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A nurse is providing patient teaching to a patient who has been experiencing unstable angina. What will the nurse's explanation of this condition include?
- A. A coronary vessel has become completely occluded and is unable to deliver blood to the heart.
- B. The pain is caused by a spasm of a blood vessel not just by the vessel narrowing.
- C. Your body response to a lack of oxygen in the heart muscle is pain.
- D. There is a serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart.
Correct Answer: B,D
Rationale: The correct answers are B and D. For choice B, in unstable angina, the pain is often caused by a spasm of a blood vessel in addition to vessel narrowing, leading to reduced blood flow. This explanation is important for the patient to understand the multifactorial nature of their condition. For choice D, unstable angina is typically due to a serious narrowing of a coronary artery, resulting in reduced oxygen supply to the heart. This explanation helps the patient comprehend the underlying cause of their symptoms. Choices A and C are incorrect as they do not accurately describe unstable angina. Choice A suggests complete vessel occlusion, which is more characteristic of a heart attack. Choice C simplifies the cause of the pain to just a lack of oxygen, omitting the role of vessel narrowing and spasm.
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The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in the patient?
- A. Gastrointestinal (GI) and lower extremity muscles.
- B. Central nervous system (CNS), memory, and cognition.
- C. Respiratory and facial muscles.
- D. Cardiovascular system and postural muscles.
Correct Answer: C
Rationale: The correct answer is C: Respiratory and facial muscles. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. Symptoms commonly affect muscles involved in breathing (respiratory) and facial expressions, such as difficulty swallowing, breathing, speaking, and facial drooping. Monitoring these systems is crucial as respiratory muscle weakness can lead to respiratory failure. Choice A is incorrect because myasthenia gravis does not typically affect gastrointestinal or lower extremity muscles primarily. Choice B is incorrect as the primary symptoms of myasthenia gravis do not involve the central nervous system but rather the neuromuscular junction. Choice D is incorrect as myasthenia gravis does not directly impact the cardiovascular system or postural muscles.
What drug enhances the output of respiratory tract fluid by reducing the adhesiveness and surface tension of the fluid which facilitates the removal of viscous mucus?
- A. Guaifenesin.
- B. Dextromethorphan.
- C. Acetylcysteine.
- D. Flunisolide.
Correct Answer: A
Rationale: The correct answer is A: Guaifenesin. Guaifenesin is an expectorant that works by increasing respiratory tract fluid output, reducing adhesiveness and surface tension of the mucus. This helps in loosening and thinning the mucus, making it easier to clear from the airways. Dextromethorphan (B) is a cough suppressant, not an expectorant. Acetylcysteine (C) is a mucolytic that reduces mucus thickness but does not directly enhance fluid output. Flunisolide (D) is a corticosteroid used for inflammation, not mucus clearance.
The nurse is providing teaching to a patient who is prescribed an HMG-CoA reductase inhibitor. What will be an important teaching point for this patient?
- A. Use barrier contraception to avoid pregnancy.
- B. Report any changes in vision.
- C. Follow a cholesterol-lowering diet.
- D. Report any respiratory symptoms.
Correct Answer: A
Rationale: The correct answer is A: Use barrier contraception to avoid pregnancy. HMG-CoA reductase inhibitors are known to cause birth defects if taken during pregnancy. Therefore, it is crucial for the patient to use effective barrier contraception to prevent pregnancy while on this medication. Reporting changes in vision (B) is not directly related to HMG-CoA reductase inhibitors. Following a cholesterol-lowering diet (C) is important but not the most critical point for this specific medication. Reporting respiratory symptoms (D) is important but not specific to this medication.
A nurse is caring for a neonate born with a congenital heart abnormality. To better help the parents understand the impact of this disorder, the nurse begins by describing the unusual flow of blood through the heart which takes what course?
- A. Deoxygenated blood from the lungs enters the left atrium through the pulmonary artery.
- B. Deoxygenated blood from the lungs enters the right atrium through the pulmonary artery.
- C. Oxygenated blood from the lungs enters the right atrium through the pulmonary veins.
- D. Oxygenated blood from the lungs enters the left atrium through the pulmonary veins.
Correct Answer: D
Rationale: The correct answer is D. In a normal heart, oxygenated blood from the lungs enters the left atrium through the pulmonary veins. This oxygen-rich blood then flows into the left ventricle and is pumped out to the body. In a neonate with a congenital heart abnormality, this pathway may be disrupted, leading to potential complications.
Choice A is incorrect because deoxygenated blood from the body, not the lungs, enters the right atrium through the vena cava. Choice B is incorrect as deoxygenated blood from the lungs enters the right atrium through the superior and inferior vena cava. Choice C is incorrect as oxygenated blood from the lungs enters the left atrium, not the right atrium.
Understanding the normal flow of blood through the heart is crucial for comprehending the impact of congenital heart abnormalities on circulation and oxygenation in neonates.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.