Question 1

A 66-year-old obese man with diagnoses of ischemic heart disease has been diagnosed with heart failure that his care team has characterized as attributable to systolic dysfunction. Which of the following assessment findings is inconsistent with his diagnosis?
A) His resting blood pressure is normally in the range of 150/90, and an echocardiogram indicates his ejection fraction is 30%.
B) His end-diastolic volume is higher than normal, and his resting heart rate is regular and 82 beats/minute.
C) He is presently volume overloaded following several days of intravenous fluid replacement.
D) Ventricular dilation and wall tension are significantly lower than normal.

Accepted Answer

Systolic dysfunction is associated with increased ventricular dilation and wall tension. Hypertension, low ejection fraction, high preload, and volume overload are all commonly associated with systolic dysfunction.

Question 2

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client
A) has a distended bladder, facial edema, and nighttime difficulty breathing.
B) complains of dyspnea and has adventitious breath sounds on auscultation (listening).
C) has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain.
D) has cyanotic lips and extremities, low urine output, and low blood pressure.

Accepted Answer

Right-sided failure is associated with peripheral edema, fatigue, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-sided failure when the liver becomes engorge. Facial edema, pulmonary edema, peripheral cyanosis, low urine output, and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs and symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.

Question 3

An 81-year-old male resident of a long-term care facility has a long-standing diagnosis of heart failure. Which of the following short-term and longer-term compensatory mechanisms are least likely to decrease the symptoms of his heart failure?
A) An increase in preload via the Frank-Starling mechanism
B) Sympathetic stimulation and increased serum levels of epinephrine and norepinephrine
C) Activation of the renin-angiotensin-aldosterone system and secretion of brain natriuretic peptide (BNP)
D) AV node pacemaking activity and vagal nerve suppression

Accepted Answer

Reassignment of cardiac pacemaking activities and suppression of the vagal nerve are not noted compensatory actions related to heart failure. Increased preload and sympathetic stimulation, increased levels of epinephrine and norepinephrine, and activation of the renin-angiotensin-aldosterone system and secretion of brain natriuretic peptide (BNP) are all noted compensatory mechanisms.

Question 4

The nurse working in the ICU knows that chronic elevation of left ventricula end-diastolic pressure will result in the patient displaying which of the following clinical manifestations?
A) Chest pain and intermittent ventricular tachycardia
B) Dyspnea and crackles in bilateral lung bases
C) Petechia and spontaneous bleeding
D) Muscle cramping and cyanosis in the feet

Accepted Answer

Although it may preserve the resting cardiac output, the resulting chronic elevation of left ventricular end-diastolic pressure is transmitted to the atria and the pulmonary circulation, causing pulmonary congestion.

Question 5

A 77-year-old patient with a history of coronary artery disease and heart failure has arrived in the emergency room with a rapid heart rate and feeling of "impending doom." Based on pathophysiologic principles, the nurse knows the rapid heart rate could
A) decrease renal perfusion and result in the development of ascites.
B) be a result of catecholamines released from SNS that could increase the myocardial oxygen demand.
C) desensitize the $\beta$-adrenergic receptors leading to increase in norepinephrine levels.
D) prolong the electrical firing from the SA node resulting in the development of a heart block.

Accepted Answer

An increase in sympathetic activity by stimulation of the $\beta$-adrenergic receptors of the heart leads to tachycardia, vasoconstriction, and arrhythmias. Acutely, tachycardia ^{significantly increases the workload of the heart, thus increasing myocardial O}2 ^demandand leading to cardiac ischemia, myocyte damage, and decreased contractility.Decreased renal perfusion would activate the RAA system, increasing heart rate and BP further. Ventricular arrhythmias are primarily seen at this stage of HF.

Question 6

A nurse educator in a geriatric medicine unit of a hospital is teaching a group of new graduates specific assessment criteria related to heart failure. Which of the following assessment criteria should the nurses prioritize in their practice?
A) Measurement of urine output and mental status assessment
B) Pupil response and counting the patient's apical heart rate
C) Palpation of pedal (foot) pulses and pain assessment
D) Activity tolerance and integumentary inspection

Accepted Answer

Both increased and decreased urine output can be markers of heart failure, as can changes in mental status not attributable to other factors. While heart auscultation, pedal pulses, and activity tolerance are relevant parameters, integumentary inspection, pupil response, and pain assessment are less likely to be relevant assessment components.

