ch42.doc

[Osborn] chapter 42

Learning Outcomes [Number and Title] Learning Outcome 1 Evaluate the etiology, incidence, and prevalence of heart

failure.Learning Outcome 2 Distinguish between systolic and diastolic dysfunction.Learning Outcome 3 Describe the pathophysiology of heart failure and the

compensatory neurohormonal responses that occur.Learning Outcome 4 Compare and contrast right-sided versus left-sided symptoms

of heart failure.Learning Outcome 5 Evaluate the diagnostic work-up used to determine the presence

of heart failure.Learning Outcome 6 Describe a comprehensive treatment plan including the

medical, device, and surgical components of treatment, using the multidisciplinary team approach.

Learning Outcome 7 Describe the self-management concepts necessary for patients with heart failure.

Learning Outcome 8 Compare and contrast potential comorbidities associated with heart failure.

Learning Outcome 9 Describe components of end-of-life care for end-stage heart failure.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. A client with heart failure is given discharge instructions by the nurse. As the client leaves the hospital, the nurse recognizes that, statistically, this client has a _______ likelihood of readmission within 6 months.

1. 30% to 50% 2. 50% to 75% 3. 0% to 20% 4. 20% to 30%

Correct Answer: 30% to 50%

Rationale: The likelihood of readmission for a client with heart failure within 6 months is between 30% and 50%. The other answer choices are therefore not correct.

Cognitive Level: ApplicationNursing Process: EvaluationClient Need: Health Promotion and Maintenance LO: 1


2. The nurse knows that the client who is diagnosed with heart failure has a higher mortality rate. The best way to help decrease the incidence of heart failure is to:

1. Teach clients about modifiable risk factors.2. Teach clients about the higher incidence of sudden cardiac death.3. Discuss the higher mortality with the health care provider.4. Discuss heart failure statistics at a nursing meeting.

Correct Answer: Teach clients about modifiable risk factors.

Rationale: Modifying a client’s risk factors may help to decrease the client’s susceptibility to heart failure. Limiting smoking and cardiotoxic substances, decreasing the likelihood of cardiac disease, and increasing activity may all help to decrease the soaring incidence of heart failure in the United States. Discussion with the client about higher incidence of sudden cardiac death will not impact the incidence of heart failure unless it scares a client into taking action. Discussion with the health care provider and nurses about heart failure may help promote awareness of the problem, but will not impact the client directly.

Cognitive Level: Application Nursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 1


3. A 68-year-old male client is seen in the clinic complaining of fatigue and other nonspecific, vague symptoms that the nurse believes may be related to heart failure. The nurse questions the client regarding risk factors for heart disease. Which of the following could be modifiable risk factors for this client regarding heart failure?

1. Hemoglobin A1C 9.0%2. Male3. Father-in-law died from heart disease a year ago4. Blood pressure 119/78

Correct Answer: Hemoglobin A1C 9.0%

Rationale: Hemoglobin A1C of 9.0% indicates an average blood sugar of 240 mg/dL. Therefore the client is likely to have undiagnosed diabetes, which is a modifiable risk factor for heart failure. Being male is a risk factor, but is not modifiable. An in-law’s death from cardiac disease is unrelated to the client’s risk factors. Hypertension is a modifiable risk factor, but the blood pressure of 119/78 is not hypertensive.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 1


4. The nurse is performing an admission assessment on a client who presents to the emergency department (ED) complaining of poor appetite, bloated abdomen, and peripheral edema. The nurse recognizes these symptoms as:

1. Right-sided failure.2. Left-sided failure.3. Diastolic dysfunction.4. A myocardial infarction.

Correct Answer: Right-sided failure.

Rationale: Right-sided failure includes symptoms of poor appetite, nausea, vomiting, bloated abdomen, ascites, and peripheral edema. Left-sided failure symptoms include a cough, shortness of air, orthopnea, and activity intolerance. Diastolic dysfunction symptoms are often similar to systolic dysfunction symptoms. A myocardial infarction (MI) may initially cause the insult to the cardiac system that results in heart failure.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


5. An elderly female client has a left ventricular ejection fraction (LVEF) of 60%. She complains of activity intolerance, shortness of air, and peripheral edema. The nurse knows that this client’s diagnosis differs from that of another client who has systolic dysfunction because this client’s:

1. LVEF is within normal limits.2. LVEF is low.3. Symptoms are unique to diastolic dysfunction.4. Symptoms are unique to systolic dysfunction.

