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NURSING 100/ NURS 100/ NUSING100/ NURS100: HEART FAILURE: University Of Massachusetts (GRADE A)

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Heart Failure A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? . A client is in the earl y stage of heart failure. During this time, which compensatory mechanism occurs? When assessing a client with left-sided heart failure, the nurse expects to note: The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? In which of the following disorders would the nurse expect to assess sacral edema in bedridden client? Which of the following symptoms might a client with right-sided heart failure exhibit? Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? Heart failure Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. Which of the following symptoms might a client with right-sided heart failure exhibit? With which of the following disorders is jugular vein distention most prominent? Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be: Nurse Chona teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help… . Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet? Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema? Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? A patient admitted with HF appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patient’s anxiety (select all that apply)? A male patient with a long-standing history of HF has recently qualified for hospice care. Which of the following measures should the nurse now prioritize when providing care for this patient? The nurse is providing care for a patient who has decreased cardiac output related to heart failure. The nurse recognizes that cardiac output is Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? A 63-year-old accountant was admitted to the cardiac ICU with full-blown pulmonary edema. After he was revived, the nurse discusses his symptoms with the client and his wife. What is a typical, subtle symptom that communicates right-sided heart failure? Gradual, unexplained weight gain. A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? Bibasilar crackles A nursing student is caring for one of the nurse's assigned cardiac clients. The student asks, "How can I tell the difference between sinus rhythm and sinus bradycardia when I look at the EKG strip" The best reply by the nurse is which of the following? "The only difference is the rate, which will be below 60 bpm in sinus bradycardia." Show Less

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NURSING 100/ NURS 100/ NUSING100/
NURS100: HEART FAILURE: University Of
Massachusetts (GRADE A)

Heart Failure
A client is diagnosed with myocardial infarction. Which data collection findings indicate that the
client has developed left-sided heart failure?
Orthopnea
Cough
Crackles
RATIONALES: Left-sided heart failure produces primarily pulmonary signs and symptoms, such as
orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and
symptoms, such as ascites, jugular vein distention, and hepatomegaly.

A client is in the early stage of heart failure. During this time, which compensatory mechanism
occurs?
Low blood pressure triggers the baroreceptors to increase sympathetic nervous system
stimulation.
RATIONALES: In the early stage of heart failure, low blood pressure triggers baroreceptors in the
carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster
heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood
flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone
and antidiuretic hormone, in turn causing sodium and water retention and arterial vasoconstriction.

When assessing a client with left-sided heart failure, the nurse expects to note:
air hunger.
RATIONALES: With left-sided heart failure, the client typically has air hunger and other signs of
pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of
right-sided heart failure.

The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients
with heart failure are:
fine crackles.
RATIONALES: Fine crackles are caused by fluid in the alveoli and commonly occur in clients
with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused
by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
Crackles: Short, explosive or popping sounds usually heard during inspiration. They may be coarse
(loud and low in pitch) or fine (less intense and high in pitch) and resemble the sounds heard when
rolling hair between the fingers near the ear.


1

, After an anterior wall myocardial infarction, which of the following problems is indicated by
auscultation of crackles in the lungs?
Left-sided heart failure
The left ventricle is responsible for the most of the cardiac output. An anterior wall MI may result in a
decrease in left ventricular function. When the left ventricle doesn’t function properly, resulting in
left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes
crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.

In which of the following disorders would the nurse expect to assess sacral edema in bedridden client?
Right-sided heart failure
The most accurate area on the body to assessed dependent edema in a bedridden client is the sacral
area. Sacral, or dependent, edema is secondary to right-sided heart failure. Diabetes mellitus,
pulmonary emboli, and renal disease aren’t directly linked to sacral edema.

Which of the following symptoms might a client with right-sided heart failure exhibit?
Oliguria
Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid
retention, which causes oliguria (少尿). Adequate urine output, polyuria, and polydipsia aren’t
associated with right-sided heart failure.

Which of the following classes of medications maximizes cardiac performance in clients with heat
failure by increasing ventricular contractility?
Inotropic agents
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and
calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart.
Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of
the heart.

Which of the following conditions is most closely associated with weight gain, nausea, and a decrease
in urine output?
Right-sided heart failure
Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure.
Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure
causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn’t cause
weight gain, nausea, or a decrease in urine output.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure.
Which assessment component would elicit specific information regarding the client's left-sided
heart function?
1.Listening to lung sounds
2.Monitoring for organomegaly
3.Assessing for jugular vein distention
4.Assessing for peripheral and sacral edema
2

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