Nokea
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time did he take his last medications?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours did he sleep last night?
Correct Answer: B
Rationale: Weight gain is a key indicator of fluid retention in heart failure, which can exacerbate symptoms.
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During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position?
- A. Sitting
- B. Supine
- C. Squatting
- D. Standing
Correct Answer: C
Rationale: Squatting naturally increases SVR by occluding venous return from the lower extremities, thereby increasing pulmonary blood flow.
Paroxysmal hypercyanotic attacks (hypoxic, blue, or tet spells) are a particular problem during the lst 2 yr of life. They are characterized by
- A. early evening occurrence
- B. an increase in intensity of the systolic murmur
- C. unpredictable onset
- D. metabolic alkalosis
Correct Answer: A
Rationale: Unpredictable onset and metabolic alkalosis are common features of tet spells.
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, 'visual sensory/perceptual alterations.' This diagnosis is based on which etiology?
- A. Limited eye movement
- B. Decreased peripheral vision
- C. Blurred distance vision
- D. Photosensitivity
Correct Answer: B
Rationale: Open angle glaucoma primarily affects peripheral vision, leading to visual sensory/perceptual alterations.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
- A. Excruciating pain on inspiration
- B. Left lateral chest wall pain
- C. Disorientation and confusion
- D. Numbness and tingling of the arm
Correct Answer: C
Rationale: Older adults may present with atypical symptoms of myocardial infarction, such as confusion or disorientation, rather than classic chest pain.
What should the nurse assess prior to administering digoxin? (Select all that apply.)
- A. Sclera
- B. Apical pulse rate
- C. Cough
- D. Liver function test
Correct Answer: B
Rationale: Because digoxin decreases the heart rate, the apical pulse should be assessed. If the HR is below 60 beats per minute, digoxin should not be administered.