Nokea
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.
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If the client is typical of others who have angina pectoris, the nurse should expect the client to report that chest pain is best relieved by which major medical measure?
- A. Taking a deep breath
- B. Resting in a chair
- C. Applying heat to the chest
- D. Rubbing the chest
Correct Answer: B
Rationale: Angina pectoris is relieved by rest, which reduces myocardial oxygen demand, allowing blood flow to meet the heart's needs.
An adult client with peripheral vascular disease tells the nurse he is afraid his left leg is not improving and may need to be amputated. How should the nurse respond?
- A. You and your wife should discuss your feelings before surgery.'
- B. You sound concerned about your leg and possible surgery.'
- C. It is better to have an amputation when the ulcers are not improving.'
- D. You don't need to be afraid of surgery.'
Correct Answer: B
Rationale: Reflecting the client’s concern encourages open communication and validates his feelings, promoting therapeutic dialogue.
A low-sodium, low-cholesterol, weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
- A. Baked skinless chicken and mashed potatoes
- B. Stir-fried Chinese vegetables and rice
- C. Tuna fish salad with celery sticks
- D. Grilled lean steak Ascertainly grilled lean steak with carrots
Correct Answer: A
Rationale: Baked skinless chicken and mashed potatoes are low in sodium and cholesterol, making them suitable for a heart-healthy diet. Stir-fried vegetables may contain high sodium sauces, tuna salad may include high-sodium dressings, and grilled steak is higher in cholesterol.
The nurse assumes that the client understands how an echocardiogram is performed when that client tells the nurse that this examination involves imaging the heart using which of one of the following?
- A. Ultrasound waves
- B. X-ray beams
- C. Radioactive isotopes
- D. Magnetic fields
Correct Answer: A
Rationale: An echocardiogram uses ultrasound waves to create images of the heart's structure and function.
During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.