Correct Answer: LVEF is within normal limits.

Rationale: Diastolic dysfunction is diagnosed based upon a client’s LVEF being normal and the client exhibiting clinical symptoms of heart failure. This client is an elderly female, which is typical of diastolic dysfunction. In systolic dysfunction, the LVEF is low, with the client exhibiting clinical symptoms of heart failure. Systolic and diastolic dysfunctions tend to have similar symptoms.



6. A client has been diagnosed with left-sided heart failure. The nurse collects the following data: peripheral edema, abdominal bloating, bradycardia, bilateral crackles, weight loss, and a cough. Which of the data would be indicative of left-sided heart failure?

1. Cough2. Bradycardia3. Abdominal bloating4. Weight loss

Correct Answer: Cough

Rationale: A cough and bilateral crackles would be indicative of left-sided heart failure. Peripheral edema and abdominal bloating would be indicators of right-sided heart failure. Tachycardia would be a symptom of heart failure, not bradycardia. Weight loss could be a symptom of right-sided heart failure, since these clients report loss of appetite. However, there is usually enough fluid gain to mask any actual nutritional deficits.

Cognitive Level: Application Nursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


7. A client with heart failure has orthopnea, tachycardia, fatigue, and activity intolerance. The nurse instructs the client that these symptoms are a result of the client’s:

1. Inherent compensatory mechanisms trying to maintain a good blood pressure and oxygenation.

2. Inability to cope with the body’s changing health.3. Inability to follow instructions.4. Inherent compensatory mechanisms that are malfunctioning.

Correct Answer: Inherent compensatory mechanisms trying to maintain a good blood pressure and oxygenation.

Rationale: The client’s compensatory mechanisms attempt initially to compensate for the failing blood pressure and oxygen levels. At the outset, these mechanisms are able to keep up with the body’s demands. However, long term, they create bigger problems. The client’s symptoms are not a result of the client’s inability to cope with the body’s changing health or to follow instructions, since the client has no power over the compensatory mechanisms. The client’s inherent compensatory mechanisms are not malfunctioning, but instead continue to attempt to maintain homeostasis.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 3


8. The nurse notes that one of her clients is more anxious than usual. The client states, “I don’t understand how I can still be alive when my heart has failed.” The nurse’s most appropriate response is:

1. “It must be very confusing. Heart failure doesn’t mean your heart has quit, just that it no longer is as efficient as it once was. You have internal mechanisms that work to try to keep your blood pressure from falling, but eventually these mechanisms work against the heart’s ability to pump blood easily.”

2. “It seems like you are upset. Would you like for me to call the health care provider to explain this to you?”

3. “Heart failure is pretty complicated. It means the heart is failing to work.”4. “Heart failure is a common problem in the United States. Many people have it.

They all have problems such as yours.”

Correct Answer: “It must be very confusing. Heart failure doesn’t mean your heart has quit, just that it no longer is as efficient as it once was. You have internal mechanisms that work to try to keep your blood pressure from falling, but eventually these mechanisms work against the heart’s ability to pump blood easily.”

Rationale: An explanation that helps alleviate the client’s concerns may be helpful. Contacting the health care provider is not necessary, since the nurse should know how to respond to this question. Answering with “Heart failure is pretty complicated. It means the heart is failing to work” does not provide the client with enough information. Sharing with the client that heart failure is a common problem doesn’t help the client understand the heart issue any better.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 3


9. Which of the following nursing diagnoses is most appropriate for the client with acute systolic heart failure?

1. Excess Fluid Volume2. Disturbed Body Image3. Imbalanced Nutrition: more than body requirements4. Ineffective Airway Clearance

Correct Answer: Excess Fluid Volume

Rationale: The client with acute systolic heart failure will have excess fluid volume. If there is an imbalance in nutrition, it is more likely to be less than body requirements. Ineffective airway clearance is not applicable, since these clients do not have issues with clearing the airway as much as issues with impaired gas exchange. It is not common for the client to have disturbed body image related to heart failure.

