Essentials of Pathophysiology 4th Edition Porth Test Bank

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Essentials of Pathophysiology 4th Edition Porth Test Bank

ISBN-13: 978-1451190809

ISBN-10: 1451190808



Essentials of Pathophysiology 4th Edition Porth Test Bank

ISBN-13: 978-1451190809

ISBN-10: 1451190808




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Free Nursing Test Questions:

Chapter 20- Heart Failure and Circulatory Shock

1. When lecturing to a group of students about the pathophysiological principles behind heart failure, the instructor explains that cardiac output represents:
  A) Strength of the right ventricular pump to move blood
  B) The amount of blood the heart pumps each minute
  C) The amount of blood pumped out of the heart with each beat
  D) The volume of blood stretching the heart muscle at the end of diastole
  Ans: B
  Cardiac output, which is the major determinant of cardiac performance, reflects how often the heart beats each minute (heart rate) and how much blood it ejects with each beat (stroke volume). Preload reflects the volume of blood that stretches the ventricle at the end of diastole, just before the onset of systole.



2. A client has been experiencing increasing fatigue in recent months, a trend that has prompted an echocardiogram. Results of this diagnostic test suggest that the client’s end-diastolic volume is insufficient. Which of the following parameters of cardiac performance will directly decrease as a result of this?
  A) Inotropy
  B) Cardiac contractility
  C) Preload
  D) Afterload
  Ans: C
  Preload is the volume of blood stretching the heart muscle at the end of diastole and is normally determined mainly by the venous return to the heart. Afterload represents the force that the contracting heart muscle must generate to eject blood from the filled heart. Cardiac contractility, or inotropy, is the contractile performance of the heart.



3. One of the principal mechanisms by which the heart compensates for increased workload is:
  A) Myocardial hypertrophy
  B) Sodium and water retention
  C) Endothelin vasoconstrictors
  D) Ventricular wall tension increase
  Ans: A
  The development of myocardial hypertrophy constitutes one of the principal mechanisms by which the heart compensates for an increase in workload. There are at least two types of endothelin receptors, and it is thought that the peptide may play a role in mediating noncompensatory pulmonary hypertension in persons with heart failure. One effect of a lowered cardiac output in heart failure is a noncompensatory reduction in renal blood flow and glomerular filtration rate, which leads to salt and water retention. Because increased wall tension increases myocardial oxygen requirements, it can produce noncompensatory ischemia and further impairment of cardiac function.



4. A client with heart failure asks, “Why am I taking a ‘water pill’ when it’s my heart that is having a problem?” While educating the client about the Frank-Starling mechanism, which of the following explanations is most appropriate to share?
  A) “You must be drinking way too many liquids. Your kidneys cannot filter all that you are drinking during the day.”
  B) “Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water.”
  C) “Your heart muscle is overstretchedRemember, it’s not able to pump all the blood out. The prescribed ‘water pills’ help by decreasing your weight.”
  D) “Since your heart function is impaired, the lungs are not able to oxygenate the blood and your kidneys are wearing out.”
  Ans: B
  In heart failure with a reduced ejection fraction, a decrease in cardiac output and renal blood flow leads to increased sodium and water retention by the kidney with a resultant increase in vascular volume and venous return to the heart and an increase in ventricular end-diastolic volume. Drinking water may increase volume but is not the physiological reason for retention of fluid. Diuretics do decrease weight as a result of diuresis, but weight loss is not the purpose for giving diuretics. The lungs are not the primary cause of heart failure.



5. The most recent blood work of a client with a diagnosis of heart failure indicates increased levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). What is the most likely effect of these peptides on the client’s physiology?
  A) Water retention
  B) Increased tubular sodium reabsorption
  C) Inhibition of the renin–angiotensin–aldosterone system
  D) Sympathetic nervous stimulation
  Ans: C
  The NPs inhibit the sympathetic nervous system and the renin–angiotensin–aldosterone system, in addition to decreasing tubular sodium and water reabsorption.



