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Health & Illness Concepts III
Terms in this set (50)
A pregnant woman at risk of preterm labor is diagnosed with hypertension. Which drug should be administered?
D. Magnesium sulfate.
A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply.
A. Suggest that the client have annual Papanicolaou (Pap) smears and mammograms
B. Promote dietary modifications by using varied techniques
C. Assess the client's current lifestyle and promote lifestyle changes
D. Monitor the client's blood pressure and weight and establish blood pressure screening programs
E. Teach the client about correct body mechanics and the availability of mechanical appliances
B, C, D
Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. ____________tablet(s)
Which statements related to initial assessment of hypertension by the nurse requires correction? Select all that apply.
A. "Deflating the cuff too slowly will show false-high diastolic readings."
B. "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading."
C. "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable."
D. "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure."
E. "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm."
The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what?
A. Chemically stimulate the loop of Henle
B. Diminish the thirst response of the client
C. Prevent reabsorption of water in the distal tubules
D. Cause fluid to move toward the interstitial compartment
Hypertension develops in a school-aged child with acute glomerulonephritis. What medication does the nurse anticipate that the healthcare provider will prescribe?
The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching?
A. Do not change to a standing position suddenly.
B. Lightheadedness is a common adverse effect that need not be reported.
C. The medication may cause a sore throat for the first few days.
D. Schedule blood tests weekly for the first 2 months.
What is the priority nursing action when caring for a client receiving nitroglycerin for the treatment of angina?
A. Asking the client to sit or stand slowly
B. Monitoring the client's urine output frequently
C. Advising the client to report when experiencing a headache
D. Reporting to the healthcare provider if pain does not subside after 5 minutes
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client?
A. 1 to 3 minutes
B. 4 to 5 seconds
C. 30 to 45 seconds
D. 20 to 45 minutes
Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the client with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin?
A. Once the tablet is dissolved, spit out the saliva.
B. Take tablets 3 minutes apart up to a maximum of five tablets.
C. Common side effects include headache and low blood pressure.
D. Once opened, the tablets should be refrigerated to prevent deterioration.
What instructions about the use of nitroglycerin should the nurse provide to a client with angina?
A. "Identify when pain occurs, and place two tablets under the tongue."
B. "Place one tablet under the tongue, and swallow another when pain is intense."
C. "Before physical activity, place one tablet under the tongue, and repeat the dose in 5 minutes if pain occurs."
D. "Place one tablet under the tongue when pain occurs, and use an additional tablet after the attack to prevent recurrence."
A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan?
A. Apply the patch on a distal extremity
B. Remove a previous patch before applying the next one.
C. Massage the area gently after applying the patch to the skin.
D. Apply a warm compress to the site before attaching the patch.
A client with a long history of cardiovascular problems, including angina and hypertension, is scheduled to have a cardiac catheterization. During preprocedure teaching, what does the nurse explains to the client is the major purpose for catheterization?
A. To obtain the pressures in the heart chambers
B. To determine the existence of congenital heart disease
C. To visualize the disease process in the coronary arteries
D. To measure the oxygen content of various heart chambers
A client with a history of angina is scheduled for a cardiac catheterization. Catheter entry will be through the femoral artery. What should the nurse tell the client to expect?
A. Remain fully alert during the procedure
B. Ambulate shortly after the procedure
C. Experience a feeling of warmth during the procedure.
D. Be placed in a semi-Fowler position for 12 hours after the procedure
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic?
A. Causes mild perspiration
B. Occurs after moderate exercise
C. Continues after rest and nitroglycerin
D. Precipitates discomfort in the arms and jaws
A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session?
A. It is relieved by rest.
B. It is precipitated by light activity.
C. It is described as sharp or knifelike.
D. It is unaffected by the administration of vasodilators.
What are the clinical manifestations of myocardial infarction in women? Select all that apply.
C. Unusual Fatigue
D. Sleep disturbances
E. Tightness of the chest
B, C, D
The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what?
A. Attempts to minimize the illness
B. Lacks an emotional response to the illness
C. Refuses to discuss the condition with the client's spouse
D. Expresses displeasure with the prescribed activity program
The nurse provides medication discharge instructions to a client who received a prescription for digoxin following the client's myocardial infarction. Which statement by the client leads the nurse to conclude that the teaching was effective?
A. "I will avoid foods high in potassium."
B. "I must increase my intake of vitamin K."
C. "I should adjust the dosage according to my activities."
D. "It will be important to check my radial pulse rate daily."
A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug?
D. Sodium bicarbonate
A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of what drug?
D. Morphine sulfate
A client who is hospitalized after a myocardial infarction asks the nurse why morphine was prescribed. What will the nurse include in the reply?
A. Decreases anxiety and promotes sleep
B. Helps prevent development of atrail fibrillation
C. Relieves pain and reduces cardiac oxygen demand
D. Dilates coronary blood vessels to increase oxygen supply
A healthcare provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over 1 hour for a client experiencing a myocardial infarction. What is the nurse's priority assessment that is specific to this medication's effect?
A. Respiratory rate
B. Peripheral pulses
C. Level of consciousness
D. Intravenous insertion site
Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase?
