Deck 16: Perfusion

Question 1

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy.The client wants to know why her doctor told her she had an extra heart sound at the last visit.Which response by the nurse is appropriate?

A) "You will need to have an echocardiogram to determine the reason for extra sound."
B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy."
C) "You have what is known as a ventricular gallop and it can be a normal finding during this trimester of pregnancy."
D) "You have what is known as atrial gallop and this is cause for concern."

Answer 1

"You have what is known as a ventricular gallop and it can be a normal finding during this trimester of pregnancy."

Question 2

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia.What would the nurse expect to be prescribed for this client?

A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids

Answer 2

Beta blocker

Question 3

A client is prescribed metoprolol for a heart disorder.What should the nurse teach the client about this medication?

A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.

Answer 3

Change positions slowly.

Question 4

A nurse is performing an assessment on a client diagnosed with aortic stenosis.At which location will the nurse hear the client's murmur best?

A) Right sternal border, second intercostal space
B) Left sternal border, second intercostal space
C) Right sternal border, third intercostal space
D) Left sternal border, third to fifth intercostal space

Question 5

The nurse is preparing to conduct a cardiac assessment for a pediatric client.Which location will the nurse use when auscultating the apical pulse?

A) At the fifth intercostal space
B) At the left nipple
C) At the right nipple
D) At the 8^th intercostal space

Question 6

An older adult 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

Question 7

A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease.Which is inappropriate for the nurse to include in the teaching session?

A) Dilated cardiomyopathy
B) Restrictive cardiomyopathy
C) Hypotrophic cardiomyopathy
D) Arrythmogenic right ventricular cardiomyopathy

Question 8

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation.What should the nurse consider when planning for this client's potential health problem?

A) Encouraging ambulation every thirty minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return

Question 9

The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease.Which should be included in this teaching session? Select all that apply.

A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake.

Question 10

A client diagnosed with cardiomyopathy is being discharged to home.What client statement indicates discharge teaching has been effective?

A) "I will exercise as much as possible, regardless of feeling weak and short of breath."
B) "My pants getting tight around the waist, means I'm eating too much and should cut back on food."
C) "I will eat foods containing sodium only if drinking water with them."
D) "I will see the doctor to discuss implanting a cardiac defibrillator next week."

Question 11

A client states to the nurse,"I know I have high blood pressure 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

Question 12

The nurse is caring for a client with hypertension.When planning care for this client,the nurse knows that blood pressure is influenced by all but which factor?

A) Pumping action of the heart
B) Peripheral vascular resistance
C) Heart rate
D) Blood volume

Question 13

A client's stroke volume (SV)is 85mL/beat and the heart rate (HR)is 71 beats per minute.What is the client's cardiac output (CO)rounded to the nearest whole number?

Question 14

The nurse educator is teaching a group of student nurses regarding the various layers of the heart.Which statements will the educator include? Select all that apply.

A) "The endocardium covers the entire heart and great vessels."
B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat."
C) "The outermost layer of the heart is the epicardium."
D) "The myocardium consists of myofibril cells."
E) "The myocardium has four layers."

Question 15

The nurse is preparing teaching for a client with hypertrophic cardiomyopathy.Based on this diagnosis,which medication classification should the nurse prepare to include in the teaching?

A) Digitalis
B) Vasodilators
C) Nitrates
D) Beta blocker

Question 16

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? Select all that apply.

A) Monitor brain natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.

Question 17

An older adult client is diagnosed with dilated cardiomyopathy.Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.

A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Jugular vein distention

Question 18

A client is admitted with complaints of lower extremity edema and occasional shortness of breath.Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion?

A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric

Question 19

A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 mL in 8 hours.What should the nurse do to assist this client?

A) Assist the client to ambulate.
B) This is a normal urine output and the client does not need anything.
C) Notify the healthcare provider, as the client could be dehydrated.
D) Measure abdominal girth as a true assessment of the client's fluid status.

Question 20

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

Question 21

A client with angina complains that the pain is prolonged and severe,and occurs at the same time each day while at rest.There are no precipitating factors to the pain.Which term will the nurse use when documenting the angina experienced by the client?

