Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders
Test Bank
MULTIPLE CHOICE
1. The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve
who has symptoms of infective endocarditis (IE). Which question by the nurse is most
appropriate?
a. “Do you have a history of a heart attack?”
b. “Is there a family history of endocarditis?”
c. “Have you had any recent immunizations?”
d. “Have you had dental work done recently?”
ANS: D
Dental procedures place the patient with a prosthetic mitral valve at risk for infective
endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of
endocarditis are not risk factors for IE.
DIF: Cognitive Level: Apply (application) REF: 812 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
2. During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse
would expect to find
a. substernal chest pressure.
b. a new regurgitant murmur.
c. a pruritic rash on the chest.
d. involuntary muscle movement.
ANS: B
New regurgitant murmurs occur in IE because vegetations on the valves prevent valve
closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical
manifestations of other cardiac disorders such as angina and rheumatic fever.
DIF: Cognitive Level: Understand (comprehension) REF: 811 | 821
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the patient with infective endocarditis (IE) based on which assessment
finding(s)?
a. Fever, chills, and diaphoresis
b. Urine output less than 30 mL/hr
c. Petechiae on the inside of the mouth and conjunctiva
d. Increase in heart rate of 15 beats/minute with walking
ANS: B
, Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine
output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by
decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.
DIF: Cognitive Level: Apply (application) REF: 812
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE),
which intervention is a priority for the nurse to include?
a.Monitor labs for streptococcal antibodies.
b.Arrange for placement of a long-term IV catheter.
c.Teach the importance of completing all oral antibiotics.
d.Encourage the patient to begin regular aerobic exercise.
ANS: B
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the
bacteria, which will require a long-term IV catheter such as a peripherally inserted central
catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are
recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the
infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to
monitor the effectiveness of antibiotic therapy.
DIF: Cognitive Level: Apply (application) REF: 814
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to
teach the patient about the purpose of
a. echocardiography.
b. daily blood cultures.
c. cardiac catheterization.
d. 24-hour Holter monitor.
ANS: A
Echocardiograms are useful in detecting the presence of the pericardial effusions associated
with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis.
Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for
pericarditis.
DIF: Cognitive Level: Apply (application) REF: 816
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should
a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.
b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.
c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction
rub.
d. feel the precordial area with the palm of the hand to detect vibrations with cardiac
contraction.
ANS: B
, Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The
nurse should ask the patient to hold his or her breath during auscultation to distinguish the
sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and
are not confined to systole. Rubs are not assessed by palpation.
DIF: Cognitive Level: Understand (comprehension) REF: 815
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
7. The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the
presence of pulsus paradoxus, the nurse should
a. note when Korotkoff sounds are auscultated during both inspiration and expiration.
b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
c. check the electrocardiogram (ECG) for variations in rate during the respiratory
cycle.
d. listen for a pericardial friction rub that persists when the patient is instructed to stop
breathing.
ANS: A
Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when
Korotkoff sounds can be heard during only expiration and when they can be heard throughout
the respiratory cycle. The other methods described would not be useful in determining the
presence of pulsus paradoxus.
DIF: Cognitive Level: Understand (comprehension) REF: 816
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a
patient with acute pericarditis. The priority intervention by the nurse for this problem is to
a. teach the patient to take deep, slow breaths to control the pain.
b. force fluids to 3000 mL/day to decrease fever and inflammation.
c. remind the patient to request opioid pain medication every 4 hours.
d. place the patient in Fowler’s position, leaning forward on the overbed table.
ANS: D
Sitting upright and leaning forward frequently will decrease the pain associated with
pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths
will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused
by acute inflammatory conditions and are usually ordered PRN. The patient would receive
scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).
DIF: Cognitive Level: Apply (application) REF: 817
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
NCLEX: Physiological Integrity
9. The nurse is admitting a patient with possible rheumatic fever. Which question on the admission
health history will be most pertinent to ask?
a. “Do you use any illegal IV drugs?”
b. “Have you had a recent sore throat?”
c. “Have you injured your chest in the last few weeks?”
,d. “Do you have a family history of congenital heart disease?”
