Chapter 4, 24, 30

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "When did you start experiencing this indigestion?" b. "What do you understand about what happened to you?" c. "Chili is high in fat and calories; it would be a good idea to stop eating it." d. "The primary health care provider has prescribed an antacid every morning."

Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain. The correct answer is: "What do you understand about what happened to you?"

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Smoking while taking this medication will increase your risk of a stroke." c. "Rise slowly when getting out of bed in the morning." d. "Stopping this medication suddenly increases your risk for a heart attack

Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack. The correct answer is: "Smoking while taking this medication will increase your risk of a stroke."

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Assess the client's peripheral pulses. b. Obtain blood and sputum cultures. c. Administer an albuterol treatment. d. Notify the Rapid Response Team.

Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the client. The correct answer is: Notify the Rapid Response Team.

An older adult recently retired and reports "being depressed and lonely." What information would the nurse assess as a priority? a. Role of work in the adult's life b. Previous stressful events c. History of previous depression d. Usual leisure time activities

Establishing and maintaining relationships with others throughout life are especially important to the older person's happiness. When people retire, they may lose much of their social network, leading them to feeling depressed and lonely. This loss from a sudden change in lifestyle can easily lead to depression. The nurse would first assess the role that work played in the client's life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population. The correct answer is: Role of work in the adult's life

A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population includes which components? (Select all that apply.) a. Frequent illness b. Slowed physical activity c. Weakness d. Exhaustion e. Dementia f. Weight gain

Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent illness could occur due to frailty, but is also not part of the syndrome. The correct answers are: Exhaustion, Weakness, Slowed physical activity

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. "My kids come to see me every weekend." b. "I think I am coping very well on my own." c. "Oh, I have lots of friends at the senior center." d. "I have had the same best friend for decades."

Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis. The person who is "coping well on my own" may actually need resources to help with this transition. Having children visit is important but not as important as intimate, long-term friendships. "Friends at the senior center" may refer to good acquaintances and not real friends. The correct answer is: "I have had the same best friend for decades."

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. A 65-year-old woman with diabetes mellitus. b. A 32-year-old man with colorectal cancer. c. An 86-year-old man with a history of asthma. d. e. A 53-year-old postmenopausal woman who takes bisphosphonates.

Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease. The correct answer is: A 65-year-old woman with diabetes mellitus.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. White rice b. Black beans c. Barley soup d. Whole-wheat bread

Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole-wheat products. The correct answer is: White rice

A home health care nurse assesses an older adult for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. Cheese sticks b. 1% milk c. Oranges d. Vitamin D supplements e. Lean ground beef f. Carrots

Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients. The correct answers are: 1% milk, Carrots, Vitamin D supplements, Oranges

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Assess the client's medications. c. Administer 1 mg of atropine. d. Initiate external pacing.

Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent. The correct answer is: Assess the client's medications.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client has reduced breath sounds—nurse calls primary health care provider immediately. c. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate. d. Client's heart rate is 55 beats/min—nurse withholds pain medication.

A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate. The correct answer is: Client has reduced breath sounds—nurse calls primary health care provider immediately.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. Pulse oximetry is 93% on 2 L of oxygen. b. The trachea is shifted toward the opposite side of the neck. c. A small amount of drainage from the site is noted. d. The client rates pain as a 5/10 at the site of the procedure.

A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team. The correct answer is: The trachea is shifted toward the opposite side of the neck.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Explain the procedure in detail to the client and the family. b. Verify that the client understands all possible complications. c. Measure oxygen saturation before and after a 12-minute walk. d. Validate that informed consent has been given by the client.

A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis. The correct answer is: Validate that informed consent has been given by the client.

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Workshop on prevention from becoming an abuse victim c. Financial planning seminar series for older adults d. Social events such as dances and group dinners

All activities would be beneficial for the older population in the community. However, failure in performing one's own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need. The correct answer is: Exercise program to improve physical function

An emergency department nurse triages client who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who reports cramping substernal pain. b. Client who reports moderate pain that is worse on inspiration. c. Client who describes intense squeezing pressure across the chest. d. Client who describes pain as a dull ache.

All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction. The correct answer is: Client who describes intense squeezing pressure across the chest.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Instruct the client to use the garage door instead. b. Have the client use a walker or cane on the steps. c. Teach the client to hold the handrail when using the steps d. Tell the client to use a two-footed gait on the steps.

As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Combined with diminished visual acuity, this can create a fall hazard. Holding the handrail would help keep the person safer. If the client does not need an assistive device, he or she would not use a cane or walker just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step. The correct answer is: Teach the client to hold the handrail when using the steps

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer prescribed albuterol c. Administer oxygen therapy. d. Position the client in high-Fowler position.

Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal. The correct answer is: Document the findings.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Document the finding as "left pedal pulse of +1/4." b. Assess the color and temperature of the left leg. c. Elevate the leg and apply a sandbag to the entrance site. d. Increase the flow rate of intravenous fluids.

Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem. The correct answer is: Assess the color and temperature of the left leg.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Perform a delirium screening test. d. Evaluate the client for gait abnormalities.

Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse would determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client's condition. The correct answer is: Determine if there are new medications.

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Tachypnea b. Rapid, shallow respirations c. Pain with respirations d. New-onset cough e. Purulent sputum f. Bradycardia

Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset "nagging" cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection. The correct answers are: New-onset cough, Pain with respirations, Tachypnea

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Initiation of an external pacemaker b. Administration of IV furosemide c. Assistance with endotracheal intubation d. Placement of central venous access

The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction. The correct answer is: Initiation of an external pacemaker

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Instruct the client to increase fluid intake the day before the MRI. c. Notify the primary health care provider before scheduling the MRI. d. Request lab for cardiac enzymes from the primary health care provider. Feedback

The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider. The correct answer is: Notify the primary health care provider before scheduling the MRI.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? a. "Do you have any chronic breathing problems?" b. "What is your occupation and what are your hobbies?" c. "Are you taking any medications or herbal supplements?" d. "How often do you perform aerobic exercise?"

The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first. The correct answer is: "Do you have any chronic breathing problems?"

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.)a. "Drink at least eight glasses of water each day." b. "Set a quit date and stick to it." c. "Identify a consequence for yourself in case you backslide." d. "Make a list of reasons you want to stop smoking." e. "Find an activity that you enjoy and will keep your hands busy." f. "Keep snacks like potato chips on hand to nibble on."

The nurse would teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit date and stick to it. The nurse would also encourage the client not to be upset if he or she backslides and has a cigarette but to try to determine what conditions caused him or her to smoke. The correct answers are: "Find an activity that you enjoy and will keep your hands busy.", "Set a quit date and stick to it.", "Drink at least eight glasses of water each day.", "Make a list of reasons you want to stop smoking."

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? a. Let the client have a small sip to see whether he or she can swallow. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Call the primary health care provider and request food and water for the client.

The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex. The correct answer is: Assess the client's gag reflex before giving any food or water.

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Respiratory rate of 8 breaths/min d. Oxygen saturation of 90%

When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later. The correct answer is: Heart rate of 120 beats/min

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Prepare for continuous blood pressure and pulse monitoring. b. Explain to the client that dobutamine will simulate exercise for this examination. c. Administer the client's prescribed beta blocker. d. Assist the primary health care provider to place a central venous access device. e. Give the client nothing by mouth 3 to 6 hours before the procedure.

Your answer is partially correct. Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results. The correct answers are: Explain to the client that dobutamine will simulate exercise for this examination., Prepare for continuous blood pressure and pulse monitoring., Give the client nothing by mouth 3 to 6 hours before the procedure.