A) Non-anginal pain
B) Atypical angina (Prinzmetal angina)
C) Unstable angina
D) Stable angina

Question 22

A nurse working in the newborn nursery is assessing a term baby for congenital heart defects.Which clinical manifestations would indicate an atrial septal defect (ASD)? Select all that apply.

A) Pulmonary artery hypotension
B) Midsystolic murmur at lower right sternal border
C) Mitral valve regurgitation with cleft on mitral valve.
D) S1 heart tone may be split due to forceful left ventricular contraction.
E) Congestive heart failure

Question 23

A client,admitted with irregular chest pain and shortness of breath,complains of fatigue with activity.The client's body mass index (BMI)is 30.5.Which is the priority nursing diagnosis for this client?

A) Ineffective Coping
B) Fear
C) Imbalanced Nutrition: More than Body Requirements.
D) Fluid Volume Deficit

Question 24

A nurse working in the neonatal intensive care unit (NICU)is caring for a preterm infant with a congenital heart defect.When planning this infant's care,which should the nurse take into consideration regarding how this conditions are characterized?

A) By the severity of defect
B) By the pathophysiology and hemodynamics of defect
C) By the location of defect
D) By the infant's age when defect diagnosed

Question 25

The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA).Which medication should the nurse plan to provide this client?

A) Indomethacin
B) NSAIDS
C) Antidepressant
D) Insulin

Question 26

The nurse is providing care to a client who has experienced several episodes of angina.Which is a primary outcome for this client?

A) The client will experience relief of chest pain with therapeutic lifestyle changes.
B) The client will experience relief of chest pain with aspirin therapy.
C) The client will experience relief of chest pain with nitrate therapy.
D) The client will experience relief of chest pain with anticoagulant therapy.

Question 27

A nurse is educating the parents of a child born with tetralogy of Fallot.Which statement will the nurse include regarding this defect?

A) "Increased pulmonary blood flow causes symptoms with this disease."
B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta."
C) "Your child has a decreased amount of red blood cells because of this disease."
D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta."

Question 28

A client with cardiomyopathy is experiencing tachycardia.Which medication prescription does the client's nurse anticipate?

A) ACE Inhibitor
B) Angiotensin II receptor blocker
C) Beta blocker
D) Cardiac glycoside

Question 29

The nurse is assessing a toddler diagnosed with tetralogy of Fallot.Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.

A) Palpable thrill in the pulmonic area
B) Nail clubbing
C) Cough
D) Apneic periods
E) Knee-chest position

Question 30

A healthcare provider caring for a client with hypoplastic left heart syndrome has provided the client's family with information regarding which surgical repair necessary for this condition?

A) Glenn procedure.
B) Jatene procedure.
C) Fontan procedure.
D) Damus-Kaye-Stansel procedure.

Question 31

The mother of a baby born with a congenital heart defect is upset,as no one else in the family has been born with this condition.To determine the cause of the defect,which question is appropriate for the nurse to ask the mother?

A) "Did you consume any alcohol during before you knew you were pregnant?"
B) "Is there a history of diabetes in your family?"
C) "Was the baby's father exposed to any toxins in the work environment?"
D) "Do you have a history of hypertension?"

Question 32

A client with a history of myocardial infarctions states to the nurse,"I have been smoking for 35 years.It will not matter if I stop now." Which is the priority response from the nurse?

A) "Your risk of continued coronary heart disease will decrease by half when you stop."
B) "Quitting will enhance the effects of your medications."
C) "Your risk of lung cancer will be reduced."
D) "Quitting will decrease any complications you might develop."

Question 33

A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity Intolerance.Which intervention is inappropriate for this nursing diagnosis?

A) Spacing out nursing activities so client fatigue is lessened.
B) Assisting with client ADLs as necessary.
C) Using passive and active range-of-motion (ROM) exercises as tolerated.
D) Consulting with a physical therapist on an activity plan.

Question 34

A nurse is educating a client with cardiomyopathy about diet choices which are appropriate for the client's condition.Which statement is inappropriate for the nurse to include in the teaching session?

A) "It is important to monitor your sodium intake."
B) "Increasing your dietary protein helps with cardiac cell repair."
C) "Here is a list of high-fat, high-cholesterol foods to avoid."
D) "I have notified the dietitian regarding your condition in order to provide you with more information."

Question 35

The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect.Which intervention should the nurse include to support the client's fluid status?