ANS: B
, Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal
infection. Although illicit IV drug use should be discussed with the patient before discharge, it
is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the
patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause
musculoskeletal chest pain rather than rheumatic fever.
DIF: Cognitive Level: Apply (application) REF: 819 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and
polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate?
a. Pain related to permanent joint fixation
b. Activity intolerance related to arthralgia
c. Risk for infection related to open skin lesions
d. Risk for impaired skin integrity related to pruritus
ANS: B
The patient’s joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic
fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint
inflammation is a temporary clinical manifestation of rheumatic fever and is not associated
with permanent joint changes.
DIF: Cognitive Level: Apply (application) REF: 819-820
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack
of knowledge regarding long-term management of rheumatic fever when a 30-year-old
recovering from rheumatic fever without carditis says which of the following?
a. “I will need prophylactic antibiotic therapy for 5 years.”
b. “I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain.”
c. “I will call the doctor if I develop excessive fatigue or difficulty breathing.”
d. “I will be immune to further episodes of rheumatic fever after this infection.”
ANS: D
Patients with a history of rheumatic fever are more susceptible to a second episode. Patients
with rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5
years. The other patient statements are correct and would not support the nursing diagnosis of
ineffective health maintenance.
DIF: Cognitive Level: Apply (application) REF: 820 TOP: Nursing
Process: Diagnosis MSC: NCLEX: Physiological Integrity
12. When developing a community health program to decrease the incidence of rheumatic fever,
which action would be most important for the community health nurse to include?
a. Vaccinate high-risk groups in the community with streptococcal vaccine.
b. Teach community members to seek treatment for streptococcal pharyngitis.
c. Teach about the importance of monitoring temperature when sore throats occur.
, d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
B
The incidence of rheumatic fever is decreased by treatment of streptococcal infections with
antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization
that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring
temperature will not decrease the incidence of rheumatic fever.
DIF: Cognitive Level: Apply (application) REF: 820
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess
for
a. diastolic murmur.
b. peripheral edema.
c. shortness of breath on exertion.
d. right upper quadrant tenderness.
ANS: C
The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting
in hypoxemia and dyspnea. The other findings also may be associated with mitral valve
disease but are not indicators of possible hypoxemia.
DIF: Cognitive Level: Apply (application) REF: 821 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to
treat mitral stenosis. Which information should the nurse include when explaining the
advantages of valvuloplasty over valve replacement to the patient?
a. Biologic valves will require immunosuppressive drugs after surgery.
b. Mechanical mitral valves need to be replaced sooner than biologic valves.
c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement.
d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
ANS: C
Long-term anticoagulation therapy is needed after mechanical valve replacement, and this
would restrict decisions about career and childbearing in this patient. Mechanical valves are
durable and last longer than biologic valves. All valve repair procedures are palliative, not
curative, and require lifelong health care. Biologic valves do not activate the immune system,
and immunosuppressive therapy is not needed.
DIF: Cognitive Level: Apply (application) REF: 824-825 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
15. While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular
regurgitation, the nurse determines that discharge teaching has been effective when the patient
states that it will be necessary to
, a. take antibiotics before any dental appointments.
b. limit physical activity to avoid stressing the heart.
c. take an aspirin a day to prevent clots from forming on the valve.
d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
D
Use of stimulant medications should be avoided by patients with MVP because these may
exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients
with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but
will not be necessary for this patient.
DIF: Cognitive Level: Apply (application) REF: 822 TOP: Nursing
Process: Evaluation MSC: NCLEX: Physiological Integrity
16. While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute
pain related to decreased coronary blood flow. A priority nursing intervention for this patient
would be to
a. promote rest to decrease myocardial oxygen demand.
b. teach the patient about the need for anticoagulant therapy.
c. teach the patient to use sublingual nitroglycerin for chest pain.
d. raise the head of the bed 60 degrees to decrease venous return.
ANS: A
Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest
pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so
nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is
not recommended unless the patient has atrial fibrillation.
