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The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion?
- A. The client has a history of coronary artery disease (CAD).
- B. The client has a history of diabetes insipidus (DI).
- C. The client has a history of chronic obstructive pulmonary disease (COPD).
- D. The client has a history of multiple fractures from a motor-vehicle accident.
Correct Answer: A
Rationale: CAD (A) directly impairs cardiac perfusion due to atherosclerosis, an antecedent to perfusion issues. DI (B), COPD (C), and fractures (D) are less directly related.
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Which assessment finding would support the possibility of right-sided heart failure?
- A. Jugular vein distention
- B. Bradycardia
- C. Dry, hacking cough
- D. Flushed, red face
Correct Answer: A
Rationale: Jugular vein distention indicates increased venous pressure, typical of right-sided heart failure.
When the client asks why the physician ordered the ECG, how does the nurse correctly explain its purpose?
- A. It will show how the heart performs during exercise.
- B. It will determine the client's potential target heart rate.
- C. It will verify how much the client needs to improve fitness.
- D. It will help predict whether the client will have a heart attack soon.
Correct Answer: A
Rationale: A stress ECG evaluates heart function under physical stress, detecting ischemia or abnormal rhythms indicative of coronary artery disease.
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
- A. Blood clots
- B. Ecchymotic areas
- C. Jaundice
- D. Infection
Correct Answer: B
Rationale: The normal clotting time is 9 to 12 minutes. A prolonged clotting time suggests a bleeding tendency, so the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a shorter clotting time. Jaundice is related to liver damage or red blood cell breakdown. Infection is associated with low white blood cell counts.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client?
- A. Pulsus paradoxus.
- B. Complaints of fatigue and arthralgias.
- C. Petechiae and splinter hemorrhages.
- D. Increased chest pain with inspiration.
Correct Answer: D
Rationale: Pericarditis causes pleuritic chest pain, worse with inspiration (D), due to pericardial inflammation. Pulsus paradoxus (A) and rub are less common, fatigue/arthralgias (B) are nonspecific, and petechiae/hemorrhages (C) suggest endocarditis.