Cardiac Disorders NCLEX Latest Update with Verified Solutions

Cardiac Disorders NCLEX Latest Update with Verified Solutions The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate? 1. expiratory wheezes 2. friction rub 3. harsh vesicular 4. crackles Answer: 4 Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not associated w/ chronic heart failure. Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most likely note the following statement in the physician's written report following cardiac catheterization? 1. "Pressures in the left ventricle & atrium are increased." 2. "Pressures in the left ventricle & atrium are decreased." 3. "Pressures in the right ventricle & atrium match the ventricle pressures." 4. "Pressures in the right ventricle reflect functioning of all heart chambers." Answer: 1 Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. A nurse caring for a pt w/ heart failure would expect to find which of the following during assessment of the pt? 1. S1, S2 & flat neck veins 2. S3 & distended neck veins 3. S2 is heard the loudest & followed by S1 4. S4 & flat neck veins Answer: 2 Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal finding. Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle & the neck veins distend because of the increased venous pressure. Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in intensity. Rationale 4: S4 (gallop) may be present but neck veins would be distended. When obtaining the health history of a pt who is being assessed for possible congestive heart failure, it is significant when the pt says which of the following? 1. "I break out in a cold sweat when I eat a large meal." 2. "I am sleepy after I eat lunch each day." 3. "I have to prop myself up on three pillows to sleep at night, otherwise I can't breathe." 4. "I feel better w/ my legs down when I sit in my favorite chair." Answer: 3 Rationale 1: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. Rationale 2: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. Rationale 3: Needing to prop oneself up w/ pillows at night in order to breathe describes orthopnea, which is consistent w/ congestive heart failure (CHF). Congestive heart failure produces a volume excess, congestion in the lungs, & dyspnea when attempting to lie down. Rationale 4: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. A pt is admitted w/ acute heart failure. The nurse realizes that acute heart failure is associated w/ an abrupt onset of which of the following? Select all that apply. 1. cardiomyopathy 2. heart valve disease 3. coronary heart disease (CHD) 4. massive infarction (MI)) 5. myocardial injury Correct Answer: 4,5 Rationale 1,2,3: Cardiomyopathy, valve disease, & coronary heart disease (CHD) are all associated w/ chronic heart failure. Rationale 4,5: Pts often present for care w/ signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI). Blood tests are ordered for a pt who is diagnosed w/ possible congestive heart failure (CHF). The nurse underst&s which of the following lab tests indicates heart failure? The most specific test(s) to accurately indicate CHF would be which of the following? 1. liver function 2. urinalysis & blood urea nitrogen (BUN)