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Which intervention should the nurse include in the plan of care for a client with pericarditis? Select all that apply.
- A. Monitor for signs of cardiac tamponade.
- B. Administer anti-inflammatory medications.
- C. Encourage deep breathing exercises.
- D. Elevate the head of the bed.
- E. Restrict all physical activity.
- F. Check vital signs every 8 hours.
Correct Answer: A,B,D,E
Rationale: Monitoring for tamponade, administering anti-inflammatories, elevating the bed, and restricting activity manage pericarditis effectively.
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Which assessment finding in a client with endocarditis requires immediate action?
- A. Splinter hemorrhages under nails
- B. Mild joint pain
- C. New heart murmur
- D. Fatigue after activity
Correct Answer: C
Rationale: A new heart murmur may indicate valve damage or worsening infection, requiring urgent evaluation.
The nurse is monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.
Which activity should the nurse advise a client with cardiomyopathy to avoid?
- A. Walking at a moderate pace
- B. Heavy weightlifting
- C. Swimming for 20 minutes
- D. Yoga with gentle stretches
Correct Answer: B
Rationale: Heavy weightlifting increases cardiac strain, which is dangerous in cardiomyopathy.
The client with cardiomyopathy reports swelling in the legs. What should the nurse do first?
- A. Elevate the client's legs.
- B. Check the client's weight.
- C. Administer a diuretic as prescribed.
- D. Restrict all fluid intake.
Correct Answer: B
Rationale: Checking weight assesses for fluid retention, a common cause of leg swelling in cardiomyopathy.
Which client would be most likely to develop an abdominal aortic aneurysm?
- A. A 45-year-old female with a history of osteoporosis.
- B. An 80-year-old female with congestive heart failure.
- C. A 69-year-old male with peripheral vascular disease.
- D. A 30-year-old male with a genetic predisposition to AAA.
Correct Answer: C
Rationale: Older males with PVD (C) are at highest risk for AAA due to atherosclerosis. Osteoporosis (A), CHF (B), and young age (D) are lower risk, even with genetics.