Cognitive Level: AnalysisNursing Process: DiagnosisClient Need: Physiological IntegrityLO: 3


10. Reflecting upon the client’s other symptoms and past history, the nurse determines the client likely has right-sided heart failure when the client:

1. Consumes 5% of meals and complains of nausea. 2. Admits to anxiety over learning the new medication regimen.3. Has trouble concentrating on the conversation.4. Is dyspneic with activity.

Correct Answer: Consumes 5% of meals and complains of nausea.

Rationale: Poor appetite and complaints of nausea and vomiting correspond to right-sided heart failure. Dyspnea with activity is more commonly associated with left-sided heart failure. Anxiety over new medications and difficulty concentrating on the conversation are not likely related to heart failure, but could be symptoms of depression.



11. The client has been diagnosed with heart failure. The nurse is asked if the client’s symptoms are more likely right or left heart failure. Which of the following symptoms would indicate left-sided heart failure?

1. Respiration of 36 per minute2. Right upper quadrant pain3. Dependent edema4. Anasarca

Correct Answer: Respirations of 36 per minute

Rationale: The client with left-sided heart failure has pulmonary involvement and therefore will be tachypneic. Right upper quadrant pain, dependent edema, and anasarca are all symptoms of right-sided heart failure.

Cognitive Level: AnalysisNursing Process: DiagnosisClient Need: Physiological IntegrityLO: 4


12. A client with left-sided heart failure is admitted to the unit. Which item is a priority assessment upon arrival?

1. Airway and oxygenation status2. Neurological status3. Abdominal assessment4. Presence of peripheral edema

Correct Answer: Airway and oxygenation status

Rationale: The client with left-sided failure will exhibit symptoms of a respiratory nature. The priority assessment for this client would be the airway and oxygenation status. The neurological status will decline as the lack of oxygenation progresses. An abdominal assessment and presence of peripheral edema will be included in the assessment, but are more common in right-sided failure than in left-sided failure.



13. The nurse is assessing a client who has been admitted with heart failure. The nurse anticipates which of the following lab tests to be ordered to validate the severity of the diagnosis?

1. BNP2. CBC3. Troponin4. Lipid panel

Correct Answer: BNP

Rationale: A BNP, renal function, and liver function studies may provide an indication of the severity of the heart failure. CBC, troponin, and lipid panel may give an indication of the etiology of this client’s heart failure.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 5


14. A client is admitted with heart failure. The nurse establishes a nursing diagnosis of decreased cardiac output related to ventricular dysfunction. Which one of the following parameters might the nurse establish to measure the client’s outcome?

1. PCWP 6−12 mmHg2. CO 2−3 L/min3. BP 100/484. Daily weight same as the day before

Correct Answer: PCWP 6−12 mmHg

Rationale: The overall desired outcome is to achieve an adequate cardiac output. The only parameter that is within normal limits is the PCWP of 6−12 mmHg. The CO and BP are both low, which would indicate the cardiac output is still low. The daily weight would need to be lower than the previous day to show continued weight loss.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Physiological IntegrityLO: 5


15. The client may have several diagnostic tests completed to assist with the diagnosis of heart failure. Which of the following diagnostic studies would rule out heart failure being present?

1. BNP 50 pg/mL2. Hemoglobin 10g/dl3. Sodium 148 mEq/L4. Normal EKG

Correct Answer: BNP 50pg/mL

Rationale: A BNP within normal limits will rule out heart failure. An elevated BNP is indicative of heart failure, but will often only be one indicator of heart failure. Hemoglobin of 10 gm/dl is low, and heart failure clients will often have anemia. Sodium level is slightly high. The EKG results are normal. However, the low hemoglobin, a sodium slightly high, and a normal EKG cannot rule heart failure in or out.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 5


16. A client with heart failure will be undergoing the insertion of a pacemaker. The nurse is providing instructions preoperatively regarding the client’s length of stay following the procedure. On which of the following will the nurse instruct the client?

1. Following the procedure and recovery, the client may expect to stay at the hospital up to 24 hours, but often the stay is less.

2. Following the procedure, the client may expect to go home immediately.3. Following the procedure, the client will be required to stay in the hospital up to 2

days.4. Following the procedure, the client will be required to stay in the hospital up to a

week.

Correct Answer: Following the procedure and recovery, the client may expect to stay at the hospital up to 24 hours, but often the stay is less.

