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Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease?
- A. Polycythemia
- B. Cardiomyopathy
- C. Endocarditis
- D. Low blood pressure
Correct Answer: A
Rationale: Polycythemia, which is an abnormally elevated level of red blood cells in the blood, is commonly associated with congenital heart disease. In cases where there is a congenital heart defect that causes reduced oxygen levels in the blood, the body compensates by producing more red blood cells to try to improve oxygen delivery. This increased red blood cell production can lead to polycythemia. In turn, polycythemia can increase the risk of thrombosis, which is a known risk factor for cerebrovascular accidents (CVAs) or strokes. Therefore, polycythemia is most likely associated with a CVA resulting from congenital heart disease.
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Which of the ff nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest c.Elevate the clients head
- B. Administer a prescribed anti pyretic
- C. Administer supplemental oxygen
Correct Answer: C
Rationale: Administering supplemental oxygen is the most appropriate nursing intervention to relieve tachycardia that may develop in a client with myocarditis from hypoxemia. Myocarditis can lead to decreased oxygen delivery to the tissues, which may result in tachycardia as the body tries to compensate for the lack of oxygen. Providing supplemental oxygen will help increase oxygen levels in the blood, improving tissue perfusion and thus reducing the tachycardia. This intervention aims to address the underlying cause of the tachycardia in this situation.
The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The presence of polyps in the colon is a significant risk factor for developing colorectal cancer. Polyps are abnormal growths in the inner lining of the colon or rectum that can potentially become cancerous over time if left untreated. Therefore, if a client has a history of polyps, the nurse may suspect the possibility of colorectal cancer and should closely monitor the client for any signs or symptoms. While the other conditions listed may sometimes be associated with colorectal cancer, having a history of polyps is the most concerning in this context.
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
- A. Pulse, respirations, temperature
- B. Temperature, pulse, respirations
- C. Respirations, temperature, pulse
- D. Respirations, pulse, temperature
Correct Answer: A
Rationale: When performing a newborn assessment, it is important to measure the vital signs in the sequence of pulse, respirations, and temperature. This sequence is recommended because measuring the pulse first provides immediate information on the baby's cardiovascular status, followed by respirations to assess respiratory function, and ending with temperature which can be influenced by the other vital signs. This comprehensive approach helps ensure all vital signs are assessed accurately and in a logical order.
A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?
- A. "I don't'd understand why I have to keep taking pills when my blood pressure is normal."
- B. "I can't see the numbness on the label to know how much selt is in food."
- C. "I feel dizzy, I'll skip my dose foe a few days."
- D. "If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor."
Correct Answer: C
Rationale: The statement by the client, "I feel dizzy, I'll skip my dose for a few days," supports the nursing diagnosis of noncompliance with medication therapy. Prazosin is typically prescribed for conditions such as hypertension or benign prostatic hyperplasia, and abruptly stopping the medication can lead to negative consequences such as rebound hypertension. The client's decision to skip doses due to feeling dizzy indicates noncompliance with the prescribed medication regimen, which can pose risks to their health. It is essential for healthcare providers to educate the client on the importance of consistent medication adherence and to address any concerns or side effects promptly.
An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?
- A. Hyponatremia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypomagnesemia
Correct Answer: A
Rationale: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Sodium plays a crucial role in regulating the body's fluid balance and is essential for nerve and muscle function. Elderly individuals are at a higher risk of developing hyponatremia due to various factors, including medication use, reduced thirst sensation, and impaired kidney function.