S3U4

The client with erectile dysfunction is being evaluated for the use of sildenafil (Viagra). Which of the following questions should the nurse ask before initiating therapy with sildenafil? 1) Are you currently taking medication for angina? 2) Do you have a history of diabetes? 3) Have you ever had an allergic reaction to dairy products? 4) Have you ever been treated for migraine headaches?

1) Are you currently taking medication for angina? Life-threatening hypotension is an adverse effect in clients taking sildenafil and organic nitrates.

A woman is considered to be in menopause after she missed how many menstrual cycles?

12

Most common reason for hospital admission in adults over 65 A. HF B. MI C. Dysrhythmias D. Depression

A. HF

Which are vasodilators ? (select all that apply) A. nitroglycerin B. Sodium nitroprusside (Nipride) C. Nesiritide (Natrecor) D. Milirinone

A. nitroglycerin B. Sodium nitroprusside (Nipride) C. Nesiritide (Natrecor)

What is an early symptom of ADHF? What is an early symptom of chronic HF?

ADHF early symptom: increased RR, Chronic HF early symptom: fatigue

select all statements that at true about IV nitroglycerine A. Vasodilator that reduces blood volume B. Improves coronary artery circulation C. Reduces preload D. Slightly reduces after-load E. Increases myocardial oxygen supply)

ALL are correct statements

True or False: The SA node is located in the left atrium.

False

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

b. Infection c. Rejection e. Sudden cardiac death

At what age does menopause typically begin?

51

A patient is dx with left side systolic heart failure. What is the expected findings? A. EF 38% B. EF 65 % C. EF 20% D. jugular vein distension

A. EF 38%

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. A. Lethargy B. Ambivalence C. Emotional lability D. Increased appetite E. Long periods of sleep

A. Lethargy B. Ambivalence C. Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.

A client with heart failure is receiving digoxin and hydrochlorothiazide. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply . A. Nausea B. Yellow vision C. Irregular pulse D. Increased urine output E. Heart rate of 64 beats per minute

A. Nausea B. Yellow vision C. Irregular pulse Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, ECG findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of the diuretic furosemide; a pulse rate of 64 beats per minute is an acceptable rate when a client is receiving digoxin.

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention? A. Obtaining information about her perception of the incident B. Notifying legal authorities that a sexual assault has occurred C. Talking with the husband about his feelings concerning sexual assault D. Teaching the client how to obtain a midstream clean-catch urine specimen

A. Obtaining information about her perception of the incident In a crisis situation it is important for the individual to talk about the situation to enable her to move past shock and disbelief. Notifying the legal authorities that a sexual assault has occurred is the client's decision ( if a minor nurse must report). Although the nurse might talk with the husband, the priority is the woman not the husband. Teaching the client how to obtain a midstream clean-catch urine specimen is contraindicated because the use of water or an antiseptic solution during the procedure will wash away sperm or blood evidence.

A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should: A. Refer the mother to the psychiatrist. B. Explain to the mother the results of the tests. C. Suggest that the mother call the psychologist. D. Teach the mother about the tests that were administered.

A. Refer the mother to the psychiatrist. It is the responsibility of the psychiatrist, who is the primary care provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered.

What is the correct sequence of electrical conduction of the heart? A. SA node, inter-nodal pathways, AV node, Bundle of His, Right and Left Bundle Branch, Purkinje fibers B. None of the options are correct C. SA node, inter-nodal pathways, AV node, Purkinje Fibers, Right and Left Bundle Branch, Bundle of His D. AV node, inter-nodal pathways, SA node, Bundle of His, Right and Left Bundle Branch, Purkinje fibers

A. SA node, inter-nodal pathways, AV node, Bundle of His, Right and Left Bundle Branch, Purkinje fibers

A new mother is diagnosed with depression. Which antidepressant may be prescribed to this client? A. Sertraline B. Fluoxetine C. Amphetamine D. Carbamazepine

A. Sertraline Sertraline is considered safe in lactating females. Dosing immediately after breast-feeding can reduce the risk of the drug excreted in the breast milk by the next feeding time. Fluoxetine and amphetamine are not recommended for breast-feeding clients. Carbamazepine is not used to treat depression.

