Question 1

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

A)Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.
B)Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.
C)Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.
D)Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.

Question 2

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

A)Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.
B)Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.
C)Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.
D)Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.

Question 3

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 4

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)The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Abdominal girth is not an objective measurement of fluid volume; daily weight is more precise.
B)The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Abdominal girth is not an objective measurement of fluid volume; daily weight is more precise.
C)The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Daily weights are an objective measurement of fluid volume; abdominal girth is not.
D)The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Abdominal girth is not an objective measurement of fluid volume; daily weight is more precise.

Question 5

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 6

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 7

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)During pregnancy, red blood cell (RBC)production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.
B)During pregnancy, red blood cell (RBC)production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.
C)During pregnancy, red blood cell (RBC)production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.
D)During pregnancy, red blood cell (RBC)production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.

Question 8

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

A)Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart's pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.
B)Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart's pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.
C)Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart's pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.
D)Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart's pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.

Question 9

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 10

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

A)The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.
B)The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.
C)The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.
D)The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.

Question 11

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

A)Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.
B)Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.
C)Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.
D)Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.

Question 12

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

A)Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
B)Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
C)Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.
D)Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

Question 13

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 14

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 15

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

A)When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.
B)When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.
C)When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.
D)When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.

Question 16

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 17

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)Two other heart sounds may be present in some healthy individuals. The third heart sound (S₃)may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S₂ and is termed a ventricular gallop. When the atrioventricular (AV)valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S₃ sound during diastole. There is no need for an echocardiogram. While the S₃ sound can be associated with heart failure, this is not the case during pregnancy. S₄, also known as an atrial gallop, can also be present in healthy individuals. B)Two other heart sounds may be present in some healthy individuals. The third heart sound (S₃)may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S₂ and is termed a ventricular gallop. When the atrioventricular (AV)valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S₃ sound during diastole. There is no need for an echocardiogram. While the S₃ sound can be associated with heart failure, this is not the case during pregnancy. S₄, also known as an atrial gallop, can also be present in health individuals. C)Two other heart sounds may be present in some healthy individuals. The third heart sound (S₃)may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S₂ and is termed a ventricular gallop. When the atrioventricular (AV)valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S₃ sound during diastole. There is no need for an echocardiogram. While the S₃ sound can be associated with heart failure, this is not the case during pregnancy. S₄, also known as an atrial gallop, can also be present in health individuals. D)Two other heart sounds may be present in some healthy individuals. The third heart sound (S₃)may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S₂ and is termed a ventricular gallop. When the atrioventricular (AV)valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S₃ sound during diastole. There is no need for an echocardiogram. While the S₃ sound can be associated with heart failure, this is not the case during pregnancy. S₄, also known as an atrial gallop, can also be present in health individuals.

Question 18

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

A)The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.
B)The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.
C)The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.
D)The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.

Question 19

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

A)The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
B)The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
C)The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
D)The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.
E)The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

Question 20

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

A)The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.
B)The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.
C)The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.
D)The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.

Quiz 16: Perfusion

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 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.

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

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 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?

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?

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 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.

Which nursing intervention related to perfusion can be performed independently?

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?

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'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?

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

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 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 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?

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

Blood pressure is influenced by all except which factor?