6. At the cellular level, cardiac muscle cells respond to an increase in ventricular volume to the point of overload by: Select all that apply.
  A) Elongating the cardiac muscle cells
  B) Thickening of the individual myocytes
  C) Replicating the myofibrils
  D) Decreasing the ventricular wall thickness
  E) Symmetrically widening and lengthening the hypertrophy
  Ans: A, D
  At the cellular level, cardiac muscle cells respond to stimuli from stress placed on the ventricular wall by pressure and volume overload by initiating several different processes that lead to hypertrophy. With ventricular volume overload, the increase in wall stress leads to replication of myofibrils in series, elongation of the cardiac muscle cells, and eccentric hypertrophy. Eccentric hypertrophy leads to a decrease in ventricular wall thickness or thinning of the wall with an increase in diastolic volume and wall tension. Production of a symmetric hypertrophy occurs with a proportionate increase in muscle length and width, as occurs in athletes; concentric hypertrophy with an increase in wall thickness, as occurs in hypertension; and eccentric hypertrophy with a disproportionate increase in muscle length, as occurs in dilated cardiomyopathy. When the primary stimulus for hypertrophy is pressure overload, the increase in wall stress leads to parallel replication of myofibrils, thickening of the individual myocytes, and concentric hypertrophy. Concentric hypertrophy may preserve systolic function for a time, but eventually the work performed by the ventricle exceeds the vascular reserve, predisposing to ischemia.



7. From the following clients, who are at high risk for developing heart failure as a result of diastolic dysfunction? Select all that apply.
  A) A 48-year-old client with uncontrolled hypertension
  B) A marathon runner with history of chronic bradycardia whose pulse rate is 46
  C) A 57-year-old client with history of ischemic heart disease
  D) A 70-year-old with enlarged left ventricle due to myocardial hypertrophy
  Ans: A, D
  Conditions that reduce the heart’s ability to adequately fill during diastole, such as myocardial hypertrophy and tachycardia, can lead to heart failure. Hypertension remains the leading cause of diastolic dysfunction. Ischemic heart disease is associated with systolic heart failure, or impaired contractile performance. It is normal for athletes, like marathon runners, to have slow pulses.



8. The most common causes of left-sided heart failure include:
  A) Acute myocardial infarction
  B) Chronic pulmonary disease
  C) Impaired renal blood flow
  D) Tricuspid valve regurgitation
  Ans: A
  The most common causes of left-sided heart failure are acute myocardial infarction and hypertension. Acute or chronic pulmonary disease can cause right heart failure, referred to as cor pulmonale. The causes of right-sided heart failure include stenosis or regurgitation of the tricuspid or pulmonic valves, right ventricular infarction, and cardiomyopathy. Manifestations (rather than causes) of heart failure reflect the physiologic effects of the impaired pumping ability of the heart, including decreased renal blood flow.



9. Assessment of an elderly female client reveals the presence of bilateral pitting edema of the client’s feet and ankles and pedal pulses that are difficult to palpate. Auscultation of the client’s lungs reveals clear air entry to bases, and the client’s oxygen saturation level is 93%, and vital signs are within reference ranges. What is this client’s most likely health problem?
  A) Right-sided heart failure
  B) Pericarditis
  C) Cardiogenic shock
  D) Cor pulmonale
  Ans: A
  A major effect of right-sided heart failure is the development of peripheral edema. A client who is in shock would not have stable vital signs. Cor pulmonale would be accompanied by manifestations of lung disease. Pericarditis is an inflammation of the pericardium exhibited by fever, precordial pain, dyspnea, and palpitations.



10. While teaching a client with new-onset right-sided heart failure, the nurse should educate the client to monitor for fluid accumulation by:
  A) Weighing every day at the same time with same type of clothing
  B) Measuring all of the client’s urine output daily to check for a decrease in output
  C) Listening to the breath sound with a stethoscope every morning
  D) Take blood pressure daily and call doctor if it is decreased
  Ans: A
  When the right heart fails, a damming back of blood occurs, leading to its accumulation in the systemic venous system, causing an increase in right atrial, right ventricular end-diastolic, and systemic venous pressures. The accumulation of fluid (edema) is evidenced by a gain in weight (i.e., 1 pint of accumulated fluid results in a 1-pound weight gain). Shortness of breath due to congestion of the pulmonary circulation is one of the major manifestations of left-sided heart failure. It is unrealistic to expect clients to listen to their own breath sounds. BP measurement could be an intervention; however, it is not a primary indicator of edema from right-sided heart failure. With impairment of left heart function, there is a decrease in cardiac output, with resulting decreased renal perfusion and output.



