Nokea
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.
You may also like to solve these questions
Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
- A. A loud S1, S2 split, and a mitral opening snap.
- B. A holosystolic murmur heard best at the cardiac apex.
- C. A midsystolic ejection click or murmur heard at the base.
- D. A high-pitched sound heard at the third left intercostal space.
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (B) due to backflow. S1/S2 snap (A) is mitral stenosis, ejection click (C) is aortic/pulmonic, and high-pitched sound (D) is nonspecific.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
- A. Pulmonary embolus (PE).
- B. Cerebrovascular accident.
- C. Hemoptysis.
- D. Deep vein thrombosis.
Correct Answer: B
Rationale: Mitral valve vegetations can embolize to the brain, causing a stroke (B). PE (A) is right-sided, hemoptysis (C) is not typical, and DVT (D) is unrelated to embolization.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
- A. The client's peripheral pitting edema has gone from 3+ to 4+.
- B. The client is able to take the radial pulse accurately.
- C. The client is able to perform ADLs without dyspnea.
- D. The client has minimal jugular vein distention.
Correct Answer: C,D
Rationale: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?
- A. Notify the health-care provider immediately.
- B. Elevate the head of the client's bed.
- C. Document this as a normal and expected finding.
- D. Administer morphine intravenously.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure, requiring HCP notification. Elevating HOB (B) is supportive, documenting as normal (C) is incorrect, and morphine (D) is for pain.