Nokea
Which nursing response is most appropriate at this time?
- A. Cleaning up the floor and saying nothing
- B. Finding out what food would be preferred
- C. Allowing the client to vent his or her feelings
- D. Leaving the client alone until feeling better
Correct Answer: C
Rationale: Allowing the client to vent feelings addresses emotional distress and supports coping.
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According to the nurse, when is the correct time to note the diastolic blood pressure reading?
- A. When the loud knocking sounds become muffled
- B. When the last loud knocking sound is heard
- C. When the swishing sound is a second
- D. When the swishing sound becomes faint
Correct Answer: B
Rationale: The diastolic blood pressure is recorded at the point when the last loud knocking sound (Korotkoff phase V) is heard, indicating the pressure at which blood flow is fully restored.
Which of the following electrocardiogram (ECG) changes supports the diagnosis that the client is experiencing a myocardial infarction (MI)?
- A. Inverted P wave
- B. Prolonged PR interval
- C. Widened QRS complex
- D. Elevated ST segment
Correct Answer: D
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The licensed practical nurse (LPN) is assisting the registered nurse (RN) in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
- A. Deficient fluid volume
- B. Impaired verbal communication
- C. Chronic pain
- D. Activity intolerance
Correct Answer: D
Rationale: Activity intolerance is common in congestive heart failure due to reduced cardiac output and fatigue. Fluid volume excess, not deficit, is typical, and communication or pain are less likely.
The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?
- A. The client is keeping the affected extremity straight.
- B. The pressure dressing to the right femoral area is intact.
- C. The client is complaining of numbness in the right foot.
- D. The client's right pedal pulse is 3+ and bounding.
Correct Answer: C
Rationale: Numbness (C) suggests vascular compromise or nerve compression, requiring immediate intervention. Keeping the leg straight (A), intact dressing (B), and strong pulse (D) are expected.
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?
- A. I should keep the tablets in the dark-colored bottle they came in.'
- B. If the tablets do not burn under my tongue, they are not effective.'
- C. I should keep the bottle with me in my pocket at all times.'
- D. If my chest pain is not gone with one tablet, I will go to the ER.'
Correct Answer: B
Rationale: Burning under the tongue (B) is not a reliable indicator of nitroglycerin effectiveness; potency is maintained in a dark bottle (A, C). Persistent pain requires up to 3 doses, not immediate ER (D).