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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.
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A nurse prepares a client for coronary artery bypass graft surgery. The client states, 'I am afraid I might die.' How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low
- B. Would you like to speak with a chaplain prior to surgery?
- C. Tell me more about your concerns about the surgery
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: The nurse should explore the client's fears by encouraging open discussion, which helps address concerns and provide emotional support. Dismissing fears, redirecting to a chaplain, or focusing on support systems does not directly address the client's stated concern.
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 an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart
- B. Initiate external pacing
- C. Assess the client's medications
- D. Administer 1 mg of atropine
Correct Answer: C
Rationale: Bradycardia in older adults can result from a decrease in pacemaker cells or medication effects. The nurse should first assess the client's medications, as certain drugs (e.g., beta blockers) can cause a low heart rate. This step precedes documentation, pacing, or administering atropine.
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.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse suspect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node, resulting in an increased heart rate. A heart rate of 120 beats/min is indicative of tachycardia, which is a compensatory mechanism for low blood pressure.