Nokea
The nurse completes discharge teaching for the client with chronic stage 2 hypertension. Which statement by the client indicates that teaching was effective?
- A. “I will limit my intake of potassium by eating bananas only once a week.”
- B. “I will start a rigorous exercise program to lose this excess weight.”
- C. “I will call my doctor immediately if I have sudden vision changes.”
- D. “I will strive to maintain my body mass index (BMI) at 32.”
Correct Answer: C
Rationale: Teaching is effective if the client states to call the HCP immediately if experiencing vision changes. Sudden vision changes may be associated with stroke, a complication of hypertension. Limiting potassium is unnecessary unless hyperkalemia is present, rigorous exercise should be gradual, and a BMI of 32 is obese, which is a risk factor for hypertension.
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The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
The client with chronic HF tells the nurse, “I get so scared at night; I wake up and feel like I can hardly breathe.” Which is the nurse’s best response?
- A. “You are experiencing a condition called paroxysmal nocturnal dyspnea.”
- B. “Tell me if these are related to your having vivid nightmares?”
- C. “You may be experiencing this from an increased sodium intake in your diet.”
- D. “Tell me more about how often this is occurring and how you deal with it.”
Correct Answer: D
Rationale: When the client with HF expresses concerns about breathing, the nurse should further explore the comment with an open-ended statement because more information may be gained about how the client could diminish or handle the occurrence. Naming the condition (A), assuming nightmares (B), or sodium intake (C) does not facilitate further assessment.
The client is admitted with acute infective endocarditis (IE). Which assessment findings should the nurse associate with IE? Select all that apply.
- A. Skin petechiae
- B. Crackles in lung bases
- C. Peripheral edema
- D. Murmur
- E. Arthralgia
- F. Hemangioma
Correct Answer: A;B;C;D;E
Rationale: The nurse should associate: A) Skin petechiae from microembolism; B) Crackles from HF secondary to IE; C) Peripheral edema from HF; D) Murmur from valve incompetence; E) Arthralgia from microembolism. Hemangioma is not associated with IE.
The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.