Nokea
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to do which of the following?
- A. Increase activity tolerance
- B. Relieve anxiety
- C. Protect from injury
- D. Help build a positive body image
Correct Answer: C
Rationale: Protecting from injury is critical for a client with peripheral vascular disease and ischemic ulcers to prevent infection and further tissue damage. Other goals are secondary.
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When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to:
- A. check peripheral pulses.
- B. maintain NPO.
- C. apply heat to the insertion site.
- D. start range of motion exercises immediately.
Correct Answer: A
Rationale: Checking peripheral pulses post-cardiac catheterization is essential to detect complications like arterial occlusion or hematoma at the insertion site. Maintaining NPO, applying heat, or starting range of motion exercises immediately are not standard priorities.
When the client asks the nurse how propranolol helps to prevent angina, what is the best explanation?
- A. Propranolol promotes excretion of body fluid.
- B. Propranolol reduces the rate of heart contraction.
- C. Propranolol alters pain receptors in the heart.
- D. Propranolol dilates the major coronary arteries.
Correct Answer: B
Rationale: Propranolol, a beta-blocker, reduces heart rate and contractility, decreasing myocardial oxygen demand and preventing angina.
Which assessment finding is most closely correlated with an evolving MI?
- A. Nausea
- B. Facial flushing
- C. Severe headache
- D. Coughing up pink-tinged mucus
Correct Answer: A
Rationale: Nausea is a common symptom of myocardial infarction due to vagal stimulation or pain-induced stress response.
The client tells the nurse of being extremely frightened. What is the most appropriate action for the nurse to take at this time?
- A. Stay with the client.
- B. Explain the procedures.
- C. Tell the client it will be fine.
- D. Record the collected data.
Correct Answer: A
Rationale: Staying with the client provides emotional support, reducing fear during a crisis.
The nurse assumes that the client understands how an echocardiogram is performed when that client tells the nurse that this examination involves imaging the heart using which of one of the following?
- A. Ultrasound waves
- B. X-ray beams
- C. Radioactive isotopes
- D. Magnetic fields
Correct Answer: A
Rationale: An echocardiogram uses ultrasound waves to create images of the heart's structure and function.