Cardiomyopathy Nclex Style questions w/rationales

Cardiomyopathy Nclex Style questions w/rationales
The nurse is caring for a client diagnosed with dilated cardiomyopathy.
which clinical manifestation does the nurse anticipate during the
physical assessment? SATA
A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Angina Correct Answer-Answer: A, B, D
A) Fatigue
B) Lower extremity edema
D) Dyspnea
Rationale: 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.


A client states to the nurse, "I know I have high BP, 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 Correct Answer-C) Cardiomyopathy

,Rationale: Hypertension places the client at risk for development of
cardiomyopathy. Hypertension has not been associated with gastritis,
diabetes, or metabolic syndrome.


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 Correct Answer-B) Decreased cardiac
output
Rationale: 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.


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 Correct Answer-C) Activity Intolerance
Rationale: 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.


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? SATA
A) Monitor B-type natriuretic peptide (BNP) level.
B) Provide O2 as prescribed
C) Assess respiratory status and lung sounds every 4 hours as needed.
D) Provide information about activity upon discharge
E) Monitor intake and output Correct Answer-Answer: C, E
C) Assess respiratory status and lung sounds q 4hr PRN
E) Monitor I & Os
Rationale: 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