Nokea
As part of the discharge instructions, the nurse correctly instructs the client that which symptom is a sign of artificial pacemaker malfunction?
- A. Tingling in the chest area
- B. Dizziness during activity
- C. Pain radiating to the arm
- D. Tenderness beneath the skin
Correct Answer: B
Rationale: Dizziness during activity may indicate pacemaker failure to maintain adequate heart rate.
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Avoiding which of the following foods is the best evidence that the client understands the nurse's dietary instructions?
- A. Pepperoni pizza
- B. Vinegar and oil salad dressing
- C. Liver and onions
- D. Lemon-pepper chicken
Correct Answer: A
Rationale: Pepperoni pizza is high in fat and sodium, which should be avoided in a low-fat, low-sodium diet post-MI.
Based on the client's complaint, the nurse would expect the pain to have which possible effect on the vital signs?
- A. Temperature may be elevated.
- B. Pulse rate may become rapid.
- C. Respiratory rate may slow.
- D. Blood pressure may fall.
Correct Answer: B
Rationale: Acute pain activates the sympathetic nervous system, increasing pulse rate due to stress response.
Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
A client with angina will have to make lifestyle modifications. Which of the following statements by the client would indicate that he understands the necessary modifications in lifestyle to prevent angina attacks?
- A. I know that I will need to eat less, so I will only eat one meal a day.'
- B. I will need to stay in bed all the time so I won't have the pain.'
- C. I'll stop what I'm doing whenever I have pain and take a pill.'
- D. I will need to walk more slowly and rest frequently to avoid the angina.'
Correct Answer: D
Rationale: Walking slowly and resting frequently helps prevent angina by reducing cardiac workload. Eating one meal a day, staying in bed, or only stopping during pain do not address preventive lifestyle modifications.
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.