When assessing a client with left-sided heart failure, the nurse expects to note:
air hunger.
RATIONALES: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
fine crackles.
RATIONALES: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
Crackles: Short, explosive or popping sounds usually heard during inspiration. They may be coarse (loud and low in pitch) or fine (less intense and high in pitch) and resemble the sounds heard when rolling hair between the fingers near the ear.
After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?
Left-sided heart failure
The left ventricle is responsible for the most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn’t function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.
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In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
Right-sided heart failure
The most accurate area on the body to assessed dependent edema in a bedridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure. Diabetes mellitus, pulmonary emboli, and renal disease aren’t directly linked to sacral edema.
Which of the following symptoms might a client with right-sided heart failure exhibit?
Oliguria
Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria (??). Adequate urine output, polyuria, and polydipsia aren’t associated with right-sided heart failure.
Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility?
Inotropic agents
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?
Right-sided heart failure
Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn’t cause weight gain, nausea, or a decrease in urine output.
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function?
1.Listening to lung sounds 2.Monitoring for organomegaly 3.Assessing for jugular vein distention
4.Assessing for peripheral and sacral edema
The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.
A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about
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the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed?
1. "I'm not supposed to eat cold cuts."
2. "I can have most fresh fruits and vegetables."
3. "I'm going to weigh myself daily to be sure I don't gain too much fluid."
4. "I'm going to have a ham and cheese sandwich and potato chips for lunch."
When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms?1.Left atrium 2.Right atrium 3.Left ventricle 4.Right ventricle
Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more chronic.
A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply.
1.Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease
5.Recent upper respiratory infection
Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise?
1.Oxygen saturation decreased from 96% to 91%. 2.Pulse rate increased from 80 to 104 beats per minute.
3. Blood pressure decreased from 140/86 to 112/72 mm Hg.
4. Respiratory rate increased from 16 to 19 breaths per minute.
Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory
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rate remains within the normal range. Additionally, it reflects a minimal increase. A pulse rate increase to a rate over 100 beats per minute during mild exercise does not show tolerance, nor does a 5% decrease in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is not a sign indicating tolerance of activity.
A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a.ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of sodium in the patient's diet.
b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods.
c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring.
d. educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.
Rationale: The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening; it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate interventions but are not the first nursing actions indicated. There is no evidence that the patient's weight gain is caused by excessive dietary intake of fat or calories, so the answer beginning "instruct the patient in a low-calorie, low-fat diet" describes an inappropriate action.
During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is
a.activity intolerance related to venous congestion. b.disturbed body image related to massive leg swelling. c.impaired skin integrity related to peripheral edema.
d.impaired gas exchange related to chronic heart failure.
Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate.
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
a.eggs and other high-cholesterol foods. b.canned and frozen fruits.
c.fresh or frozen vegetables.
d.milk, yogurt, and other milk products.
Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such
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as processed cheeses, have very high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.
When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as
a.administering sedatives to promote rest and decrease myocardial oxygen demand. b.positioning the patient in a high-Fowler's position with the feet horizontal in the bed. c.administering oxygen per mask or nasal cannula.
d.encouraging leg exercises to improve venous return.
Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload.
During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is
a.activity intolerance related to venous congestion. b.disturbed body image related to massive leg swelling. c.impaired skin integrity related to peripheral edema.
d.impaired gas exchange related to chronic heart failure.
Rationale: The patient's findings of severe dependent edema and weeping serous fluid from the legs support the nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance, disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate.
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?
Heart failure
These are the classic signs of failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure but isn’t related to these symptoms.
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?
Right-sided heart failure
Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn’t cause weight gain, nausea, or a decrease in urine output.
In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client?
Right-sided heart failure
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The most accurate area on the body to assess dependent edema in a bed-ridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure.
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
Decreased cardiac output related to structural and functional changes.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
Which of the following symptoms might a client with right-sided heart failure exhibit?
Oliguria
Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.
With which of the following disorders is jugular vein distention most prominent?
Heart failure
Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. JVD isn’t a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure, however, in and of itself, an MI doesn’t cause JVD.
Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects
to hear when listening to client’s lungs indicative of chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
Nurse Chona teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
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This study source was downloaded by 100000815948112 from CourseHero.com on 05-15-2021 09:44:52 GMT -05:00
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance
When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?
Apples
Tomato juice Whole wheat bread Beef tenderloin
Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet. BRING ON THE STEAK!
Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?
Risk for infection related to stasis of alveolar secretions Impaired skin integrity related to pressure
Activity intolerance related to pump failure
Constipation related to immobility
Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related to immobility.
Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
Activity intolerance related to increased cardiac output.
Decreased cardiac output related to structural and functional changes.
Impaired gas exchange related to decreased sympathetic nervous system activity.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
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A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure?
Recent URI Nutritional anemia Peptic ulcer disease A-Fib
Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
A patient admitted with HF appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patient’s anxiety (select all that apply)?
A) Position patient in a semi-Fowler’s position.
B) Administrate ordered morphine sulfate.
C) Position patient on left side with head of bed flat.
D) Instruct patient on the use of relaxation techniques.
E) Use a calm, reassuring approach while talking to patient.
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety. The patient should be positioned in semi- Fowler’s position to improve ventilation.
A male patient with a long-standing history of HF has recently qualified for hospice care. Which of the following measures should the nurse now prioritize when providing care for this patient?
A) Tapering the patient off his current medications
B) Continuing education for the patient and his family
C) Pursuing experimental therapies or surgical options
D) Choosing interventions to promote comfort and prevent suffering
The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue but providing comfort is paramount. Medications should be continued unless they are not tolerated and experimental therapies and surgeries are not commonly used in the care of hospice patients.
The nurse is providing care for a patient who has decreased cardiac output related to heart failure. The nurse recognizes that cardiac output is
A) Calculated by multiplying the patient's stroke volume by the heart rate.
B) The average amount of blood ejected during one complete cardiac cycle.
C) Determined by measuring the electrical activity of the heart and the patient's heart rate.
D) The patient's average resting heart rate multiplied by the patient's mean arterial blood pressure. Cardiac output is determined by multiplying the patient's stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.
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Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?
Restrictive
These are the classic symptoms of heart failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances and a flushed face. Myocardial infarction causes heart failure but isn’t related to these symptoms.
A 63-year-old accountant was admitted to the cardiac ICU with full-blown pulmonary edema. After he was revived, the nurse discusses his symptoms with the client and his wife. What is a typical, subtle symptom that communicates right-sided heart failure?
Gradual, unexplained weight gain.
A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?
Bibasilar crackles
A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip" The best reply by the nurse is which of the following?
"The only difference is the rate, which will be below 60 bpm in sinus bradycardia."
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