11. The shortness of breath and cyanosis that occur in clients experiencing acute heart failure syndrome are primarily caused by: Select all that apply.
  A) Accumulation of fluid in the alveoli and airways
  B) Lung stiffness
  C) Worsening renal failure
  D) Myocardial muscle necrosis
  E) Impaired gas exchange
  Ans: A, B, E
  Acute pulmonary edema is the most dramatic symptom of AHFS. It is a life-threatening condition in which capillary fluid moves into the alveoli. The accumulated fluid in the alveoli and airways causes lung stiffness, makes lung expansion more difficult, and impairs the gas exchange function of the lung. With the decreased ability of the lungs to oxygenate the blood, the hemoglobin leaves the pulmonary circulation without being fully oxygenated, resulting in shortness of breath and cyanosis. Worsening renal failure and MI may cause volume overload but are more likely secondary causes of chronic heart failure.



12. While in the ICU, a client’s status changes. The health care providers suspect heart failure. Which of the following diagnostic procedures would give the staff information about pulmonary capillary pressures, which will lead to the most appropriate interventions?
  A) Echocardiography
  B) Radionuclide ventriculography
  C) Cardiac magnetic resonance imaging
  D) Hemodynamic monitoring
  Ans: D
  Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. These monitoring methods include central venous pressure (CVP), pulmonary artery pressure monitoring, measurements of cardiac output, and intra-arterial measurements of blood pressure. Echocardiography plays a key role in assessing ejection fraction, right and left ventricular wall, wall thickness, ventricular chamber size, valve function, heart defects, and pericardial disease. Radionuclide ventriculography is recommended if there is reason to suspect coronary artery disease or ischemia as the underlying cause for heart failure. Cardiac magnetic resonance imaging and cardiac computed tomography are used to document ejection fraction, ventricular preload, and regional wall motion.



13. A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which of the following statements demonstrates an accurate understanding of his new diagnosis?
  A) “I’ll be sure to take my beta blocker whenever I feel short of breath.”
  B) “I’m going to avoid as much physical activity as I can so that I preserve my strength.”
  C) “I know it’s healthy to drink a lot of water, and I’m going to make sure I do this from now on.”
  D) “I’m trying to think of ways that I can cut down the amount of salt that I usually eat.”
  Ans: D
  Salt and fluid restrictions are indicated for most clients with heart failure (HF). Beta blockers do not address shortness of breath, and cardiac medications are not normally taken in response to acute symptoms. Clients should be encouraged to maintain, and increase, physical activity within the limits of their condition.



14. A client with a diagnosis of heart failure has returned from a visit with his primary care provider with a prescription for a change in his daily medication regimen. Which of the following drugs is likely to improve the client’s cardiac function by increasing the force and strength of ventricular contractions?
  A) A b-adrenergic blocker
  B) A diuretic
  C) A cardiac glycoside
  D) An ACE inhibitor
  Ans: C
  Cardiac glycosides improve cardiac function by increasing the force and strength of ventricular contractions. b-Adrenergic blockers decrease left ventricular dysfunction associated with activation of the sympathetic nervous system. ACE inhibitors block the conversion of angiotensin I to II, whereas diuretics promote the excretion of fluid.



