Nokea
A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?
- A. Reports the client to the police for illegal drug use
- B. Explains to the client the damage that cocaine does to the heart
- C. Tells the client it is imperative to stop before myocardial infarction occurs
- D. Teaches about the effects of cocaine on the heart and offers a referral for further help
Correct Answer: D
Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police or simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care.
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A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?
- A. Anterior chest pain
- B. Pericardial friction rub
- C. Weakness and irritability
- D. Chest pain that worsens with inspiration
Correct Answer: B
Rationale: Pericardial friction rub is a distinctive sign of pericarditis, characterized by a scraping or grating sound heard on auscultation, which helps differentiate pericarditis from other cardiopulmonary conditions. Anterior chest pain may be present in various cardiopulmonary issues. Weakness and irritability are nonspecific symptoms, and chest pain worsening with inspiration is more indicative of pleuritic conditions.
The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?
- A. Surgical tourniquet
- B. Dry sterile dressings
- C. Incentive spirometer
- D. Over-the-bed trapeze
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of angina is scheduled for an exercise electrocardiography (ECG) test. The nurse should explain that the purpose of this test is to evaluate which factor?
- A. The heart's response to physical stress
- B. The client's overall physical fitness
- C. The presence of electrolyte imbalances
- D. The effectiveness of anti-anginal medications
Correct Answer: A
Rationale: An exercise electrocardiography (ECG) test is used to evaluate the heart's response to physical stress. During the test, the heart's electrical activity is monitored while the client exercises, helping to identify any areas of ischemia or abnormal rhythms. This test helps healthcare providers assess the heart's function and detect any potential issues related to angina or other cardiac conditions.
A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic?
- A. Dark pink base
- B. Deep and painful
- C. Accompanied by very slight pain
- D. Brown pigmentation of surrounding skin
Correct Answer: B
Rationale: Arterial ischemic ulcers are typically characterized by being deep and painful, often with a pale or necrotic base. The lack of adequate blood flow leads to tissue damage, resulting in these ulcers having a deep appearance and causing significant pain to the individual. The other options are not commonly associated with arterial ischemic ulcers; a dark pink base, very slight pain, or brown pigmentation of surrounding skin are not typical features of this type of ulcer.
The healthcare provider is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The provider should place the highest priority on making sure that which is available at the bedside?
- A. Bedside commode
- B. Rolling shower chair
- C. Oxygen tubing and flowmeter
- D. Twelve-lead electrocardiogram (ECG) machine
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.