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The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below. The nurse identifies that this rhythm is:
- A. Atrial fi brillation
- B. Ventricular tachycardia
- C. Premature ventricular contractions.
- D. Third-degree heart block.
Correct Answer: D
Rationale: Third-degree heart block occurs when atrial stimuli are blocked at the atrioventricular junction. Impulses from the atria and ventricles are conducted independently of each other. The atrial rate is 60 to 100 bpm; the ventricular rate is usually 10 to 60 bpm.
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A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dofetilide (Tikosyn). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Torsades de pointes.
- D. Weight gain.
Correct Answer: C
Rationale: Dofetilide can cause torsades de pointes, a life-threatening arrhythmia, requiring close monitoring.
The clinic nurse provides home care instructions to an adult client diagnosed with influenza. Which instructions should the nurse provide to the client? Select all that apply.
- A. Practice frequent hand washing.
- B. Remain at home until feeling better.
- C. Sneeze or cough into the upper sleeve.
- D. Return in 1 week for an influenza vaccine.
- E. Take acetaminophen for myalgia.
- F. Completely isolate self in a room from other family members and use a separate bathroom until feeling better.
Correct Answer: A,B,C,E
Rationale: Influenza (commonly known as the flu) refers to an acute viral infection of the respiratory tract. It is a communicable disease spread by droplet infection, and measures are instituted to prevent its spread. The client is instructed to practice frequent hand washing, remain at home, and cover the nose and mouth when sneezing and coughing. Supportive measures to relieve fever and myalgia such as the use of acetaminophen are also encouraged. It is unrealistic to completely isolate oneself in a room from other family members, and there is no useful reason to use a separate bathroom because the infection is spread through droplets. Influenza immunization is administered before the start of the 'flu' season, not after developing the infection.
A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse include?
- A. Strategies to manage memory loss and confusion.
- B. Instructions to limit physical activity to prevent falls.
- C. The need for a low-protein diet to reduce metabolic stress.
- D. The importance of avoiding all medications that affect the brain.
Correct Answer: A
Rationale: Multi-infarct dementia involves memory loss and confusion due to multiple small strokes. Teaching strategies to manage these symptoms, such as memory aids and structured routines, is essential for supporting the client and family.
The nurse is caring for a client with a suspected anaphylactic reaction. Which assessment finding confirms this diagnosis?
- A. Wheezing and hypotension
- B. Fever and rash
- C. Bradycardia and hypertension
- D. Nausea and diarrhea
Correct Answer: A
Rationale: Wheezing and hypotension are hallmark signs of anaphylaxis, indicating airway constriction and systemic vasodilation requiring immediate intervention.