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. A. Tell a staff member to get the electrocardiogram machine. B. Notify the x-ray department that a chest x-ray exam must be done stat. C. Have a staff member notify the nursing supervisor of the change in client status. D. Notify the healthcare provider of the change in the oxygen saturation to ask what to do. E. Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. F. Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.

A. Tell a staff member to get the electrocardiogram machine. B. Notify the x-ray department that a chest x-ray exam must be done stat. C. Have a staff member notify the nursing supervisor of the change in client status F. Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider. A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.

When using a 5-electrode lead ECG monitoring system, the nurse recognizes which lead is most optimal for detecting dysrhythmias?A. III B. V1 C. V5 D. aVR

Answer: B Rationale: Five-electrode ECG monitoring systems use four electrode leads to provide six limb lead tracings (leads I, II, III, aVR, aVL, oraVF) and the fifth electrode lead is a chest electrode that can be placed in any of the standard V1 to V6 locations. But in general, V1 is selected because of its value in detecting dysrhythmias (e.g., arrhythmia monitoring).

A normal PR interval how many seconds and how many boxes? A. less than 12 seconds (2 boxes) B. 0.12-0.2 seconds (3-5 boxes) C. Greater than 20 seconds (6-8 boxes)

B. 0.12-0.2 seconds (3-5 boxes)

Select all the correct statements about the pharmacodynamics of Beta-blockers for the treatment of heart failure: A. These drugs produce a negative inotropic effect on the heart by increasing myocardial contraction. B. A side effect of these drugs include bradycardia. C. These drugs are most commonly prescribed for patients with heart failure who have COPD. D. Beta-blockers are prescribed with ACE or ARBs to treat heart failure.

B. A side effect of these drugs include bradycardia. D. Beta-blockers are prescribed with ACE or ARBs to treat heart failure.

True or False: Bachmann's bundle is located in the left artrium.

True

True or False: Depolarization of the heart muscle is when the muscle contracts and repolarization is when the heart muscle rests.

True

True or False: Patients with left-sided diastolic dysfunction heart failure usually have a normal ejection fraction.

True

The nurse is discussing menopause with a​ 40-year-old client. During this​ discussion, the nurse identified which factor that determines when perimenopause may​ occur? a Genetics b Age of menarche c Being sexually active d Alcohol use

a Genetics The age of perimenopause is genetically programmed and unrelated to the age of menarche. Cigarette smoking and living at high altitudes can lead to earlier menopause. Alcohol use and being sexually active does not influence perimenopause.

What are the clinical manifestations of​ menopause?​ (Select all that ​apply.) a Vaginal dryness b Thinning hair c Headaches d Hot flashes e Cold intolerance

a Vaginal dryness b Thinning hair c Headaches d Hot flashes

2. A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

a. AV node b. Left ventricle d. Right ventricle

The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions

a. Establish trust and rapport

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels. b. Teach the patient how to take a pulse rate. c. Keep an accurate measure of intake and output. d. Teach the patient about dietary restriction of potassium. e. Withhold digitalis and notify health care provider if pulse is irregular.

a. Monitor serum potassium levels.b. Teach the patient how to take a pulse rate.

10. Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses

The nurse recognizes that primary manifestations of systolic failure include a. ↓ EF and ↑ PAWP. b. ↓ PAWP and ↑ EF. c. ↓ pulmonary hypertension associated with normal EF. d. ↓ afterload and ↓ left ventricular end-diastolic pressure.

a. ↓ EF and ↑ PAWP (pressure within the pulmonary arterial system)

Secondary effects of abuse often manifest as arrested development in children due to the fact that: a. Coping is easier than emotional growth b. Energy for development is diverted to coping c. Children cannot differentiate love from abuse d. Abuse fosters a sense of belonging, even if dysfunctional

b. Energy for development is diverted to coping

The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and the elderly due to: a. The love they have for parents or children. b. Their limited options. c. The need to feel safe at home. d. Other relatives do not want them.

b. Their limited options.