A. Lactate dehydrogenase (LDH-1)
B. Creatine kinase-MB band (CK-MB)
C. Erythrocyte sedimentation rate (ESR)
D. Serum aspartate aminotransferase (AST)
A client is admitted to the emergency department with chest pain and shortness of breath. An electrocardiogram indicates that the client is experiencing a myocardial infarction. An emergency cardiac catheterization is scheduled. What information should the nurse include in the preprocedure teaching?
A. Mild sedation is maintained during the procedure.
B. The procedure will take approximately 15 minutes to complete.
C. Ambulation is encouraged shortly after the procedure.
D. It will take approximately 24 hours to determine whether blockage is present.
The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.
A. Rapid pulse
B. Deep respirations
C. Warm, flushed skin
D. Increased blood pressure
E. Decreased urinary output
A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse?
A. "This test will detect your heart sounds."
B. "This test will reflect any heart damage."
C. "This procedure helps us change your heart's rhythm."
D. "The ECG will tell us how much stress your heart can tolerate."
A client who recently had a myocardial infarction is admitted to the cardiac care unit. How can the nurse best determine the effectiveness of the client's ventricular contractions?
A. Observing anxiety levels
B. Monitoring urinary output hourly
C. Evaluating cardiac enzyme results
D. Assessing breath sounds frequently
A client is admitted to the cardiac care unit with a diagnosis of myocardial infarction. The client asks the nurse, "What is causing the pain I am having?" Which explanation of the cause of the pain is the most appropriate response by the nurse?
A. Compression of the heart muscle
B. Release of myocardial isoenzymes
C. Rapid vasodilation of the coronary arteries
D. Inadequate oxygenation of the myocardium
A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?
A. Arterial spasm
B. Heart muscle ischemia
C. Blocking of the coronary viens
D. Irritation of nerve endings in the cardiac plexus
A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?
A. Cold, clammy skin
B. Slow, bounding pulse
C. Increased blood pressure
D. Hyperactive bowel sounds
While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure?
A. Child client
B. Pregnant client
C. Older adult client
D. Young adult client
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema?
A. Shift of fluid into the interstitial spaces
B. Weakening of the cell wall
C. Increased intravascular compliance
D. Increased intracellular fluid volume
An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value will the nurse report to the healthcare provider?
A. Sodium of 140 mEq/L (140 mmol/L)
B. Ionized calcium of 2.35 mEq/L (1.2 mmol/L)
C. Chloride of 102 mEq/L (102 mmol/L)
D. Potassium of 3.0 mEq/L (3.0 mmol/L)
A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin?
D. Junctional tachycardia
A healthcare provider prescribes milrinone for a client with a diagnosis of congestive heart failure who was unresponsive to conventional drug therapy. What is most important for the nurse to do first?
A. Administer the loading dose over 10 minutes
B. Monitor the ECG continuously for dysrhythmias during infusion.
C. Assess the heart rate and blood pressure continuously during infusion.
D. Have the prescription, dosage calculations, and pump settings checked by a second nurse.
A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day?
A. Maintaining potassium levels
B. Preventing increased sodium levels
C. Limiting the drugs' synergistic effects
D. Correcting the associated dehydration
A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?
A. Perform daily weights
B. Auscultate breath sounds
C. Monitor intake and output
D. Assess for dependent edema
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention?
A. Initiate oxygen therapy
B. Obtain chest x-ray film immediately
C. Place client in a high-Fowler position
D. Assess the client for a pleural friction rub
A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess?
C. Tissue ischemia
D. Thrombus formation
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?
A. Providing small, frequent feedings
B. Positioning the child flat on the back
C. Encouraging nutritional fluids often
D. Measuring the head circumference daily
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.
A. Dependent edema
B. Swollen hands and fingers
C. Collapsed neck veins
D. Right upper quadrant discomfort
A, B, D
The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.
A. Weight loss
B. Extreme fatigue
C. Coughing at night
D. Excessive urination
E. Difficulty breathing
B, C, E
An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do?
A. Suppress fears
B. Deny the illness
C. Maintain independence
D. Reassure the adult child
When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?
A. Interview the client for a health history.
B. Assess the client's heart and lung sounds.
C. Monitor the client's pulse and temperature.
D. Obtain the client's blood specimen for electrolytes.
A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take?
A. Double the dose of potassium chloride and administer it with the prescribed digoxin.
B. Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately.
C. Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider.
D. Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.
How can the nurse best describe heart failure to a client?
A. A cardiac condition caused by inadequate circulating blood volume
B. An acute state in which the pulmonary circulation pressure decreases
C. An inability of the heart to pump blood in proportion to metabolic needs
D. A chronic state in which the systolic blood pressure drops below 90 mm Hg
A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client?
A. Increases the cardiac workload
B. Interferes with usual respirations
C. Produces an elevation in temperature
D. Decreases the amount of oxygen used
A client has left ventricular heart failure. For which clinical indicators should the nurse assess the client? Select all that apply.
C. Peripheral edema
D. Dyspnea on exertion
E. Jugular vein distention
A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care?
A. Client has decreased plasma colloid osmotic pressure.
B. Client has increased tissue colloid osmotic pressure.
C. Client has increased plasma hydrostatic pressure.
D. Client has decreased tissue hydrostatic pressure.
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