15. A client awaiting a heart transplant is experiencing decompensation of her left ventricle that will not respond to medications. The physicians suggest placing the client on a ventricular assist device (VAD). The client asks what this equipment will do. The health care providers respond:
  A) “Pull your blood from the right side of the heart and run it through a machine to oxygenate it better, and then return it to your body.”
  B) “Measure the pressures inside your heart continuously to asses pumping ability of your left ventricle.”
  C) “Have a probe at the end of a catheter to obtain thermodilution measuresRemember, cardiac output can be calculated.”
  D) “This device will decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure.”
  Ans: D
  Refractory heart failure reflects deterioration in cardiac function that is unresponsive to medical or surgical interventions. Ventricular assist devices (VADs) are mechanical pumps used to support ventricular function. VADs are used to decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure. This decreases the workload on the ventricle and allows it to rest and recover. The rest of the distractors relate to the monitoring in an ICU of cardiac functioning. Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. With the balloon inflated, the catheter monitors pulmonary capillary pressures (i.e., pulmonary capillary wedge pressure or pulmonary artery occlusion pressure), which reflect pressures from the left ventricle. The pulmonary capillary pressures provide a means of assessing the pumping ability of the left ventricle. One type of pulmonary artery catheter is equipped with a thermistor probe to obtain thermodilution measurements of cardiac output.



16. An 86-year-old male client is disappointed to learn that he has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which of the following age-related changes predisposes older adults to developing heart failure?
  A) Increased vascular stiffness
  B) Orthostatic hypotension
  C) Increased cardiac contractility
  D) Loss of action potential
  Ans: A
  Increased vascular stiffness in older adults causes a progressive increase in systolic blood pressure with advancing age, which in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. A loss of action potential does not typically accompany aging, and contractility tends to decrease as a result of cardiac stiffness. Orthostatic hypotension is neither a normal age-related change nor a cause of heart failure.



17. A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client’s heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of:
  A) Pulmonary embolism due to development of deep vein thrombosis
  B) Side effects from versed administration causing excessive vasoconstriction
  C) Renal failure due to an overdose of medication
  D) Hypovolemic shock due to acute intravascular volume loss
  Ans: D
  Hypovolemic shock is characterized by diminished blood volume such that there is inadequate filling of the vascular compartment. Hypovolemic shock also can result from an internal hemorrhage or from third-space losses, when extracellular fluid is shifted from the vascular compartment to the interstitial space or compartment, without fluid movement in/out of the cells. Within seconds after the onset of hemorrhage or the loss of blood volume, compensatory manifestations of tachycardia, vasoconstriction, and other signs of sympathetic and adrenal medullary activity appear. There is no indication that this client has developed a pulmonary embolism, is having side effects from versed administration, or is going into renal failure due to an overdose of medication.



18. Electrical burns over a large surface area of a client’s body have resulted in hypovolemic shock after the loss of large amounts of blood and plasma. Following physical assessment, which findings lead the nurse to believe the client’s body is compensating for this fluid loss? Select all that apply.
  A) Increased heart rate
  B) Vasodilation with warm extremities
  C) Diuresis with output of 100 mL/hour
  D) The client complaining of extreme thirst
  E) Deep, rapid respirations
  Ans: A, D, E
  Compensatory mechanisms in hypovolemic shock include increased heart rate, peripheral vasoconstriction, and fluid and sodium retention in order to preserve vascular volume. Urine output decreases very quickly in hypovolemic shock. Thirst is an early symptom in hypovolemic shock. As shock progresses, the respirations become rapid and deep to compensate for the increased production of acid and decreased availability of oxygen.



19. In an ICU setting, one assessment that would lead the nurse to suspect shock has resulted in decrease blood flow to vital organs is:
  A) Warm legs with peripheral vasodilation
  B) Urine output less than 20 mL/hour
  C) Blood pressure staying in the 98/72 range for the past hour
  D) Sleepiness and difficulty to arouse without using painful stimuli
  Ans: B
  Continuous measurement of urine output is essential for assessing the circulatory status of a person in shock. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion. Continuous measurement of urine output is essential for assessing the circulatory and volume status of the person in shock and monitoring the response to fluid replacement. As the shock progresses and blood flow to the brain decreases, restlessness is replaced by apathy and stupor. Sympathetic stimulation also leads to intense vasoconstriction of the skin vessels and activation of the sweat glands. As a result, the skin is cool and moist. There is an increase in heart rate, cool and clammy skin, a decrease in arterial blood pressure, and a decrease in urine output.



