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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.
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During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse?
- A. Suggest the client stop exercising
- B. Reassure these are normal changes associated with aging
- C. Ensure the client is evaluated by his/her medical provider
- D. Check laboratory values for hypothyroidism
Correct Answer: C
Rationale: The correct action for the nurse in this situation would be to ensure the client is evaluated by his/her medical provider. Chest fluttering, also known as palpitations, can sometimes be related to cardiac arrhythmias, which can be a concern in older adults. Even though the client reports no other symptoms and the frequency is intermittent, it is essential for the medical provider to assess and determine the cause of the fluttering to rule out any serious underlying cardiac issues. Taking appropriate action promptly can help prevent any potential complications and ensure the client's well-being.
A patient has heard of several friends being diagnosed with colon cancer and does not want to develop the same health problem. What should the nurse recommend to this patient? Select all that apply.
- A. Obtain regular exercise
- B. Maintain a healthy weight
- C. Ingest two servings of red wine every day
- D. Obtain recommended screening after age 50 e. Consume a diet high in fruit and vegetables and low in saturated fat and red meat
Correct Answer: A
Rationale: A. Regular exercise has been shown to reduce the risk of developing colon cancer. Exercise helps in maintaining a healthy weight, supporting the immune system, and promoting overall health.
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.
A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication?
- A. It causes pain that occurs during periods of inactivity.
- B. It causes pain that increases when the legs are elevated and decreases when the legs are dependent.
- C. It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity.
- D. It is often described as a burning sensation in the lower legs.
Correct Answer: C
Rationale: Intermittent claudication is a symptom of peripheral vascular disease (PVD) characterized by cramping or aching pain in the lower extremities and buttocks that occurs with a predictable level of activity, such as walking a certain distance. This pain typically resolves with rest. The pain is due to inadequate blood flow to the muscles during activity, causing a buildup of lactic acid, which leads to muscle pain. This symptom is an important indicator of decreased arterial blood flow and is a common presentation in individuals with PVD. Therefore, when teaching the client about intermittent claudication, the nurse should emphasize the predictable nature of the pain related to activity and the relief experienced with rest.
A patient is scheduled for an electromyogram. What should the nurse instruct the patient to do in preparation for this diagnostic test? Select all that apply.
- A. Do not smoke for 3 hours before the test
- B. Avoid taking muscle relaxants before the test
- C. Avoid taking oral hypoglycemic agents before the test
- D. Alert the healthcare provider about an allergy to shellfish e. Avoid fluids containing caffeine for 3 hours before the test
Correct Answer: B
Rationale: B. It is essential for the patient to avoid taking muscle relaxants before the electromyogram test because these medications can affect the results by altering muscle activity and electrical signals, which are critical for diagnosing muscle and nerve disorders.