Nokea
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
- A. Thrombophlebitis
- B. Stroke
- C. Pulmonary embolism
- D. Myocardial infarction
- E. Cardiac tamponade
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
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An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs
- B. I see lights flashing in front of my eyes
- C. I have trouble remembering things
- D. I wake up to urinate multiple times at night
Correct Answer: A
Rationale: Dyspnea on exertion, such as shortness of breath when climbing stairs, is an early manifestation of heart failure due to reduced cardiac output during activity. The other symptoms are not specific to heart failure.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. An 80-year-old male with a history of asthma
- B. A 32-year-old Asian-American male with colorectal cancer
- C. A 45-year-old American Indian female with diabetes mellitus
- D. A 53-year-old postmenopausal woman who is on hormone therapy
Correct Answer: C
Rationale: The incidence of coronary artery disease and hypertension is higher in American Indians than in other populations. Diabetes mellitus further increases the risk for cardiovascular disease in any population, making the 45-year-old American Indian female with diabetes mellitus the client with the greatest risk.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
- A. I wake up to go to the bathroom at night
- B. My shoes fit tighter by the end of the day
- C. I drink at least eight glasses of water a day
- D. I have gained 5 pounds in the last month
Correct Answer: B
Rationale: Edema is characterized by fluid accumulation in interstitial spaces, often causing swelling that makes shoes or clothing feel tighter, especially at the end of the day. This symptom is indicative of edema, unlike the other options.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching?
- A. The best way to lose weight is a high-protein, low-carbohydrate diet
- B. Follow the American Heart Association guidelines for nutrition
- C. A nutritionist will provide you with information about your new diet
- D. If you exercise more frequently, you won't need to change your diet
Correct Answer: B
Rationale: Clients at high risk for coronary artery disease should follow the American Heart Association guidelines, which emphasize a balanced diet low in saturated fats and high in fruits, vegetables, and whole grains to reduce cardiovascular risk.
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 or confusion
- D. Numbness and tingling of the arm
Correct Answer: C
Rationale: In older adults, myocardial infarction may present with atypical symptoms such as disorientation or confusion due to poor cardiac output and reduced cerebral perfusion. While pain or numbness may occur, confusion is a critical manifestation in this population.