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An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
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The nurse understands that the client's hesitation in going to the hospital is an example of which coping mechanism?
- A. Regression
- B. Projection
- C. Denial
- D. Undoing
Correct Answer: C
Rationale: Denial involves minimizing or ignoring symptoms, such as attributing chest pain to muscle strain, delaying medical care.
When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.
An adult who is admitted for a cardiac catheterization asks the nurse if she will be asleep during the cardiac catheterization. What is the best initial response for the nurse to make?
- A. You will be given a general anesthesia.'
- B. You will be sedated but not asleep.'
- C. The doctor will give you an anesthetic if you are having too much pain.'
- D. Why do you want to be asleep?'
Correct Answer: B
Rationale: During cardiac catheterization, clients receive sedation but remain awake, as their cooperation may be needed. General anesthesia is not used, and pain is managed with sedation, not additional anesthetics. Asking 'why' may make the client defensive and does not provide the requested information.
The nurse is caring for a client who is being evaluated for arteriosclerosis obliterans. Which complaint is the client most likely to have?
- A. Burning pain in the legs that wakens him or her at night
- B. Numbness of the feet and ankles with exercise
- C. Leg pain while walking that becomes severe enough to force him or her to stop
- D. Increasing warmth and redness of the legs when they are elevated
Correct Answer: C
Rationale: Intermittent claudication, or leg pain during walking that resolves with rest, is the hallmark symptom of arteriosclerosis obliterans due to arterial insufficiency.
Which statement is the best indication that the client understands the surgical procedure involving mitral valve replacement?
- A. My blood will be circulated through a heart-lung machine.
- B. The surgeon will enlarge my valve by inserting a stent.
- C. My blood will be opened during surgery, but my heart will not.
- D. A piece of my leg vein will be used to replace the diseased valve.
Correct Answer: A
Rationale: Mitral valve replacement requires a heart-lung machine for cardiopulmonary bypass.