ATI Care of Patients with Cardiac Problems, Questions and Answers with Explanations

1. A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?

a.	A decrease in blood pressure and urine output
b.	An increase in creatinine and extremity edema
c.	An increase in heart rate and respiratory rate
d.	A decrease in respirations and oxygen saturation

ANS: C

In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 746

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change?

a.	Increase in stroke volume
b.	Decrease in tissue perfusion
c.	Increase in oxygen saturation
d.	Decrease in arterial vasoconstriction

ANS: B

In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure?

a.	Middle-aged woman with aortic stenosis
b.	Middle-aged man with pulmonary hypertension
c.	Older woman who smokes cigarettes daily
d.	Older man who has had a myocardial infarction

ANS: A

Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure?

a.	“I have been drinking more water than usual.”
b.	“I have been awakened by the need to urinate at night.”
c.	“I have to stop halfway up the stairs to catch my breath.”
d.	“I have experienced blurred vision on several occasions.”

ANS: C

Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 748

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client?

a.	“Please come into the clinic for an evaluation.”
b.	“Increase your fluid intake during waking hours.”
c.	“Use an over-the-counter cough suppressant.”
d.	“Sleep on two pillows to facilitate postnasal drainage.”

ANS: A

The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure?

a.	“I sleep with four pillows at night.”
b.	“My shoes fit really tight lately.”
c.	“I wake up coughing every night.”
d.	“I have trouble catching my breath.”

ANS: B

Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 748

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation)

MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse notes that the client’s apical pulse is displaced to the left. What conclusion can be drawn from this assessment?

a.	This is a normal finding.
b.	The heart is hypertrophied.
c.	The left ventricle is contracted.
d.	The client has pulsus alternans.

ANS: B

The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Category	ATI
Release date	2021-09-14
Pages	23
Language	English
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