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The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be in which stage?
- A. stage A.
- B. stage B.
- C. stage C.
- D. stage D.
Correct Answer: A
Rationale: The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease.
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The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called
Correct Answer: automaticity
Rationale: Automaticity is the special ability of the myocardium to contract in a rhythmic pattern.
The nurse reinforcing a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for which change?
- A. reduction of alcohol intake.
- B. avoiding cold remedies.
- C. cessation of smoking.
- D. weight reduction.
Correct Answer: C
Rationale: The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.
The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a
Correct Answer: cardioversion
Rationale: Cardioversion is the restoration of the heart's normal sinus rhythm with the delivery of synchronized electric shock.
The plan of care for a patient recovering from hip surgery mentions prevention of deep vein thrombosis (DVT). Which aspect of the plan of care addresses this concern?
- A. Massaging the calves of the leg twice daily
- B. Explaining the need for fluid restriction after surgery
- C. Assisting the patient to change positions frequently
- D. Encouraging the patient to take the anti-embolism stockings off at night for better sleep.
Correct Answer: C
Rationale: The plan of care to prevent deep vein thrombosis should mention changing positions, dorsiflexing the feet and rotating ankles every 2 to 4 hours. Massaging the calves of the leg is contraindicated, as the massage could loosen a blood clot. There is no need to restrict fluids. Removing the stockings off at night is not an appropriate intervention, because a DVT could form.
The nurse would reinforce teaching for a patient with Raynaud disease to include which teaching point?
- A. Warming hands and feet with a heating pad
- B. Using mittens in cold weather
- C. Practicing stress-reducing techniques
- D. Complete smoking cessation
- E. Using caution when cleaning the refrigerator or freezer
Correct Answer: B,C,D,E
Rationale: Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.