Nokea
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
- A. Sympathetic nervous system activation.
- B. Renin-angiotensin-aldosterone system activation.
- C. Myocardial hypertrophy.
- D. Natriuretic peptide release.
- E. Ventricular dilation.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (A), renin-angiotensin-aldosterone system (B), myocardial hypertrophy (C), natriuretic peptide release (D), and ventricular dilation (E) to compensate for reduced cardiac output.
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After a laminectomy, the client states, 'The physician said that I can do anything I want to.' Which of the following client-stated activities indicates the need for further teaching?
- A. Drying the dishes.
- B. Sitting outside on firm cushions.
- C. Making the bed walking from side to side.
- D. Sweeping the front porch.
Correct Answer: D
Rationale: Sweeping involves twisting and bending, which can strain the surgical site post-laminectomy.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
A client has undergone an amputation of several toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated for her while sitting in a chair?
- A. Crossing the legs
- B. Elevating the legs
- C. Flexing the ankles
- D. Extending the knees
Correct Answer: A
Rationale: Crossing the legs is contraindicated post-femoral-popliteal bypass and toe amputation, as it compresses blood vessels, impairing circulation and increasing the risk of graft occlusion or ischemia. Elevating legs, flexing ankles, and extending knees are generally acceptable unless otherwise specified.
A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
- A. Position changes every 4 hours.
- B. Nasotracheal suctioning to clear secretions.
- C. Frequent linen changes.
- D. Frequent offering of a bedpan.
Correct Answer: C
Rationale: Diaphoresis from fever causes damp linens, which can lead to discomfort and skin breakdown; frequent linen changes are needed. Position changes aid lung expansion but are less urgent. Suctioning is invasive and not routinely required. Bedpan use depends on mobility, not fever.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.