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The nurse hears a grating sound while assessing the range of motion of a patient’s hip. How should the nurse document this finding?
- A. Crackles
- B. Arthritis
- C. Synovitis
- D. Crepitation
Correct Answer: D
Rationale: Crepitation refers to a grating sound or sensation that occurs when there is rubbing together of the roughened articular surfaces of bones within a joint. It is commonly associated with conditions such as osteoarthritis or joint injury. Therefore, if the nurse hears a grating sound while assessing the range of motion of a patient's hip, the appropriate documentation of this finding would be crepitation.
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A client who is taking beta-adrenergic blockers for angina is experiencing hypovolemic shock. Which does the nurse anticipate being the priority collaborative intervention for this client?
- A. Administering analgesics for control of pain
- B. Assessing the cause of bleeding
- C. Providing replacement of volume
- D. Establishing invasive cardiac monitoring
Correct Answer: C
Rationale: In a client experiencing hypovolemic shock, the priority collaborative intervention is to provide replacement of volume to improve tissue perfusion and restore organ function. Hypovolemic shock is characterized by a significant loss of intravascular volume, leading to inadequate tissue perfusion and oxygenation. Beta-adrenergic blockers can exacerbate hypovolemic shock by further decreasing cardiac output and blood pressure. Therefore, the immediate priority is to address the hypovolemia by providing volume replacement through fluid resuscitation to stabilize the patient before assessing the cause of bleeding or establishing invasive cardiac monitoring. Administering analgesics for pain control is important but not the priority in this situation.
A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
- A. The client will not disturb the intravenous infusion.
- B. The client will comply with dietary restrictions.
- C. The client will not experience bleeding.
- D. The client will keep the right leg elevated on two pillows.
Correct Answer: C
Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.
After a stroke, sensory-perceptual changes increase the client's risk for what?
- A. Aspiration
- B. Injury
- C. Bleeding
- D. Infection
Correct Answer: B
Rationale: After a stroke, sensory-perceptual changes such as impaired proprioception, altered sensation, and decreased awareness of the affected side can increase the client's risk for injury. These changes can result in difficulties with balance, coordination, and spatial awareness, making the individual more prone to falls and accidents. It is important to implement safety measures and interventions to minimize the risk of injury in these clients, such as providing a structured environment, using assistive devices, and encouraging regular monitoring and assistance as needed.
The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?
- A. Cardiomyopathy
- B. Paroxysmal nocturnal dyspnea
- C. High-output failure
- D. Multisystem heart failure
Correct Answer: B
Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.
A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. What is the mechanism of action of this drug?
- A. Prevents conversion of angiotensin I to angiotensin II
- B. Prevents beta-receptor stimulation in the heart
- C. Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells
- D. Blocks alpha-receptors in the vascular smooth muscle
Correct Answer: D
Rationale: Terazosin is an alpha-1 adrenergic receptor blocker. By blocking alpha-1 receptors in the vascular smooth muscle, terazosin causes dilation of both arteries and veins, leading to reduced peripheral vascular resistance and decreased blood pressure. This dilation effect is achieved by preventing the binding of norepinephrine to alpha-1 receptors, thereby inhibiting vasoconstriction. Terazosin is commonly used in the treatment of hypertension to help lower blood pressure by reducing the workload on the heart and improving blood flow to organs and tissues.