Question 7

Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is to
A) have medical supply department bring up suction equipment.
B) apply oxygen via nasal cannula at 3 lpm.
C) page the respiratory therapist to come give him a breathing treatment.
D) call for emergency assistance utilizing hospital protocol.

Accepted Answer

Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The patient needs the emergency responder team (including ICU nurses, physicians, respiratory therapist, etc.) ^{to intervene. Applying O}2 ^{by mask will not increase his oxygen level fast enough, and}he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course respiratory therapist will arrive with the emergency assistance team.

Question 8

A female older adult client has presented with a new onset of shortness of breath, and her physician has ordered measurement of her brain natriuretic peptide (BNP) levels along with other diagnostic tests. What is the most accurate rationale for the physician's choice of blood work?
A) BNP is released as a compensatory mechanism during heart failure, and measuring it can help differentiate the client's dyspnea from a respiratory pathology.
B) BNP is an indirect indicator of the effectiveness of the renin-angiotensin- aldosterone (RAA) system in compensating for heart failure.
C) BNP levels correlate with the client's risk of developing cognitive deficits secondary to heart failure and consequent brain hypoxia.
D) BNP becomes elevated in cases of cardiac asthma, Cheyne-Stokes respirations, and acute pulmonary edema, and measurement can gauge the severity of pulmonary effects.

Accepted Answer

BNP is released to compensate for heart failure, and elevated levels help confirm the diagnosis of heart failure as opposed to respiratory etiologies. It does not measure the effectiveness of the RAA system, the risk of cognitive deficits, or the specific severity of pulmonary symptoms of heart failure.

Question 9

A nurse is administering morning medications to a number of patients on a medical unit. Which of the following medication regimens is most suggestive that the patient has a diagnosis of heart failure?
A) Antihypertensive, diuretic, antiplatelet aggregator
B) Diuretic, ACE inhibitor, beta-blocker
C) Anticoagulant, antihypertensive, calcium supplement
D) Beta-blocker, potassium supplement, anticoagulant

Accepted Answer

Diuretics, ACE inhibitors, and beta-blockers are all commonly used in the treatment of heart failure. Antiplatelet aggregators, calcium and potassium supplements, and anticoagulants are less likely to relate directly to a diagnosis of heart failure.

Question 10

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which of the following phenomena is most likely taking place?
A) The man's $\alpha$- and $\beta$-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate.
B) Hemolysis and blood pooling are taking place in the man's peripheral circulation.
C) Bronchoconstriction and hyperventilation are initiated as a compensatory mechanism.
D) Intracellular potassium and extracellular sodium levels are rising as a result of sodium-potassium pump failure.

Accepted Answer

$\alpha$- and $\beta$-adrenergic receptor activation is a central response to all types of shock. Hemolysis is not a noted accompaniment to shock. Bronchodilation, not bronchoconstriction, often results from adrenergic stimulation, and sodium-potassium pump failure results in increased extracellular potassium and intracellular sodium.

Question 11

Following coronary bypass graft (CABG) surgery for a massive myocardial infarction (MI) located on his left ventricle, the ICU nurses are assessing for clinical manifestations of cardiogenic shock. Which of the following assessment findings would confirm that the client may be in the early stages of cardiogenic shock? Select all that apply.
A) Decreasing mean arterial pressure (MAP)
B) Low BP reading of 86/60
C) Urine output of 15 mL last hour
D) Low pulmonary capillary wedge pressure (PCWP)
E) Periods of confusion

Accepted Answer

Signs and symptoms of cardiogenic shock include indications of hypoperfusion with hypotension (BP 96/60), decrease in mean arterial pressure (MAP) due to poor stroke volume, and a narrow pulse pressure. Urine output decreases because of lower renal perfusion pressures. PCWP is usually elevated due to increased preload. Periods of confusion or altered cognition/consciousness may occur because of low cardiac output.

