ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 24 : Caring for Clients With Valvular Disorders of the Heart Questions
Question 1 of 5
The nurse is caring for a client who just received a percutaneous balloon valvuloplasty for the treatment of mitral stenosis. For which finding should the nurse assess?
Correct Answer: B
Rationale: The balloon valvuloplasty stretches the valve and can impair the papillary muscles, resulting in regurgitation of blood back through the mitral valve. A percutaneous balloon valvuloplasty does not have an incision and does not use a porcine graft. The septum is perforated and can allow shunting of blood but the shunting, if occurs, will move from left to right.
Question 2 of 5
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
Correct Answer: A
Rationale: A cough with productive, pink, frothy sputum and crackles in the bases of the lungs are signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive failure, thrombophlebitis, or cardiogenic shock.
Question 3 of 5
The nurse is interviewing a client who is being admitted for possible mitral regurgitation. Which historical fact is of greatest value to the nurse?
Correct Answer: B
Rationale: Rheumatic fever and subsequent heart disease is the prominent cause of valvular insufficiency. Congenital neural tube defect is associated with spina bifida not mitral regurgitation. Smoking and insertion of pacemaker are significant to heart disorders but not of greatest value as rheumatic fever.
Question 4 of 5
The nurse provides care for an older adult client who is diagnosed with valvular heart disease. On auscultation of the client's heart sounds, the nurse notes an erratic heart rhythm. Which age-related change is the most likely cause for this finding?
Correct Answer: A
Rationale: Age-related effects, such as stiffening of the aorta, calcification, and fibrotic thickening (not thinning) of the mitral and aortic valves, contribute to development of symptoms (e.g., increased systolic blood pressure [BP], dangerous arrhythmias [erratic heart rhythms or rates that are too fast or slow] sometimes referred to as dysrhythmias) and complications (e.g., increased myocardial oxygen demand, heart failure, and alterations in cardiac output) in the older adult with valvular heart disease. A decrease in metabolism is an age-related effect for clients with valvular heart disease; however, this affects the dosage of prescribed medication and is not the cause of the client's dysrhythmia. A decrease, not increase, in thirst sensation is an age-related change that could lead to dehydration, and, thus, changes in the client's heart rhythm.
Question 5 of 5
The nurse is caring for a client with mitral stenosis. Which assessment finding would cause the greatest concern in providing nursing care to this client?
Correct Answer: A
Rationale: A damaged mitral valve leads to incomplete emptying of the left atrium and accumulation of blood resulting in increased pressure. As the backup of blood continues, pressure is increased into the lungs and right ventricle and cardiac output decreases.