Nokea
The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?
- A. Q waves
- B. Flipped T waves
- C. Peaked T waves
- D. ST segment elevation
Correct Answer: D
Rationale: The nurse should be most concerned about ST elevation because it indicates an evolving MI. Q waves suggest a previous MI, flipped T waves indicate ischemia, and peaked T waves may indicate hyperkalemia, but ST elevation is the most acute and critical finding.
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The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homo-cysteine levels includes eating foods rich in which nutrient?
- A. Monosaturated fats
- B. B complex Vitamins
- C. Vitamin C
- D. Calcium
Correct Answer: B
Rationale: Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, Vitamin C, and Calcium do not have a direct effect on homocysteine levels.
The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply.
- A. Increase isometric arm exercises to build endurance.
- B. Wear a facemask when outdoors in cold weather.
- C. Take nitroglycerin before a stressful event even if pain free.
- D. Perform most exertional activities in the morning.
- E. Take a daily laxative to avoid straining with bowel movements.
- F. Discontinue use of all tobacco products if you use these.
Correct Answer: B;C;F
Rationale: The nurse should instruct: B) Wearing a facemask in cold weather to prevent vasoconstriction; C) Taking nitroglycerin prophylactically to improve coronary blood flow; F) Discontinuing tobacco to reduce vasoconstriction. Isometric exercises, morning exertion, and daily laxatives are not recommended as they may increase cardiac workload or cause other issues.
The nurse is assessing the client with an 8-centimeter AAA. Which finding should the nurse expect?
- A. Report of persistent nagging pain in the upper anterior chest
- B. Systolic bruit palpated over the upper abdomen
- C. Edema of the face and neck with distended neck veins
- D. A pulsating mass in the mid to upper abdomen
Correct Answer: D
Rationale: Throbbing or pulsating in the abdomen is the sign most indicative of an AAA. Chest pain, edema, and neck vein distention are associated with thoracic aneurysms, and a bruit is auscultated, not palpated.
The nurse plans teaching for a 20-year-old newly diagnosed with hypertrophic cardiomyopathy. The client is on the college soccer team. Which information should be the nurse’s priority when teaching the client?
- A. Provide pamphlets on genetic testing to avoid passing on an inherited disease.
- B. Reinforce the need to continue exercise with soccer to strengthen the heart.
- C. Provide information about CPR to persons living with the client.
- D. Counsel on foods for consuming on a low-fat, low-cholesterol diet.
Correct Answer: C
Rationale: Because sudden cardiac death is a large risk factor for those under 30 years of age, the nurse should provide information about having others living with the client trained in CPR as a preventative measure. Genetic testing, continued strenuous exercise, and diet are less immediate priorities.
The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
- A. Jugular vein distention, muffled heart sounds, and BP 84/48
- B. Temperature 96.4°F (35.8°C), heart rate 58 bpm, and shivering
- C. Increased heart rate, audible S1 and S2, and pain rated at a 5
- D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few PVCs
Correct Answer: A
Rationale: The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.