Question 12

A 22-year-old male is experiencing hypovolemic shock following a fight in which his carotid artery was cut with a broken bottle. What immediate treatments are likely to most benefit the man?
A) Resolution of compensatory pulmonary edema and heart arrhythmias
B) Infusion of vasodilators to foster prefusion and inotropes to improve heart contractility
C) Infusion of normal saline or Ringer lactate to maintain the vascular space
D) Administration of oxygen and epinephrine to promote perfusion

Accepted Answer

Maintenance of vascular volume is the primary goal in the treatment of hypovolemic shock and can be achieved in the short term through intravenous administration of saline or Ringer lactate. Resolution of pulmonary edema and heart arrhythmias and infusion of vasodilators are associated with treatment of cardiogenic shock, while oxygen and epinephrine would address anaphylactic shock.

Question 13

A 30-year-old woman presents at a hospital after fainting at a memorial service, and she is diagnosed as being in neurogenic shock. Which of the following signs and symptoms is she most likely to display?
A) Faster than normal heart rate
B) Pain
C) Dry and warm skin
D) Increased thirst

Accepted Answer

In contrast to hypovolemic shock, in which the heart rate is faster than normal and the skin is cold and clammy, a person in neurogenic shock is likely to have a slower than normal heart rate and dry, warm skin. Fainting due to emotional causes is a transient form of neurogenic shock, while increased thirst is an early sign of hypovolemic shock.

Question 14

Knowing the high incidence and prevalence of heart failure among the elderly, the manager of a long-term care home has organized a workshop on the identification of early signs and symptoms of heart failure. Which of the following teaching points is most accurate?
A) "Displays of aggression, confusion, and restlessness when the resident has no history of such behavior can be a sign of heart failure."
B) "Heart failure will often first show up with persistent coughing and lung crackles."
C) "Residents in early heart failure will often be flushed and have warm skin and a fever."
D) "Complaints of chest pain are actually more often related to heart failure than to myocardial infarction."

Accepted Answer

Cognitive changes can often accompany heart failure in the elderly. Pulmonary edema is a later sign, and they are less likely to display coughing, chest pain of flushed skin, and fever.

Question 15

A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushed skin accompanying his sudden decline in level of consciousness. The patient also has arterial and venous dilatation and a decrease in systemic vascular resistance. What is this client's most likely diagnosis?
A) Hypovolemic shock
B) Septic shock
C) Neurogenic shock
D) Obstructive shock

Accepted Answer

Low blood pressure accompanied by warm, flushed skin and cognitive changes is indicative of septic shock, as is vessel dilatation and decreased vascular resistance.

Question 16

A client has many residual health problems related to compromised circulation following recovery from septic shock. The nurse knows that which of the following complications listed below are a result of being diagnosed with septic shock and therefore should be assessed frequently? Select all that apply.
A) Profound dyspnea due to acute respiratory distress syndrome
B) Atelectasis resulting in injury to endothelial lining of pulmonary vessels, which allows fluid/plasma to build up in alveolar spaces
C) Formation of plaque within vessels supplying blood to the heart causing muscle damage and chest pain
D) Acute renal failure due to decreased/impaired renal perfusion as a result of low BP
E) Flushed skin and pounding headache that coincides with each heart beat

Accepted Answer

ARDS, atelectasis, and acute renal failure are all noted consequences of shock that might be, respectively, treated by dialysis, an ostomy, or platelet transfusion. Plaque formation to heart vessels is not directly related to any of the identified consequences of shock. Pounding headache that coincides with each heart beat may occur with migraine headaches.

Question 17

A 3-year-old child with right-sided heart failure has been admitted for worsening of his condition. Which of the following assessments would be considered one of the earliest signs of systemic venous congestion in this toddler?
A) Breathlessness with activity
B) Excessive crying
C) Enlargement of the liver
D) Increased urine output

Accepted Answer

With RV function impaired, systemic venous congestion develops. Hepatomegaly due to liver congestion often is one of the first signs on systemic venous congestion in infants and children.