Rationale: The client is usually kept in the facility overnight and released pending follow-up tests to ensure the leads and pacemaker are functioning. Only the client who experiences unforeseen complications could expect a longer length of stay.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 6


17. A client is sent home on lisinopril (Zestril). The nurse has educated the heart failure client on the actions of this medication. Which of the following best describes what the nurse instructed?

1. Lisinopril is an ACE inhibitor medication. This medication will lower the blood pressure and decrease the fluid in the body. The client may notice a cough.

2. Lisinopril is an ACE inhibitor medication that will lower the client’s heart rate and blood pressure. The client should observe closely for angioedema.

3. Lisinopril is a beta-blocking drug that will lower the client’s heart rate and blood pressure. The client should observe closely for symptoms of worsening heart failure.

4. Lisinopril is a beta-blocker drug that will increase the pumping ability of the heart. The client should observe closely for orthostatic hypotension.

Correct Answer: Lisinopril is an ACE inhibitor medication. This medication will lower the blood pressure and decrease the fluid in the body. The client may notice a cough.

Rationale: ACE inhibitor medications act by preventing vasoconstriction, thus allowing vasodilation. Since ACE inhibitors also interrupt the body’s ability to conserve sodium, the net result is fluid loss. Lisinopril does not impact the heart rate. Angioedema and a cough are side effects of ACE inhibitors. Angioedema should be reported to the health care provider immediately. Lisinopril is not a beta-blocker drug and does not impact the pumping ability of the heart. Lisinopril will not create worsening heart failure symptoms as beta blocker can. Lisinopril can create orthostatic hypotension, so the client should be advised to rise slowly.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 6


18. A client preparing for discharge asks the nurse about an appropriate diet. Which of the following replies is best?

1. “I will be reviewing your discharge plans with you, but I would also like to ask the dietitian to come visit with you to help finalize your diet.”

2. “I am glad you asked. The health care provider will be discussing the diet with you.”

3. “A special diet is important for you. Let me tell you about it in detail.”4. “The pharmacist will be talking with the physician. They will let the dietitian

know what is best for you.”

Correct Answer: “I will be reviewing your discharge plans with you, but I would also like to ask the dietitian to come visit with you to help finalize your diet.”

Rationale: Each client has special needs for discharge planning. A multidisciplinary team approach is important for the success of the client in managing the disease process at home. The client should be referred to a dietitian for any special instructions related to heart failure. While the physician is important in the health care team, the most appropriate person to discuss the details of the diet is the dietitian, not the physician.



19. The client has been instructed in the MAWDS system. Which one of the following instructions is not included in the MAWDS method?

1. Avoid large crowds. 2. Check your pulse before taking digoxin (Lanoxin) each day.3. You should rest periodically throughout the day.4. Check your weight daily.

Correct Answer: Avoid large crowds.

Rationale: MAWDS stands for medication, activity, weight, diet, and symptoms. Avoiding large crowds is not a typical instruction for a heart failure client and does not fit with the MAWDS acronym. Checking a pulse before digoxin (medication), resting periodically throughout the day (activity), and checking daily weights (weights) are all part of the MAWDS method.



20. The nurse recognizes that the heart failure client does not understand discharge instructions when the client states:

1. “I will have my spouse pick up my new medications in a few days.”2. “I will eat a low-sodium diet.”3. “I will contact the health care provider if I begin gaining weight.”4. “I will increase my activity a little every day.”

Correct Answer: “I will have my spouse pick up my new medications in a few days.”

Rationale: It is important that the client has the medication each and every day. Waiting for a few days to pick up the medication will not be effective and could demonstrate a misunderstanding of discharge instructions. Eating a low-sodium diet, increasing activity slowly, and notification of a health care provider should there be weight gain all indicate understanding.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 7


21. A client with heart failure does not have a scale to weigh on at home. What other methods might the client be instructed to use until a scale can be purchased?

1. Instruct the client to see if his or her same belt or shoes are tighter every day.2. Have the client observe if he or she feels heavier while wearing the same clothing

every day.3. Suggest the client come to the health department every other week to weigh.4. Have the client notice if his or her rings are tighter.

Correct Answer: Instruct the client to see if his or her same belt or shoes are tighter every day.

Rationale: A heart failure client who is gaining fluid will have his or her belt or shoes get tighter. However, the best method of measuring fluid build-up is with a scale, and the client should be so instructed. A client will not be able to gauge “feeling” heavier. Weighing at the health department every other week is not frequent enough. A client should be advised to weigh daily and at the same time each day. A client’s rings may get tighter, but this can also be impacted by other activities and temperature.



