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Which response by the nurse is most accurate?
- A. Sustained hypertension decreases thenvim life span of many blood cells.
- B. Sustained hypertension leads to the formation of venous blood clots.
- C. Sustained hypertension compromises blood flow to many vital organs.
- D. Sustained hypertension predisposes to narrowing of the cardiac valves.
Correct Answer: C
Rationale: Sustained hypertension increases vascular resistance, which can compromise blood flow to vital organs like the heart, brain, and kidneys, leading to organ damage.
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Which nursing action is most appropriate to perform next?
- A. The nurse notifies the physician, requesting a hypnotic or sedative.
- B. The nurse provides a video of the surgery for the client to watch.
- C. The nurse waits until the client's spouse is present to excessive the surgery.
- D. The nurse listens as the client talks about fears concerning surgery and rehabilitation.
Correct Answer: D
Rationale: Listening to the client's fears reduces anxiety and supports emotional preparation for surgery.
A low-sodium diet has been ordered for an adult client. The nurse knows that the client understands his low-sodium diet when the client selects which menu?
- A. Tossed salad, carrot sticks, and steak
- B. Baked chicken, mashed potatoes, and green beans
- C. Hot dog, roll, and coleslaw
- D. Chicken noodle soup, applesauce, and cottage cheese
Correct Answer: B
Rationale: Baked chicken, mashed potatoes, and green beans are naturally low in sodium. Steak, hot dogs, and chicken noodle soup are typically high in sodium.
Please indicate with an X the best anatomic area for the nurse to auscultate mitral valve sounds.
- A. Apex of the heart
- B. Second right intercostal space
- C. Second left intercostal space
- D. Lower left sternal border
Correct Answer: A
Rationale: Mitral valve sounds are best heard at the apex (fifth intercostal space, midclavicular line).
When the client asks the nurse how cholesterol acts as a cardiac risk factor, what is the best explanation?
- A. Excess fat in the blood expands the circulating blood volume.
- B. Excess fat in the blood thickens the lining of the arteries.
- C. Excess fat in the blood causes slower blood clotting.
- D. Excess fat in the blood stimulates the heart to beat faster.
Correct Answer: B
Rationale: High cholesterol contributes to atherosclerosis, where excess fat (lipids) deposits thicken and harden the arterial walls, narrowing the lumen and increasing cardiac risk.
The nurse understands that the client's hesitation in going to the hospital is an example of which coping mechanism?
- A. Regression
- B. Projection
- C. Denial
- D. Undoing
Correct Answer: C
Rationale: Denial involves minimizing or ignoring symptoms, such as attributing chest pain to muscle strain, delaying medical care.