Question 1

A client with disseminated intravascular coagulation (DIC)has a nursing diagnosis of Ineffective Tissue Perfusion.Which action is inappropriate for this nursing diagnosis?

Accepted Answer

A) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.
B) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.
C) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.
D) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.

Question 2

A client with disseminated intravascular coagulation (DIC)has a nursing diagnosis of Impaired Gas Exchange.Which action is inappropriate when providing care based on this nursing diagnosis?

Accepted Answer

A) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and encouraging deep breathing and coughing are all interventions the nurse should implement.
B) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and encouraging deep breathing and coughing are all interventions the nurse should implement.
C) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and encouraging deep breathing and coughing are all interventions the nurse should implement.
D) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and encouraging deep breathing and coughing are all interventions the nurse should implement.

Question 3

The nurse is positioning a client with left-sided heart failure in bed.Which sleeping position is most appropriate for this client?

Accepted Answer

A) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.
B) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.
C) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.
D) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.

Question 4

During hospitalization for congestive heart failure (CHF),a client awakens during the night frightened and short of breath.Based on this data,what is the client experiencing?

Accepted Answer

A) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.
B) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.
C) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.
D) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.

Question 5

A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition.Which condition would be excluded from the client's cause of heart failure?

Accepted Answer

A) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired myocardial function.
B) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired myocardial function.
C) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired myocardial function.
D) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired myocardial function.

Question 6

The nurse is planning care for several clients.Which client has the greatest risk of developing heart failure?

Accepted Answer

A) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.
B) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.
C) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.
D) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not considered a significant risk factor in the development of heart failure.

Question 7

The nurse is assessing a client being treated for congestive heart failure (CHF).Which physical findings would indicate that the client's condition is not improving? Select all that apply.

Accepted Answer

A) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
B) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
C) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
D) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
E) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.

Question 8

The nurse is caring for a child with heart failure (CHF).Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply.

Accepted Answer

A) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
B) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
C) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
D) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.
E) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases because of retention of fluids.

Question 9

A client diagnosed with systolic heart failure is admitted to the intensive care unit (ICU).When planning care for this client which does the nurse understand about systolic heart failure?

Accepted Answer

A) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.
B) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.
C) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.
D) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.

Question 10

The nurse teaches a client about lifestyle modifications to help manage hypertension.Which client statement indicates teaching has been effective?

Accepted Answer

A) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.
B) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.
C) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.
D) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.

Question 11

A client reports morning headache that extends into the neck and goes away as the day wears on.Based on this initial data,which does the nurse suspect that the client is experiencing?

Accepted Answer

A) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the back of the head and neck, may be present on awakening, subsiding during the day. The client is not describing a migraine or sinus headache. There is not enough information to determine whether the client has spinal stenosis.
B) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the back of the head and neck, may be present on awakening, subsiding during the day. The client is not describing a migraine or sinus headache. There is not enough information to determine whether the client has spinal stenosis.
C) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the back of the head and neck, may be present on awakening, subsiding during the day. The client is not describing a migraine or sinus headache. There is not enough information to determine whether the client has spinal stenosis.
D) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the back of the head and neck, may be present on awakening, subsiding during the day. The client is not describing a migraine or sinus headache. There is not enough information to determine whether the client has spinal stenosis.

Question 12

A client is prescribed enalapril (Vasotec)for treatment of heart failure.Which assessment finding should cause the nurse concern following the initial administration of this drug?

Accepted Answer

A) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta blockers.
B) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta blockers.
C) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta blockers.
D) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta blockers.

Question 13

A client with disseminated intravascular coagulation (DIC)is experiencing joint pain.Which nursing intervention is appropriate for this client?

Accepted Answer

A) Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
B) Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
C) Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
D) Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and are not indicated for the care of this client. Ice should not be applied but rather cool compresses.

Question 14

A nurse working in labor and delivery is caring for a client with suspected disseminated intravascular coagulation (DIC).Which pregnancy complication does the nurse anticipate when reviewing the client's chart?

Accepted Answer

A) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
B) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
C) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
D) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.

Question 15

A nurse caring for a client with disseminated intravascular coagulation (DIC)is reviewing the client's diagnostic tests.Which test result is common in DIC?