A) Encourage fluids.
B) Limit fluids.
C) Monitor pain.
D) Maintain intravenous therapy until day before discharge.

Question 36

A baby will be having surgery to correct a congenital heart defect.On which topic should the parents be instructed regarding the care of the child before surgery?

A) Restricting immunizations until after the surgery
B) Preventing exposure to infection
C) Implementing no particular precautions
D) Restricting fluids

Question 37

The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow.Which nursing diagnosis would be applicable for this client?

A) Acute Pain
B) Ineffective Breathing Pattern
C) Decreased Cardiac Output
D) Excess Fluid Volume

Question 38

The nurse is preparing preoperative teaching for an older adult client scheduled for a ventricular assist device (VAD).Which should the nurse include in these instructions?

A) Need to stay on bed rest for a week or more
B) Cardiac pain postoperatively is to be expected.
C) Risk for postoperative infection
D) Expect to be ambulating the evening of surgery.

Question 39

The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect.What statement indicates that teaching provided to these parents has been effective?

A) "Our child should be restricted in play and activity for at least 6 months."
B) "Our child will need to take antibiotics prior to having dental surgery."
C) "Fluids should be restricted to maximize lung function."
D) "Our child should not return to normal activities for at least 2 years."

Question 40

The nurse is instructing an older adult client about atorvastatin (Lipitor)to treat elevated cholesterol.Which side effects should the nurse advise the client to report to the healthcare provider?

A) Headaches and nausea
B) Muscle pain and weakness
C) Bruising and excessive bleeding
D) Shortness of breath and coughing

Question 41

The nurse has identified Ineffective Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC).What intervention would be appropriate for the client?

A) Carefully repositioning the client every 2 hours
B) Administering oxygen
C) Monitoring oxygen saturation
D) Encouraging deep breathing and coughing

Question 42

A client recovering from a cesarean section is afebrile but is experiencing tenderness,localized heat,and redness of the left leg.Which intervention is the most appropriate based on this data?

A) Encourage to ambulate freely.
B) Provide aspirin 650 mg by mouth.
C) Place on bed rest.
D) Provide Methergine IM.

Question 43

A client diagnosed with a deep vein thrombosis (DVT)is receiving intravenous heparin.Which is the priority outcome for this client?

A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows.

Question 44

A nurse is caring for a client suspected of a cocaine-induced myocardial infarction (MI).When asked to describe how cocaine can induce an MI,which rationale will the nurse use to respond?

A) Significantly increases the serum triglyceride level, leading to the development of an atheroma.
B) Alters the body's clotting mechanisms, leading to thrombus formation.
C) Increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction.
D) Alters electrolyte balance, leading to arrhythmias.

Question 45

The nurse is completing an assessment on a newly admitted client.What finding would suggest that the client is experiencing a deep venous thrombosis (DVT)?

A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with pitting edema
D) Bilateral calf tenderness after walking up a flight of stairs

Question 46

The nurse is caring for a child with disseminated intravascular coagulation (DIC).Which is a priority intervention for this child?

A) Frequent ambulation
B) Maintenance of skin integrity
C) Preparation for radiograph procedures
D) Monitoring of fluid restriction

Question 47

A nurse is providing discharge education to a client who is diagnosed with angina.Which statement would the nurse exclude from teaching?

A) "Stable angina is the most common form of angina."
B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise."
C) "Unstable angina occurs with increasing frequency, severity, and duration."
D) "Clients with unstable angina are at risk for a heart attack."

Question 48

A client with angina is experiencing acute chest pain.Which actions would the nurse implement at this time? Select all that apply.

A) Administer antianxiety medication as prescribed.
B) Coach in non-pharmacological pain management techniques.
C) Implement bed rest.
D) Administer morphine sulfate 2 mg intravenous push as prescribed.
E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.

Question 49

A client recovering from an acute myocardial infarction is prescribed aspirin.Which teaching points should the nurse include regarding this prescription? Select all that apply.

A) Report any itching after seven days of taking.
B) Check with your healthcare provider before taking herbal remedies.
C) Take at a different time of day than warfarin.
D) Report bleeding or bruising to the healthcare provider.
E) Do not skip any scheduled appointments to have blood drawn for labs.

Question 50

A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC).Which clinical manifestations does the nurse anticipate? Select all that apply.

