Nokea
When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.
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Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
- A. Diminished pedal pulses
- B. Color changes in the extremities when elevated
- C. Red, shiny skin
- D. Coolness and pallor in the leg
Correct Answer: C
Rationale: Red, shiny skin is a common sign of thrombophlebitis due to inflammation and impaired venous return. Diminished pulses, color changes with elevation, or coolness are more indicative of arterial issues.
Avoiding which of the following foods is the best evidence that the client understands the nurse's dietary instructions?
- A. Pepperoni pizza
- B. Vinegar and oil salad dressing
- C. Liver and onions
- D. Lemon-pepper chicken
Correct Answer: A
Rationale: Pepperoni pizza is high in fat and sodium, which should be avoided in a low-fat, low-sodium diet post-MI.
Please indicate with an X the best anatomic area for the nurse to auscultate mitral valve sounds.
- A. Apex of the heart
- B. Second right intercostal space
- C. Second left intercostal space
- D. Lower left sternal border
Correct Answer: A
Rationale: Mitral valve sounds are best heard at the apex (fifth intercostal space, midclavicular line).
When auscultating the client's heart and breath sounds during a routine shift assessment, which action by the nurse is most appropriate?
- A. Asking the client to hold the breath
- B. Using the bell of the stethoscope
- C. Positioning the client flat in bed
- D. Locating the xiphoid process
Correct Answer: B
Rationale: The bell of the stethoscope is best for low-pitched heart sounds in pericarditis.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.