Accepted Answer

A) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors.
B) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors.
C) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors.
D) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors.

Question 16

A client diagnosed with disseminated intravascular coagulation (DIC)is currently bleeding through the gastrointestinal tract.Which prescription does the nurse anticipate for this client?

Accepted Answer

A) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
B) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
C) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
D) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.

Question 17

A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator.The client appears comfortable at rest but displays dyspnea with activities of daily living (ADLs).In which stage of heart failure does the nurse classify this client?

Accepted Answer

A) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage, surgical intervention includes implantation of a defibrillator.
B) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage, surgical intervention includes implantation of a defibrillator.
C) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage, surgical intervention includes implantation of a defibrillator.
D) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage, surgical intervention includes implantation of a defibrillator.

Question 18

A nurse caring for clients with heart failure must be aware of the compensatory mechanisms activated in heart failure.Which physiology is not associated with the neuroendocrine compensatory mechanism?

Accepted Answer

A) When the heart begins to fail, mechanisms are activated to compensate for the impaired function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine response.
B) When the heart begins to fail, mechanisms are activated to compensate for the impaired function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine response.
C) When the heart begins to fail, mechanisms are activated to compensate for the impaired function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine response.
D) When the heart begins to fail, mechanisms are activated to compensate for the impaired function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine response.

Question 19

During an assessment,a client with congestive heart failure (CHF)and severe shortness of breath tells the nurse about not having enough money to purchase medications.What nursing diagnosis is of the greatest initial importance when planning care?

Accepted Answer

A) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.
B) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.
C) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.
D) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic Regime related to inability to purchase medications should be addressed after the client's physiological problems are resolved.

Question 20

The nurse is planning care for an infant with congestive heart failure (CHF).What should the nurse include in this child's care?

Accepted Answer

A) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
B) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
C) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
D) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.

Quiz 16: Perfusion

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Tissue Perfusion.Which action is inappropriate for this nursing diagnosis?

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange.Which action is inappropriate when providing care based on this nursing diagnosis?

The nurse is positioning a client with left-sided heart failure in bed.Which sleeping position is most appropriate for this client?

During hospitalization for congestive heart failure (CHF) ,a client awakens during the night frightened and short of breath.Based on this data,what is the client experiencing?

A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition.Which condition would be excluded from the client's cause of heart failure?

The nurse is planning care for several clients.Which client has the greatest risk of developing heart failure?

The nurse is assessing a client being treated for congestive heart failure (CHF) .Which physical findings would indicate that the client's condition is not improving? Select all that apply.

The nurse is caring for a child with heart failure (CHF) .Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply.

A client diagnosed with systolic heart failure is admitted to the intensive care unit (ICU) .When planning care for this client which does the nurse understand about systolic heart failure?

The nurse teaches a client about lifestyle modifications to help manage hypertension.Which client statement indicates teaching has been effective?

A client reports morning headache that extends into the neck and goes away as the day wears on.Based on this initial data,which does the nurse suspect that the client is experiencing?

A client is prescribed enalapril (Vasotec) for treatment of heart failure.Which assessment finding should cause the nurse concern following the initial administration of this drug?

A client with disseminated intravascular coagulation (DIC) is experiencing joint pain.Which nursing intervention is appropriate for this client?

A nurse working in labor and delivery is caring for a client with suspected disseminated intravascular coagulation (DIC) .Which pregnancy complication does the nurse anticipate when reviewing the client's chart?

A nurse caring for a client with disseminated intravascular coagulation (DIC) is reviewing the client's diagnostic tests.Which test result is common in DIC?

A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract.Which prescription does the nurse anticipate for this client?

A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator.The client appears comfortable at rest but displays dyspnea with activities of daily living (ADLs) .In which stage of heart failure does the nurse classify this client?

A nurse caring for clients with heart failure must be aware of the compensatory mechanisms activated in heart failure.Which physiology is not associated with the neuroendocrine compensatory mechanism?

During an assessment,a client with congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications.What nursing diagnosis is of the greatest initial importance when planning care?

The nurse is planning care for an infant with congestive heart failure (CHF) .What should the nurse include in this child's care?