20. A client has arrived in the emergency department in cardiogenic shock. Which of the following assessment findings confirm this diagnosis? Select all that apply.
  A) Bright red color noted in the nail beds and lips
  B) Less than 5 mL dark, concentrated urine in the past hour
  C) BP reading of 80/65
  D) Difficult to arouse with changes in level of consciousness
  E) Diminished breath sounds in the bases, bilaterally
  Ans: B, C, D
  The signs and symptoms of cardiogenic shock are consistent with those of end-stage heart failure. The lips, nail beds, and skin may become cyanotic because of stagnation of blood flow. Mean arterial and systolic blood pressures decrease due to poor stroke volume, and there is a narrow pulse pressure because of arterial vasoconstriction. Urine output decreases because of lower renal perfusion pressures and the increased release of aldosterone. Neurologic changes, such as alterations in cognition or consciousness, may occur because of low cardiac output and poor cerebral perfusion.



21. A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged and resulted in a pulmonary embolism. Which of the following types of shock is this client at risk of experiencing?
  A) Cardiogenic shock
  B) Hypovolemic shock
  C) Obstructive shock
  D) Distributive shock
  Ans: C
  Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.



22. A family member comes rushing out of a client’s room telling the nurse that the loved one can’t breathe. The nurse has just left the room after hanging IV penicillin. Which of the following clinical manifestations lead the nurse to suspect the client is experiencing anaphylactic shock? Select all that apply.
  A) Incontinent of urine
  B) Severe bronchospasm
  C) Wheezing sound on inspiration
  D) Hives over entire body
  E) Swelling around the lips and eyes
  Ans: B, C, D, E
  Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. These substances cause vasodilation of arterioles and venules along with a marked increase in capillary permeability. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema. The onset and severity of anaphylaxis depend on the sensitivity of the person and the rate and quantity of antigen exposure. Signs and symptoms associated with impending anaphylactic shock include abdominal cramps; apprehension; warm or burning sensation of the skin, itching, and urticaria (i.e., hives); and respiratory distress such as coughing, choking, wheezing, chest tightness, and difficulty in breathing.



23. For which of the following types of shock might intravenous antibiotic therapy be indicated?
  A) Obstructive shock
  B) Distributive shock
  C) Cardiogenic shock
  D) Hypovolemic shock
  Ans: B
  Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.



24. Severe shock can be followed by acute lung injury/acute respiratory distress syndrome (ALI/ARDS) characterized by:
  A) Hyperventilation
  B) Excessive surfactant
  C) Hyperinflated alveolar sacs
  D) Ventilation–perfusion mismatch
  Ans: D
  Despite the delivery of high levels of oxygen using high-pressure mechanical ventilatory support and positive end-expiratory pressure, many persons with ALI/ARDS remain hypoxic, often with a fatal outcome. Arterial blood gas analysis establishes the presence of profound hypoxemia with hypercapnia, resulting from impaired matching of ventilation and perfusion and from the greatly reduced diffusion of blood gases across the thickened alveolar membranes. Abnormalities in the production, composition, and function of surfactant may contribute to alveolar collapse and gas exchange abnormalities.



25. In the ICU setting, clients who develop shock need thorough head-to-toe assessments. Which of the following clinical manifestations would alert the health care provider that the client may be developing ischemia associated with gastrointestinal redistribution of blood flow?
  A) Gastric bleeding
  B) Nausea and vomiting
  C) Irritable bowel syndrome
  D) Copious high-volume diarrhea
  Ans: A
  In shock, there is widespread constriction of blood vessels that supply the gastrointestinal tract, causing a redistribution of blood flow that severely diminishes mucosal perfusion. Bleeding is a common symptom of gastrointestinal ulceration caused by shock, with onset usually within 2 to 10 days after the original insult. Nausea is unrelated to ischemic damage; irritable bowel syndrome is stress related. With ischemia, the bowel ceases to function, causing a lack of peristalsis and no fecal output.





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