A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions

Question 51

A client with disseminated intravascular coagulation (DIC)is anxious and has decreased oxygen saturation.Which is the priority nursing diagnosis for this client?

A) Pain
B) Impaired Gas Exchange
C) Ineffective Tissue Perfusion
D) Anxiety

Question 52

The nurse is providing discharge teaching to a postpartum client recovering from deep venous thrombosis (DVT).Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply.

A) Avoid crossing the legs.
B) Avoid long car trips.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
E) Take a daily aspirin dose of 650 mg.

Question 53

The nurse is planning care for a group of clients.Which client has the greatest risk for developing deep venous thrombosis (DVT)?

A) The client recovering from laparoscopic gallbladder surgery.
B) The client admitted with new-onset type II diabetes mellitus.
C) The client admitted with community-acquired pneumonia.
D) The client recovering from knee replacement surgery.

Question 54

A client receiving heparin therapy for deep venous thrombosis (DVT)complains of severe chest pain and shortness of breath.Suspecting a pulmonary embolism,which is the priority action by the nurse?

A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.

Question 55

The nurse is planning care for a client with deep venous thrombosis (DVT).Which nursing diagnosis would be a priority for this client?

A) Risk for Infection related to obstructed venous return
B) Excess Fluid Volume related to tissue edema
C) Ineffective Tissue Perfusion related to obstructed venous return
D) Disturbed Sleep Pattern related to tissue hypoxia

Question 56

A community health nurse is providing education to a group of adults regarding myocardial infarction (MI).When discussing ways to decrease the number of MI-related deaths,which statement by the nurse is inappropriate?

A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR) techniques."
B) "Be sure to take a baby aspirin every day to help prevent an MI."
C) "Increase your knowledge of cardiac health and cardiac-related disease."
D) "Seek immediate medical attention when you suspect an MI."

Question 57

The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC).Which observation indicates care has been successful for this client?

A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 mL per hour
D) No evidence of bleeding

Question 58

The nurse is providing care to a female client who is diagnosed with coronary artery disease.The client states to the nurse,"I don't know how this happened." Which response by the nurse is the most appropriate?

A) "Women who take oral contraceptives are more likely to develop this disease."
B) "Women who have children later in life often develop this disease"
C) "Women with a history of sexually transmitted infections are more likely to develop this disease."
D) "Women who conceive through the use in in-vitro fertilization are more likely to develop this disease."

Question 59

A client being treated for a deep venous thrombosis (DVT)is experiencing pain.Which interventions by the nurse are appropriate to assist this client? Select all that apply.

A) Apply an egg-crate mattress on the bed.
B) Maintain bed rest as ordered.
C) Apply warm moist heat to the area four times a day.
D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily.

Question 60

The nurse is planning an educational program to instruct clients on disseminating intravascular coagulation (DIC).What should the nurse include as risk factors for this health problem? Select all that apply.

A) Multiparity
B) Abruptio placentae
C) Preterm labor
D) Prolonged retention of a fetus after demise
E) Diabetes mellitus

Question 61

A client with disseminated intravascular coagulation (DIC)has a nursing diagnosis of Ineffective Tissue Perfusion.Which action is inappropriate for this nursing diagnosis?

A) Monitor the client's level of consciousness and mental status.
B) Elevate the client's knees on the bed or with a pillow.
C) Minimize the use of tape on the client's skin.
D) Assess extremity pulses, warmth, and capillary refill.

Question 62

A client with disseminated intravascular coagulation (DIC)has a nursing diagnosis of Impaired Gas Exchange.Which action is inappropriate when providing care based on this nursing diagnosis?

A) Place client in low-Fowler position to improve gas exchange.
B) Monitor the client's oxygen saturation continuously.
C) Maintain bed rest.
D) Encourage deep breathing and coughing.

Question 63

The nurse is positioning a client with left-sided heart failure in bed.Which sleeping position is most appropriate for this client?

A) Seated in a recliner with 2-3 pillows under feet
B) Lying on the left side with the head of the bed elevated 30°
C) Seated in a recliner with 2-3 pillows under head
D) Lying on either side with the head of the bed elevated 30°

Question 64

During hospitalization for congestive heart failure (CHF),a client awakens during the night frightened and short of breath.Based on this data,what is the client experiencing?

