7. A client has intra-arterial blood pressure monitoring after a myocardial infarction.
The nurse notes that the client’s heart rate has increased from 88 to 110 beats/min, and
the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse
is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
Give this one a try later!
, ANS: B
A major complication related to intra-arterial blood pressure monitoring is
hemorrhage from the insertion site. Since these vital signs are out of the
normal range, are a change, and are consistent with blood loss, the nurse
would assess the client for any bleeding associated with the arterial line.
The nurse would document the findings after a full assessment. The client
may or may not need pain medication and rest; the nurse first needs to rule
out any emergent
bleeding.
13. What form of heart disease in women of childbearing years usually has a benign
effect on pregnancy?
a. Cardiomyopathy
b. Rheumatic heart disease
c. Congenital heart disease
d. Mitral valve prolapse
Give this one a try later!
D
Mitral valve prolapse: benign and asymptomatic
cardiomyopathy -> CHF
Rheumatic Heart Disease -> HF
Congenital heart disease -> pumonary HTN/endocarditis
Mckinney ch 26
4. A nurse is teaching a community group of women about ways to decrease their risk
of cardiovascular disease. What actions does the nurse recommend? (Select all that
apply.)
a. Stop smoking
b. Drink 8 to 10 glasses of water daily
,c. Exercise on most days of the week
d. Get your blood pressure checked
e. Decrease the fat in your diet
Give this one a try later!
ACDE
Risk factor of CAD
smoking, sedentary lifestyle, HTN, high fat diet
Mckinney ch 32
9. A client is in the clinic a month after having a myocardial infarction. The client
reports sleeping well since moving into the guest bedroom. What response by the
nurse is best?
a. “Do you have any concerns about sexuality?”
b. “I’m glad to hear you are sleeping well now.”
c. “Sleep near your spouse in case of emergency.”
d. “Why would you move into the guest room?”
Give this one a try later!
ANS: A
Concerns about resuming sexual activity are common after cardiac events.
The nurse would
gently inquire if this is the issue. While it is good that the client is sleeping
well, the nurse would investigate the reason for the move. The other two
responses are likely to cause the client to be defensive.
The nurse is performing a cardiovascular assessment on a client with heart failure.
Which
item would the nurse assess to obtain the best
information about the client's left-sided
, heart function?
1. The status of breath sounds
2. The presence of peripheral edema
3. The presence of hepatojugular reflux
4. The presence of jugular vein distention
Give this one a try later!
1
The client with heart failure may present different symptoms
depending on whether the right or the left side of the heart is
failing. The assessment of breath sounds provides information about
left-sided
heart function. Peripheral edema, hepatojugular reflux, and
jugular vein distention are all signs of right-sided
heart function.
A client diagnosed with angina pectoris appears
to be very anxious and states, "So, I had a heart
attack, right?" Which response would the nurse
make to the client?
1. "No. That is not why you are hospitalized."
2. "No, but there could be some minimal
damage to your heart."
3. "No, not this time and we will do our best
to prevent a future heart attack."
4. "No, but it's necessary to monitor you and
control or eliminate your pain."
Give this one a try later!
The nurse notes that the client’s heart rate has increased from 88 to 110 beats/min, and
the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse
is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
Give this one a try later!
, ANS: B
A major complication related to intra-arterial blood pressure monitoring is
hemorrhage from the insertion site. Since these vital signs are out of the
normal range, are a change, and are consistent with blood loss, the nurse
would assess the client for any bleeding associated with the arterial line.
The nurse would document the findings after a full assessment. The client
may or may not need pain medication and rest; the nurse first needs to rule
out any emergent
bleeding.
13. What form of heart disease in women of childbearing years usually has a benign
effect on pregnancy?
a. Cardiomyopathy
b. Rheumatic heart disease
c. Congenital heart disease
d. Mitral valve prolapse
Give this one a try later!
D
Mitral valve prolapse: benign and asymptomatic
cardiomyopathy -> CHF
Rheumatic Heart Disease -> HF
Congenital heart disease -> pumonary HTN/endocarditis
Mckinney ch 26
4. A nurse is teaching a community group of women about ways to decrease their risk
of cardiovascular disease. What actions does the nurse recommend? (Select all that
apply.)
a. Stop smoking
b. Drink 8 to 10 glasses of water daily
,c. Exercise on most days of the week
d. Get your blood pressure checked
e. Decrease the fat in your diet
Give this one a try later!
ACDE
Risk factor of CAD
smoking, sedentary lifestyle, HTN, high fat diet
Mckinney ch 32
9. A client is in the clinic a month after having a myocardial infarction. The client
reports sleeping well since moving into the guest bedroom. What response by the
nurse is best?
a. “Do you have any concerns about sexuality?”
b. “I’m glad to hear you are sleeping well now.”
c. “Sleep near your spouse in case of emergency.”
d. “Why would you move into the guest room?”
Give this one a try later!
ANS: A
Concerns about resuming sexual activity are common after cardiac events.
The nurse would
gently inquire if this is the issue. While it is good that the client is sleeping
well, the nurse would investigate the reason for the move. The other two
responses are likely to cause the client to be defensive.
The nurse is performing a cardiovascular assessment on a client with heart failure.
Which
item would the nurse assess to obtain the best
information about the client's left-sided
, heart function?
1. The status of breath sounds
2. The presence of peripheral edema
3. The presence of hepatojugular reflux
4. The presence of jugular vein distention
Give this one a try later!
1
The client with heart failure may present different symptoms
depending on whether the right or the left side of the heart is
failing. The assessment of breath sounds provides information about
left-sided
heart function. Peripheral edema, hepatojugular reflux, and
jugular vein distention are all signs of right-sided
heart function.
A client diagnosed with angina pectoris appears
to be very anxious and states, "So, I had a heart
attack, right?" Which response would the nurse
make to the client?
1. "No. That is not why you are hospitalized."
2. "No, but there could be some minimal
damage to your heart."
3. "No, not this time and we will do our best
to prevent a future heart attack."
4. "No, but it's necessary to monitor you and
control or eliminate your pain."
Give this one a try later!
