Nokea
Which complication should the nurse monitor for in a client with cardiomyopathy?
- A. Heart failure
- B. Hypoglycemia
- C. Osteoporosis
- D. Gastritis
Correct Answer: A
Rationale: Cardiomyopathy impairs heart function, increasing the risk of heart failure.
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Which complaint made by the client to the nurse can best be attributed to varicose leg veins?
- A. My legs and feet feel tired after prolonged standing.
- B. My feet perspire heavily during the day.
- C. I wake up at night with a restless feeling in my legs.
- D. I have pain in my shins when I jog.
Correct Answer: A
Rationale: Varicose veins often cause fatigue and heaviness in the legs, especially after prolonged standing, due to impaired venous return.
Which finding in a client with an arterial disorder indicates a worsening condition?
- A. Cool, pale skin on the affected leg
- B. Mild leg pain at rest
- C. Heart rate of 75 beats per minute
- D. Blood pressure of 125/80 mmHg
Correct Answer: A
Rationale: Cool, pale skin indicates worsening arterial insufficiency, suggesting reduced blood flow to the limb.
The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises?
- A. Passive ROM exercises will prevent contractures from developing.
- B. The client will feel better if he is able to exercise and stretch his muscles.
- C. ROM exercises will help alleviate the pain associated with GB syndrome.
- D. They help to prevent DVTs by movement of the blood through the veins.
Correct Answer: D
Rationale: Passive ROM (D) promotes venous return, preventing DVT in immobile GB patients. Contractures (A) are musculoskeletal, feeling better (B) is subjective, and pain relief (C) is not primary.
Which complication should the nurse monitor for in a client with valvular heart disease?
- A. Pulmonary embolism
- B. Heart failure
- C. Liver failure
- D. Pneumonia
Correct Answer: B
Rationale: Valvular heart disease can lead to heart failure due to increased cardiac workload and impaired pump function.
The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor?
- A. Blood urea nitrogen (BUN) levels.
- B. Bilirubin levels.
- C. International normalized ratio (INR).
- D. Partial thromboplastin time (PTT).
Correct Answer: C
Rationale: Warfarin toxicity is monitored via INR (C), which reflects bleeding risk. BUN (A) assesses kidneys, bilirubin (B) liver, and PTT (D) is for heparin.