Nokea
The nurse points out which factor as a modifiable risk for coronary artery disease (CAD)?
- A. Diabetes mellitus
- B. Heredity
- C. Smoking
- D. Hypertension
- E. Hyperlipidemia
- F. Age
Correct Answer: A,C,D,E
Rationale: Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle, and stress.
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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.
The nurse outlines which as a condition that would disqualify a candidate for a heart transplant?
- A. Recent malignancy
- B. Dilated cardiomyopathy
- C. Peptic ulcer disease
- D. Diabetes type 2
- E. Severe obesity
- F. Inoperable coronary artery disease
Correct Answer: A,C,E
Rationale: Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant.
After an influenza-like illness, the patient reports chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of which disorder?
- A. congestive heart failure.
- B. heart block.
- C. aortic stenosis.
- D. infective endocarditis.
Correct Answer: D
Rationale: Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.
The nurse caring for a patient recovering from a myocardial infarction (MI) administers stool softeners for which reason?
- A. Prevent enema dependence in the hospitalized patient
- B. Prevent fecal impactions which can lead to bowel obstruction
- C. Stool softeners reduce the need for laxatives once the patient is discharged
- D. Reduce the necessity to strain at the stool to lessen the effect of Valsalva's maneuver
Correct Answer: D
Rationale: Stool softeners will lessen the severity of straining and will decrease the effect of the Valsalva's maneuver on intrathoracic pressure.
The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be in which stage?
- A. stage A.
- B. stage B.
- C. stage C.
- D. stage D.
Correct Answer: A
Rationale: The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease.