Nokea
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.
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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.
When assessing a patient with a possible myocardial infarction (MI), which sign or symptom should the nurse assess for?
- A. Pain radiating to left arm and jaw
- B. Visual Hallucinations
- C. Pallor
- D. Diaphoresis
- E. Apprehension
- F. Dyspnea
Correct Answer: A,C,D,E,F
Rationale: Pain radiating to the left arm and jaw, pallor, diaphoresis, apprehension/anxiety and dyspnea are signs and symptoms present in patients with an MI.
A patient with atrial fibrillation may experience decreased cardiac output, due to
Correct Answer: Incomplete ventricular filling
Rationale: Since the atria quiver, rather than contract, the normal atrial kick is lost, leading to a decrease in the cardiac output.
What do dark or 'cold' spots on a thallium scan indicate?
- A. Tissue with adequate blood supply
- B. Dilated vessels
- C. Areas of neoplastic growth
- D. Tissue that has inadequate perfusion
Correct Answer: D
Rationale: Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or 'cold spots' indicate tissues that have inadequate perfusion.
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.