Nokea
A patient is admitted from the emergency department. The emergency department health care provider notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient has which class of heart failure?
- A. moderate heart failure.
- B. severe heart failure.
- C. congestive heart failure.
- D. negligible heart failure.
Correct Answer: B
Rationale: Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.
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The nurse would reinforce teaching for a patient with Raynaud disease to include which teaching point?
- A. Warming hands and feet with a heating pad
- B. Using mittens in cold weather
- C. Practicing stress-reducing techniques
- D. Complete smoking cessation
- E. Using caution when cleaning the refrigerator or freezer
Correct Answer: B,C,D,E
Rationale: Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.
The nurse reinforcing a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for which change?
- A. reduction of alcohol intake.
- B. avoiding cold remedies.
- C. cessation of smoking.
- D. weight reduction.
Correct Answer: C
Rationale: The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.
The nurse is reinforcing instructions on a patient who will be taking digoxin. Which sign of digoxin toxicity should the nurse include?
- A. Ringing in the ears
- B. Bradycardia
- C. Headache
- D. Visual disturbance
- E. Hematuria
- F. Anorexia
Correct Answer: B,C,D,F
Rationale: Major signs of digoxin toxicity are bradycardia (HR <60), headache, visual disturbances, anorexia, as well as fatigue and arrhythmias.
The older adult patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse should reinforce which instruction?
- A. Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.'
- B. If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your health care provider and come to the hospital.'
- C. When nitroglycerin is not relieving the pain, lie down and rest.'
- D. Use oxygen at home to relieve pain when nitroglycerin is not successful.'
Correct Answer: B
Rationale: Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the health care provider. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain.
When assessing a patient with a possible myocardial infarction (MI), which sign or symptom should the nurse assess for?
- A. Pain radiating to left arm and jaw
- B. Visual Hallucinations
- C. Pallor
- D. Diaphoresis
- E. Apprehension
- F. Dyspnea
Correct Answer: A,C,D,E,F
Rationale: Pain radiating to the left arm and jaw, pallor, diaphoresis, apprehension/anxiety and dyspnea are signs and symptoms present in patients with an MI.