A) Cardiomyopathy
B) Paroxysmal nocturnal dyspnea
C) High-output failure
D) Multisystem heart failure

Question 65

A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition.Which condition would be excluded from the client's cause of heart failure?

A) Massive pulmonary embolus
B) Hyperthyroidism
C) Rheumatic fever
D) Volume overload

Question 66

The nurse is planning care for several clients.Which client has the greatest risk of developing heart failure?

A) A 69-year-old African-American male with hypertension
B) A 50-year-old African-American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma

Question 67

The nurse is assessing a client being treated for congestive heart failure (CHF).Which physical findings would indicate that the client's condition is not improving? Select all that apply.

A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus

Question 68

The nurse is caring for a child with heart failure (CHF).Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply.

A) Shortness of breath
B) Weight loss
C) Bradycardia
D) Tachycardia
E) Increased blood pressure

Question 69

A client diagnosed with systolic heart failure is admitted to the intensive care unit (ICU).When planning care for this client which does the nurse understand about systolic heart failure?

A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system.
B) Results when the heart cannot completely relax in diastole, disrupting normal filling.
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload.
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired relaxation of the heart muscle.

Question 70

The nurse teaches a client about lifestyle modifications to help manage hypertension.Which client statement indicates teaching has been effective?

A) "I won't be able to run in marathons anymore."
B) "I know I need to give up my cigarettes and alcohol."
C) "I need to get started on my medications right away."
D) "My father had hypertension, did nothing, and lived to be 90 years old."

Question 71

A client reports morning headache that extends into the neck and goes away as the day wears on.Based on this initial data,which does the nurse suspect that the client is experiencing?

A) A symptom of hypertension
B) A sinus headache
C) A migraine headache
D) Spinal stenosis

Question 72

A client is prescribed enalapril (Vasotec)for treatment of heart failure.Which assessment finding should cause the nurse concern following the initial administration of this drug?

A) Serious rash
B) Ototoxicity
C) Low blood pressure
D) Irregular pulse

Question 73

A client with disseminated intravascular coagulation (DIC)is experiencing joint pain.Which nursing intervention is appropriate for this client?

A) Splints
B) Cool compresses
C) Heat
D) Ice

Question 74

A nurse working in labor and delivery is caring for a client with suspected disseminated intravascular coagulation (DIC).Which pregnancy complication does the nurse anticipate when reviewing the client's chart?

A) Gestational diabetes
B) Polyhydramnios
C) Placental abruption
D) Placenta previa

Question 75

A nurse caring for a client with disseminated intravascular coagulation (DIC)is reviewing the client's diagnostic tests.Which test result is common in DIC?

A) Decreased prothrombin time
B) Increased platelet count
C) Decreased fibrinogen level
D) Decreased partial thromboplastin time

Question 76

A client diagnosed with disseminated intravascular coagulation (DIC)is currently bleeding through the gastrointestinal tract.Which prescription does the nurse anticipate for this client?

A) Aspirin
B) Coumadin
C) Fresh frozen plasma and platelets
D) Heparin

Question 77

A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator.The client appears comfortable at rest but displays dyspnea with activities of daily living (ADLs).In which stage of heart failure does the nurse classify this client?

A) I
B) II
C) III
D) IV

Question 78

A nurse caring for clients with heart failure must be aware of the compensatory mechanisms activated in heart failure.Which physiology is not associated with the neuroendocrine compensatory mechanism?

A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate.
B) Decreased CO stimulates the sympathetic nervous system and catecholamine release.
C) Decreased CO and decreased renal perfusion stimulate the renin-angiotensin system.
D) Antidiuretic hormone is released from posterior pituitary.

Question 79

During an assessment,a client with congestive heart failure (CHF)and severe shortness of breath tells the nurse about not having enough money to purchase medications.What nursing diagnosis is of the greatest initial importance when planning care?

A) Excess Fluid Volume related to shortness of breath
B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
C) Fatigue related to shortness of breath
D) Activity Intolerance related to shortness of breath

Question 80

The nurse is planning care for an infant with congestive heart failure (CHF).What should the nurse include in this child's care?

A) Give larger feedings less often to conserve energy.
B) Organize activities to allow for uninterrupted sleep.
C) Monitor respirations during active periods.
D) Force fluids appropriate for age.