Question 1

The nurse is providing teaching to a client diagnosed with cardiomyopathy.What statement made by the client indicates the discharge teaching was effective?
A)"I will exercise as much as possible,regardless of feeling weak and short of breath."
B)"My pants getting tight around the waist means I'm eating too much and should cut back on food."
C)"I will eat foods containing sodium only if drinking water with them."
D)"I will see my cardiologist next week to discuss implanting a pacemaker."

Accepted Answer

A)Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.
B)Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.
C)Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.
D)Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.

Question 2

The nurse is preparing to conduct a cardiac assessment for a pediatric client.Which location will the nurse use when auscultating the apical pulse?
A)At the fifth intercostal space
B)At the left nipple
C)At the right nipple
D)At the eighth intercostal space

Accepted Answer

When auscultating the apical pulse for a pediatric client, the nurse should place the stethoscope at the left nipple line, as the apical impulse is typically located at the fourth intercostal space just medial to the midclavicular line. Option A is also a common location for auscultating the apical pulse in adults, but not in children. Option C is incorrect as the apical impulse is not typically located at the right side. Option D is too low and far to the left.

Question 3

A client diagnosed with cardiomyopathy reports having to rest between activities during the day.The client asks the nurse why this is occurring.Which reason should the nurse include in the response to the client?
A)Increased stroke volume
B)Decreased cardiac output
C)An elongated and dilated aorta
D)Increased blood pressure

Accepted Answer

Cardiomyopathy can result in decreased myocardial contractility, which can lead to a decrease in cardiac output. This may cause the client to feel fatigued and require resting between activities. Increased stroke volume, an elongated and dilated aorta, and increased blood pressure are not typically associated with cardiomyopathy-related fatigue.

Question 4

Which statements are correct regarding the various layers of the heart? Select all that apply.
A)The endocardium covers the entire heart and great vessels.
B)The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C)The outermost layer of the heart is the epicardium.
D)The myocardium consists of myofibril cells.
E)The myocardium has four layers.

Accepted Answer

The epicardium is indeed the outermost layer of the heart, while the myocardium consists of myofibril cells. The endocardium, however, is not the muscular layer of the heart but rather the innermost layer that lines the chambers and valves. Additionally, there are not four layers of the myocardium but rather it is a single layer composed of cardiac muscle cells.

Question 5

The nurse is caring for a client with hypertrophic cardiomyopathy.Based on this diagnosis,which class of medications does the nurse anticipate being prescribed?
A)Digoxin
B)Vasodilators
C)Nitrates
D)Beta blockers

Accepted Answer

Hypertrophic cardiomyopathy is a condition where the heart muscle becomes thick, making it harder for the heart to pump blood. Beta blockers can be used to reduce the workload on the heart by slowing down the heart rate and reducing the force of each contraction. This can help to improve symptoms and prevent complications. Digoxin, vasodilators, and nitrates are not typically used in the treatment of hypertrophic cardiomyopathy.

Question 6

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor).What should the nurse teach the client about this medication?
A)Expect a rapid heart rate.
B)Change positions slowly.
C)Reduce protein intake.
D)Increase fluids.

Accepted Answer

Metoprolol is a beta blocker that can cause orthostatic hypotension, so the nurse should teach the client to change positions slowly to avoid falls or feeling dizzy. A is incorrect because metoprolol actually slows down the heart rate. C and D are also incorrect as they are not related to metoprolol therapy.

Question 7

The nurse is caring for a client diagnosed with dilated cardiomyopathy.Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
A)Fatigue
B)Lower extremity edema
C)Syncope
D)Dyspnea
E)Angina

Accepted Answer

A)Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.
B)Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.
C)Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.
D)Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.
E)Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.

Question 8

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation.What should the nurse consider when planning for this client's potential health problem?
A)Encouraging ambulation every 30 minutes
B)Instructing on deep breathing
C)Administering medications appropriate to increase heart rate
D)Positioning to increase blood return

Accepted Answer

A)The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.
B)The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.
C)The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.
D)The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.

Question 9

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath.Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
A)P wave smooth and round
B)Absent U wave
C)PR interval 0.30 seconds
D)ST segment isoelectric

Accepted Answer

A)The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.
B)The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.
C)The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.
D)The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.

Question 10

Blood pressure is influenced by all except which factor?
A)Pumping action of the heart
B)Peripheral vascular resistance
C)Heart rate
D)Blood volume

Accepted Answer

All of the factors listed (pumping action of the heart, peripheral vascular resistance, and blood volume) can influence blood pressure. Heart rate, however, is not one of the primary factors that directly affects blood pressure. While an increased heart rate can contribute to increased blood pressure, this effect is largely mediated through the other factors listed.

Question 11

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy.The client wants to know why her doctor told her she had an extra heart sound at the last visit.Which response by the nurse is appropriate?
A)"You will need to have an echocardiogram to determine the reason for the extra sound."
B)"You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy."
C)"You have what is known as a ventricular gallop,and it can be a normal finding during this trimester of pregnancy."
D)"You have what is known as atrial gallop,and this is cause for concern."

Accepted Answer

A ventricular gallop (also known as S3 sound) can be a normal finding during the third trimester of pregnancy due to increased blood volume and decreased vascular resistance. It is not typically a cause for concern unless other symptoms or complications are present. Atrial gallop (S4 sound) is more concerning and may indicate cardiac disease. Option A is not appropriate as an echocardiogram may not be necessary for a normal finding, and option B is incorrect as a ventricular gallop does not necessarily indicate heart failure.