DIF: Cognitive Level: Apply (application) REF: 823 | 826 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
17. During discharge teaching with a 68-year-old patient who had a mitral valve replacement with
a mechanical valve, the nurse instructs the patient on the
a. use of daily aspirin for anticoagulation.
b. correct method for taking the radial pulse.
c. need for frequent laboratory blood testing.
d. need to avoid any physical activity for 1 month.
ANS: C
Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to
prevent clotting on the valve. This will require frequent international normalized ratio (INR)
testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve.
Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume
activities of daily living as tolerated.
DIF: Cognitive Level: Apply (application) REF: 826 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
,18. A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to
10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most
appropriate for the nurse to give?
a. Fentanyl 1 mg IV
b. IV morphine sulfate 4 mg
c. Oral ibuprofen (Motrin) 600 mg
d. Oral acetaminophen (Tylenol) 650 mg
C
, The pain associated with pericarditis is caused by inflammation, so nonsteroidal
antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) are most effective. Opioid analgesics are
usually not used for the pain associated with pericarditis.
DIF: Cognitive Level: Apply (application) REF: 816 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
19. When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should
monitor the patient for the development of
a.flank pain.
b.splenomegaly.
c.shortness of breath.
d.mental status changes.
ANS: C
Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank
pain, changes in mental status, and splenomegaly would be associated with embolization from
the left-sided valves.
DIF: Cognitive Level: Apply (application) REF: 812
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy.
Which information will the nurse plan to teach the patient about managing this disorder?
a. A heart transplant should be scheduled as soon as possible.
b. Elevating the legs above the heart will help relieve dyspnea.
c. Careful compliance with diet and medications will prevent heart failure.
d. Notify the doctor about any symptoms of heart failure such as shortness of breath.
ANS: D
The patient should be instructed to notify the health care provider about any worsening of
heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy,
even patients with good compliance with therapy may have recurrent episodes of heart failure.
Elevation of the legs above the heart will worsen symptoms (although this approach is
appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or
endstage cardiomyopathy may consider heart transplantation.
DIF: Cognitive Level: Apply (application) REF: 828
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
21. The nurse is obtaining a health history from a 24-year-old patient with hypertrophic
cardiomyopathy (HC). Which information obtained by the nurse is most important?
a. The patient has a history of a recent upper respiratory infection.
b. The patient has a family history of coronary artery disease (CAD).
c. The patient reports using cocaine a “couple of times” as a teenager.
d. The patient’s 29-year-old brother died from a sudden cardiac arrest.
ANS: D
, About half of all cases of HC have a genetic basis, and it is the most common cause of sudden
cardiac death in otherwise healthy young people. The information about the patient’s brother
will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator
[AICD]) for the patient and in counseling other family members. The patient should be
counseled against the use of stimulant drugs, but the limited past history indicates that the
patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for
dilated cardiomyopathy, but not for HC.
DIF: Cognitive Level: Apply (application) REF: 828 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when
having dental procedures for which patient?
a. Patient admitted with a large acute myocardial infarction.
b. Patient being discharged after an exacerbation of heart failure.
c. Patient who had a mitral valve replacement with a mechanical valve.
d. Patient being treated for rheumatic fever after a streptococcal infection.
ANS: C
Current American Heart Association guidelines recommend the use of prophylactic antibiotics
before dental procedures for patients with prosthetic valves to prevent infective endocarditis
(IE). The other patients are not at risk for IE.
DIF: Cognitive Level: Apply (application) REF: 813
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
23. Which admission order written by the health care provider for a patient admitted with
infective endocarditis (IE) and a fever would be a priority for the nurse to implement?
a. Administer ceftriaxone (Rocephin) 1 g IV.
b. Order blood cultures drawn from two sites.
c. Give acetaminophen (Tylenol) PRN for fever.
d. Arrange for a transesophageal echocardiogram.
ANS: B
Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential
to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity
results. The echocardiogram and acetaminophen administration also should be implemented
rapidly, but the blood cultures (and then administration of the antibiotic) have the highest
priority.
DIF: Cognitive Level: Apply (application) REF: 812-813
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
NCLEX: Physiological Integrity
24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most
important to communicate to the health care provider?
a. Generalized muscle aching
b. Sudden onset right flank pain
