All the following conditions are associated with high volume pulse except
- A. Aorta to LV tunnel
- B. Coronary cameral fistula
- C. Neonatal Blalock Taussig shunt
- D. Hemitruncus
Correct Answer: C
Rationale: Neonatal Blalock Taussig shunt is not associated with a high volume pulse.
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A cardiac catheterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse 'what does all this mean for me?' What information should the nurse provide?
- A. Blood supply to the heart is diminished by atherosclerotic lesions, which necessitate lifestyle changes.
- B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
- C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.
- D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.
Correct Answer: C
Rationale: This explanation provides a clear understanding of the severity of the blockages and the implications for the client's heart function.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
- A. Skin integrity
- B. Functional ability
- C. Heart sounds
- D. Pain scale
Correct Answer: A
Rationale: These assessments help determine the effectiveness of treatment in managing pain, skin lesions, and the client's ability to perform daily activities.
A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _______ beats/min.
- A. 60
- B. 70
- C. 90 to 110
- D. 110 to 120
Correct Answer: C
Rationale: If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a 6-month-old. Sixty beats/min is the cut-off for holding the digoxin dose in an adult; 70 beats/min is the determining heart rate to hold a dose of digoxin for an older child; 110 to 120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.
Hypothalamic nuclei are responsible for:
- A. Control of hunger
- B. Temperature control
- C. Maintaining osmolarity of extracellular fluid
- D. Secretion of thyrotrophin
Correct Answer: A
Rationale: The hypothalamus plays a key role in regulating hunger through various nuclei and hormonal signals.