Question 12

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation.Which finding would be cause for concern? A)Pulse 103 bpm B)Blood pressure 108/70 C)Hematocrit 24% D)WBC count 10,340/mm³

Accepted Answer

A hematocrit level of 24% is concerning as it indicates anemia, which is lower than the normal range for pregnant women (typically 33% or higher).

Question 13

A client states to the nurse,"I know I have high blood pressure,but I don't want to take medication." Based on this data,which health problem is the client at risk for developing?
A)Gastritis
B)Diabetes
C)Cardiomyopathy
D)Metabolic syndrome

Accepted Answer

The client is at risk for developing cardiomyopathy, or a disease of the heart muscle, if they do not manage their high blood pressure with medication. High blood pressure puts a strain on the heart and can eventually lead to damage and dysfunction of the heart muscle.

Question 14

The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy.Which interventions should the nurse emphasize when planning this client's care? Select all that apply.
A)Monitor B-type natriuretic peptide (BNP)level.
B)Provide oxygen as prescribed.
C)Assess respiratory status and lung sounds every 4 hours and as needed.
D)Provide information about activity upon discharge.
E)Monitor intake and output.

Accepted Answer

A)Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed, and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.
B)Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.
C)Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.
D)Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.
E)Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.

Question 15

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system.Which of the following should be included in this teaching session? Select all that apply.
A)Limit exercise to 15 minutes a day
B)Reduce saturated fats in the diet
C)Avoid cigarette smoking
D)Wear elastic hose
E)Limit fluid intake

Accepted Answer

A)Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
B)Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
C)Interventions that would help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
D)Interventions that would help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.
E)Interventions that would help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.

Question 16

A client's stroke volume (SV)is 85mL/beat and the heart rate (HR)is 71 beats per minute (bpm).What is the client's cardiac output (CO)rounded to the nearest liter?

Accepted Answer

The answer of A client's stroke volume (SV)is 85mL/beat and...

Question 17

Which nursing intervention related to perfusion can be performed independently?
A)Administration of drug regimens
B)Insertion of device to measure central venous pressure (CVP)
C)Teaching relaxation techniques
D)Thoracentesis

Accepted Answer

Teaching relaxation techniques can be performed independently by the nurse. The other options require a healthcare provider's order or a specialized skill-set beyond the scope of independent nursing practice.

Question 18

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia.What would the nurse expect to be prescribed for this client?
A)Beta blocker
B)Digoxin
C)Nitrate medications
D)Fluids

Accepted Answer

Beta blockers are commonly prescribed for cardiomyopathy to slow the heart rate and reduce the workload on the heart. Digoxin is a medication commonly used for cardiac dysrhythmias to slow the heart rate and improve cardiac output. Nitrate medications and fluids are not typically prescribed for these conditions.

Question 19

A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours.Which action by the nurse is correct?
A)Assist the client to ambulate.
B)Document a normal urine output.
C)Notify the healthcare provider.
D)Measure abdominal girth.

Accepted Answer

A urine output of 200 mL in 8 hours is very low, indicating possible worsening of the client's condition. The nurse should notify the healthcare provider to assess and adjust the client's diuretic therapy as necessary. Other actions such as ambulating the client, documenting a normal urine output, or measuring abdominal girth are not appropriate in this situation and do not address the underlying issue of decreased urine output.

Question 20

A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities.Which nursing diagnosis does the nurse include in the client's plan of care?
A)Imbalanced Nutrition: Less than Body Requirements
B)Deficient Knowledge
C)Activity Intolerance
D)Self-Care Deficit

Accepted Answer

The client's symptoms of becoming short of breath with ambulation and eating and being fatigued with routine care activities suggest that they are experiencing activity intolerance. This nursing diagnosis addresses the client's decreased ability to perform physical activities as a result of their cardiomyopathy. The other options (imbalanced nutrition, deficient knowledge, and self-care deficit) do not directly address the client's primary symptoms.

Quiz 16: Perfusion

The nurse is providing teaching to a client diagnosed with cardiomyopathy.What statement made by the client indicates the discharge teaching was effective?

The nurse is preparing to conduct a cardiac assessment for a pediatric client.Which location will the nurse use when auscultating the apical pulse?

A client diagnosed with cardiomyopathy reports having to rest between activities during the day.The client asks the nurse why this is occurring.Which reason should the nurse include in the response to the client?

Which statements are correct regarding the various layers of the heart? Select all that apply.

The nurse is caring for a client with hypertrophic cardiomyopathy.Based on this diagnosis,which class of medications does the nurse anticipate being prescribed?

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor) .What should the nurse teach the client about this medication?

The nurse is caring for a client diagnosed with dilated cardiomyopathy.Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation.What should the nurse consider when planning for this client's potential health problem?

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath.Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?

Blood pressure is influenced by all except which factor?

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy.The client wants to know why her doctor told her she had an extra heart sound at the last visit.Which response by the nurse is appropriate?

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation.Which finding would be cause for concern?

A client states to the nurse,"I know I have high blood pressure,but I don't want to take medication." Based on this data,which health problem is the client at risk for developing?

The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy.Which interventions should the nurse emphasize when planning this client's care? Select all that apply.

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system.Which of the following should be included in this teaching session? Select all that apply.

A client's stroke volume (SV)is 85mL/beat and the heart rate (HR)is 71 beats per minute (bpm).What is the client's cardiac output (CO)rounded to the nearest liter?

Which nursing intervention related to perfusion can be performed independently?

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia.What would the nurse expect to be prescribed for this client?

A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours.Which action by the nurse is correct?

A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities.Which nursing diagnosis does the nurse include in the client's plan of care?