Nokea
The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective?
- A. "I will exercise as much as possible, regardless of feeling weak and short of breath."
- B. "My pants getting tight around the waist means I'm eating too much and should cut back on food."
- C. "I will eat foods containing sodium only if drinking water with them."
- D. "I will see my cardiologist next week to discuss implanting a pacemaker."
Correct Answer: C
Rationale: The correct statement indicating effective discharge teaching for a client diagnosed with cardiomyopathy is "I will eat foods containing sodium only if drinking water with them." This statement shows the client understands the importance of reducing sodium intake to manage cardiomyopathy effectively. Excess sodium can contribute to fluid retention and worsen symptoms of heart failure, which often accompanies cardiomyopathy. By pairing sodium-containing foods with water, the client can help mitigate the potential negative effects of sodium on their condition. The other options are incorrect as they do not demonstrate an understanding of the condition or appropriate self-care measures.
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The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?
- A. Caucasians have an increased incidence of intracerebral hemorrhage.
- B. African Americans have almost twice the number of first-ever strokes compared with Whites.
- C. Asian Americans are more likely to die following a stroke than Whites.
- D. The prevalence of hypertension among Hispanics is the highest in the world.
Correct Answer: B
Rationale: The correct statement that should be included in the presentation is that African Americans have almost twice the number of first-ever strokes compared with Whites. This is based on research and statistics that show African Americans have a higher incidence of stroke compared to other ethnic groups in the United States. It is important for healthcare providers to be aware of these disparities in order to address them effectively through targeted prevention and management strategies. Moreover, raising awareness about these risk factors can help promote early intervention and reduce the burden of stroke within the African American community.
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
- A. Slight increase in pulse
- B. Dry, warm skin
- C. Increased urine output
- D. Normal respirations
Correct Answer: A
Rationale: A. A slight increase in pulse is a common finding in hypovolemic shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain adequate perfusion.
During an assessment, the nurse determines that a patient with knee pain is at risk for osteoarthritis. What did the nurse assess in this patient?
- A. Having a history of falls
- B. Eating a diet high in calcium
- C. Walking 30 minutes each day
- D. Being overweight by 30 pounds
Correct Answer: D
Rationale: Osteoarthritis is a condition where the protective cartilage that cushions the ends of bones wears down over time. Excess weight puts extra stress on the joints, particularly weight-bearing joints like the knees. Being overweight by 30 pounds increases the risk of developing osteoarthritis in the knees because the added weight can accelerate the breakdown of cartilage. Therefore, the nurse identified the patient as at risk for osteoarthritis due to being overweight by 30 pounds.
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data?
- A. Normal
- B. Hypertension stage I
- C. Prehypertension
- D. Hypertension stage II
Correct Answer: D
Rationale: A blood pressure reading of 142/92 mmHg falls into the category of Hypertension Stage II based on the guidelines from the American Heart Association. In this classification, systolic blood pressure is 140-159 mmHg and diastolic blood pressure is 90-99 mmHg. Stage II hypertension indicates that the individual has a significantly elevated blood pressure level that requires prompt management and monitoring. It is crucial for the nurse to document this accurately to ensure appropriate interventions are provided to the client.
The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client?
- A. Infection
- B. Fluid volume
- C. Peripheral perfusion
- D. Sleep pattern
Correct Answer: C
Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.