Nokea
Which teaching point should the nurse include for a client with endocarditis? Select all that apply.
- A. Report fever or chills immediately.
- B. Brush teeth gently to avoid gum bleeding.
- C. Avoid sharing toothbrushes.
- D. Take antibiotics for the full course.
- E. Monitor for signs of heart failure.
- F. Limit physical activity during treatment.
Correct Answer: A,B,C,D,E,F
Rationale: Reporting symptoms, gentle oral hygiene, avoiding shared items, completing antibiotics, monitoring heart failure, and limiting activity prevent complications.
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The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess?
- A. Edematous arm from the axillary area to the fingertips.
- B. Painful, edematous, reddened lower forearm.
- C. Tented skin turgor over the entire left arm.
- D. Nipple retraction and peau d’orange skin.
Correct Answer: A
Rationale: Elephantiasis causes chronic lymphedema, leading to arm edema from axilla to fingertips (A). Pain/redness (B) suggests infection, tented turgor (C) is dehydration, and nipple changes (D) are breast cancer signs.
The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
Which activity should the nurse advise a client with a new pacemaker to avoid?
- A. Swimming in a chlorinated pool
- B. Using a microwave oven
- C. Lifting heavy objects for 6 weeks
- D. Walking for exercise
Correct Answer: C
Rationale: Avoiding heavy lifting for 6 weeks prevents dislodgement of pacemaker leads.
Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).
Which laboratory value should the nurse monitor closely in a client with heart failure? Select all that apply.
- A. B-type natriuretic peptide (BNP)
- B. Serum potassium
- C. Blood urea nitrogen (BUN)
- D. Hemoglobin A1c
- E. Serum sodium
- F. Platelet count
Correct Answer: A,B,C,E
Rationale: BNP indicates heart failure severity, potassium and sodium affect fluid balance and medication safety, and BUN reflects renal perfusion.