Nokea
A symptom of impending cardiac decompensation in a pregnant client with heart disease is:
- A. Increasing dyspnea
- B. Transient palpitations
- C. Occasional activity intolerance
- D. Periodic shortness of breath
Correct Answer: A
Rationale: Increasing dyspnea signals worsening cardiac function and potential decompensation, a critical symptom in pregnant clients with heart disease. Other symptoms are less specific.
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A 56-year-old male is admitted with a diagnosis of gastroesophageal reflux disease (GERD). The client is most likely to report esophageal discomfort following a meal of:
- A. Chicken in lemon sauce, rice, and fruit juice
- B. Turkey, salad, and a glass of red wine
- C. Poached salmon, mashed potatoes, and milk
- D. Hamburger, peas, and cola
Correct Answer: D
Rationale: Hamburger and cola are high-fat and carbonated, respectively, both of which exacerbate GERD symptoms.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.
Which of the following situations require the nurse's IMMEDIATE attention?
- A. A client with bipolar disorder walks into the dayroom in her underwear and begins dancing.
- B. A client with depression says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- C. A client recovering from substance abuse says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- D. A client with schizophrenia tells the nurse that it's 'God's will' that he destroy the 'evil TV'.
Correct Answer: B
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority
A 66-year-old woman is being evaluated for pernicious anemia. Which assessment findings would be most apt to be present in a client with pernicious anemia?
- A. Easy bruising
- B. Pain in the legs
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes neurological symptoms like leg pain or paresthesia. Bruising, rashes, or pruritus are less specific to this condition.