Question 18

A pediatrician is teaching a group of medical students about some of the particularities of heart failure in children as compared with older adults. Which of the physician's following statements best captures an aspect of these differences?
A) "You'll find that in pediatric patients, pulmonary edema is more often interstitial rather than alveolar, so you often won't hear crackles."
B) "Because of their higher relative blood volume, jugular venous distention is a better assessment technique for suspected heart failure in young patients."
C) "Signs and symptoms in children may sometimes mimic those of shock, with a low blood pressure and high heart rate."
D) "Fever is a sign of heart failure in children that you are unlikely to see in older adults."

Accepted Answer

The pulmonary edema that accompanies heart failure is more often interstitial rather than alveolar in children. Jugular venous distention is difficult to gauge in children, and low blood pressure and fever are not noted signs of heart failure in children.

Question 19

Which of the following changes associated with aging contributes to heart failure development in older adults? Select all that apply.
A) Increased incidence of mitral stenosis
B) Sludge buildup in the kidneys
C) Elevated diastolic BP
D) Increased vascular stiffness
E) Inflammation in the joints due to arthritis

Accepted Answer

Changes with aging contribute to the development of HF in older adults. First is reduced responsiveness to F1F1F1S1?F1F1F10-adrenergic stimulation. Second is increased vascular stiffness that contributes to ventricular hypertrophy. Third, the heart itself becomes less compliant with age. Fourth relates to altered myocardial metabolism at the level of the mitochondria. Older adults usually develop aortic stenosis and mitral regurgitation.Kidney stones do not contribute to HF. Increase in diastolic pressure compromises LV filling leading to increases in pressures predisposing to HF. Arthritis is not associated with heart failure.

Quiz 32: Structure and Function of the Kidney

A 66-year-old obese man with diagnoses of ischemic heart disease has been diagnosed with heart failure that his care team has characterized as attributable to systolic dysfunction. Which of the following assessment findings is inconsistent with his diagnosis?

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client

An 81-year-old male resident of a long-term care facility has a long-standing diagnosis of heart failure. Which of the following short-term and longer-term compensatory mechanisms are least likely to decrease the symptoms of his heart failure?

The nurse working in the ICU knows that chronic elevation of left ventricula end-diastolic pressure will result in the patient displaying which of the following clinical manifestations?

A 77-year-old patient with a history of coronary artery disease and heart failure has arrived in the emergency room with a rapid heart rate and feeling of "impending doom." Based on pathophysiologic principles, the nurse knows the rapid heart rate could

A nurse educator in a geriatric medicine unit of a hospital is teaching a group of new graduates specific assessment criteria related to heart failure. Which of the following assessment criteria should the nurses prioritize in their practice?

A female older adult client has presented with a new onset of shortness of breath, and her physician has ordered measurement of her brain natriuretic peptide (BNP) levels along with other diagnostic tests. What is the most accurate rationale for the physician's choice of blood work?

A nurse is administering morning medications to a number of patients on a medical unit. Which of the following medication regimens is most suggestive that the patient has a diagnosis of heart failure?

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which of the following phenomena is most likely taking place?

A 22-year-old male is experiencing hypovolemic shock following a fight in which his carotid artery was cut with a broken bottle. What immediate treatments are likely to most benefit the man?

A 30-year-old woman presents at a hospital after fainting at a memorial service, and she is diagnosed as being in neurogenic shock. Which of the following signs and symptoms is she most likely to display?

Knowing the high incidence and prevalence of heart failure among the elderly, the manager of a long-term care home has organized a workshop on the identification of early signs and symptoms of heart failure. Which of the following teaching points is most accurate?

A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushed skin accompanying his sudden decline in level of consciousness. The patient also has arterial and venous dilatation and a decrease in systemic vascular resistance. What is this client's most likely diagnosis?

A 3-year-old child with right-sided heart failure has been admitted for worsening of his condition. Which of the following assessments would be considered one of the earliest signs of systemic venous congestion in this toddler?

A pediatrician is teaching a group of medical students about some of the particularities of heart failure in children as compared with older adults. Which of the physician's following statements best captures an aspect of these differences?

Which of the following changes associated with aging contributes to heart failure development in older adults? Select all that apply.