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Which laboratory data confirm the diagnosis of congestive heart failure?
- A. Chest x-ray (CXR).
- B. Liver function tests.
- C. Blood urea nitrogen (BUN).
- D. Beta-type natriuretic peptide (BNP).
Correct Answer: D
Rationale: Elevated BNP (D) is specific for CHF, reflecting ventricular stress. CXR (A) shows fluid but is not diagnostic, liver tests (B) and BUN (C) are nonspecific.
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The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?
- A. Perform isometric exercises daily.
- B. Walk for 15 minutes three (3) times a week.
- C. Do not walk outside if it is less than 40°F.
- D. Wear open-toed shoes when ambulating.
Correct Answer: B
Rationale: Walking 15 minutes 3 times a week (B) is a safe, aerobic exercise for CAD. Isometric exercises (A) increase BP, cold weather (C) is a precaution, and open-toed shoes (D) are irrelevant.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
- A. Pulmonary embolus (PE).
- B. Cerebrovascular accident.
- C. Hemoptysis.
- D. Deep vein thrombosis.
Correct Answer: B
Rationale: Mitral valve vegetations can embolize to the brain, causing a stroke (B). PE (A) is right-sided, hemoptysis (C) is not typical, and DVT (D) is unrelated to embolization.
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
- A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day.
- B. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.
- C. Determine if the client has gained weight and instruct the client to keep the legs elevated.
- D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Correct Answer: B
Rationale: Leg cramps in CHF may indicate hypokalemia from diuretics. Monitoring potassium and assessing potassium-rich food intake (B) is appropriate. Edema/diuretic timing (A), weight/elevation (C), and ambulation/stretching (D) are less directly related.