22. A diabetic client received instructions from the nurse discussing ways to minimize the any further damage to the heart from heart failure. The client understands the instructions when the client states the following:

1. “I will keep my hemoglobin A1C less than 6.4.”2. “I will take a daily walk.”3. “I will follow a diet.”4. “I will weight myself every day.”

Correct Answer: “I will keep my hemoglobin A1C less than 6.4.”

Rationale: Keeping the blood sugar under control is the best way for a diabetic client with heart failure to minimize any further damage to the heart. The other answer options are all instructions to decrease exacerbation of heart failure.

Cognitive Level: AnalysisNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 8


23. The client who has hypertension and heart failure might expect to be discharged on which of the following medications?

1. ACE inhibitors2. Digoxin (Lanoxin)3. Antidysrhythmics4. Anticoagulants

Correct Answer: ACE inhibitors

Rationale: The client who has both hypertension and heart failure can expect to be taking ACE inhibitors, which impact both diseases. Digoxin is not a first-line option for a client with both hypertension and heart failure, but is often used for heart failure alone. Antidysrhythmics and anticoagulants are not used to treat heart failure or hypertension unless there are other underlying comorbidities.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 8


24. A client with diabetes and heart failure can expect better outcomes from heart failure in which of the following situations?

1. Hemoglobin A1C is 5.8%.2. Fingerstick blood sugar is 155.3. Hemoglobin is 14 g/dl.4. Creatinine is 2.2 mg/dl.

Correct Answer: Hemoglobin A1C is 5.8%.

Rationale: The client who maintains strict glycemic control as evidenced by the hemoglobin A1C being < 6% will have better heart failure outcomes. A fingerstick blood sugar of 155 is not glycemic control and is a one-time result, whereas the hemoglobin A1C is an average of the blood sugar over a 3-month time frame. The hemoglobin plays no role in long-term mortality of heart failure. A creatinine of 2.2 mg/dl is high and could indicate renal involvement.



25. A client is on hospice with a diagnosis of end-stage heart failure. The family wants to know what the goals of treatment will be. The hospice nurse relates to them that the primary goal of treatment is tp:

1. Provide comfort and reduce any distressing respiratory symptoms.2. Provide significant pain medications.3. Keep the client out of the hospital.4. Provide information to the family.

Correct Answer: To provide comfort and reduce any distressing respiratory symptoms.

Rationale: The goals of care are to provide comfort measures and reduce or eliminate any primary symptoms that may be distressing, such as respiratory distress. The treatment plan is not to cure the illness. Pain medications may be provided in the course of this plan. Attempts to keep the client out of the hospital will be a goal if the client desires to stay at home. Communication with the family and client is important to the overall plan of care.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 9


26. The nurse has explained the seriousness of a client’s condition to the family. The family understands that which one of the following problems most increases the mortality for their loved one with terminal heart failure?

1. Other serious comorbidities2. Age3. Positive mental attitude4. Taking ACE inhibitors

Correct Answer: 1Other serious comorbidities

Rationale: Many corresponding factors impact the poor prognosis of the heart failure client. Among them are other serious comorbidities. Age, positive mental attitude, and on the use of ACE inhibitors do not add to the poor prognosis.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 9


27. A client who has heart failure is asking about end of life. The priority for the nurse’s discussion with the client is to:

1. Be as honest as possible about the progression of the disease and the support needed.

2. Tell the client that nursing staff might be available if needed, but that family will need to help provide client support.

3. Have the health care provider discuss end-of-life topics with the client.4. Reassure the client that the chances for survival are good.

Correct Answer: Be as honest as possible about the progression of the disease and the support needed.

Rationale: The heart failure client who is nearing the end of life will need honest discussions regarding the progression of the disease and the support needed and available. Telling the client that nursing staff might be available, but family will need to provide support is not completely honest and likely is not helpful. The health care provider will be involved in end-of-life discussions, but the nurse as a client advocate can certainly discuss the end-of-life options with the client. Reassuring the client of survival is not honest, especially given that the survival rate for heart failure clients is not good.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 9


ch42.doc

Documents

heart failure statistics

prevalence of heart

presence of heart failure

heart disease

endstage heart failure

title learning outcome

evaluation client need

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