3. The part of the vascular system responsible for hemostasis is the a. thin capillary vessels. b. endothelial layer of the arteries. c. elastic middle layer of the veins. d. smooth muscle of the arterial wall.

b. endothelial layer of the arteries.

During the examination portion of her annual checkup, a 55-year-old client has several new complaints. Which subjective symptoms of menopause would the nurse expect to find during data collection? a Hair growth on the upper lip b Decreased skin elasticity c Night sweats d Rise in vaginal Ph

c. Night sweats Night sweats is the only symptom that is subjective, reported by the client. Facial hair, decreased skin elasticity, and a rise in vaginal pH are all objective signs that can be observed by the nurse.

What safety-related responsibility does the nurse have in any situation of suspected of abuse? a. protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties but especially the patient. d. Report suspected abuse to the proper authorities.

d. Report suspected abuse to the proper authorities.

To determine whether there is a delay in condition through the ventricles, the nurse would measure: A. P wave B. PR interval C. Q wave D. QRS complex

D. QRS complex

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea

B. Persistent cough D. Crackles F. Orthopnea The answers are B, D, and F. Persistent cough, crackles (also called rales), and orthopnea are signs and symptoms of LEFT-sided heart failure...not right-sided heart failure.

What area of the heart forms the QRS part on an EKG? A. SA node B. Purkinje fibers C. Left and right bundles D. AV node

B. Purkinje fibers

What is the treatment of choice for atrial flutter? (PP) A. Anti-dysrhythmia drugs B. Radio-frequency catheter ablation C. Calcium channel blockers D. β-blocker

B. Radio-frequency catheter ablation

Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. B. A 55 year old female with a health history of asthma and hypoparathyroidism. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. D. A 45 year old female with lung cancer stage 2. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.

A. A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza. The answers to this question are options: A, C, E. These patients are at most risk for heart failure. Remember risks factor for developing heart failure include: remember the mnemonic FAILURE: Faulty heart valves (Option C mitral stenosis in this case), Arrhythmias, Infarction (Option A), Lineage, Uncontrolled hypertension (Option E), Recreational drug usage, Evaders (Option E with influenza)

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? A. Allows excess tissue fluid to be excreted B. Helps to control the volume of food intake and thus weight C. Aids the weakened heart muscle to contract and improves cardiac output D. Assists in reducing potassium accumulation that occurs when sodium intake is high

A. Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.

Incidents of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation? A. Isolation B. Repression C. Regression D. Introjection

B. Repression Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness.

A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial action by the nurse? A. Arranging for a staff member to watch the children so the mother and nurse can talk B. Calling a facility where the mother and her children will be safe until the crisis is resolved C. Determining whether the mother is ambivalent about this decision before making permanent plans D. Suggesting that the mother and her husband return for couples counseling so the marriage can be saved

A. Arranging for a staff member to watch the children so the mother and nurse can talk This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determination of the client's ambivalence may be made, and couples counseling may be recommended eventually, all three actions are premature if a thorough assessment of the situation has not been made.

The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular fibrillation

A. Atrial fibrillation Rationale: Atrial fibrillation (AF) is the most common dysrhythmia seen in clinical practice. It is responsible for a third of hospitalizations for cardiac rhythm disturbances. Patients can live with this dysrhythmia, but most are treated with anticoagulation therapy to avoid possible blood clots.

Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. A. Checking for compliance with the client's drug regimen B. Monitoring the client's serum potassium and magnesium levels regularly C. Administering digoxin only through the intramuscular route D. Calculating the correct dosage form, prescribed amounts, and the prescriber's order E. Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly

A. Checking for compliance with the client's drug regimen B. Monitoring the client's serum potassium and magnesium levels regularly D. Calculating the correct dosage form, prescribed amounts, and the prescriber's order E. Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. Administering digoxin through the intramuscular route is not advised because this method is very painful.

Which blood test can help confirm if a mown is beginning menopause? A. FSH B. Testosterone C. Progesterone D. Cholesterol

A. FSH

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? A. Fluid retention B. Urinary retention C. Renal insufficiency D. Abdominal distention

A. Fluid retention With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).

First drug choice to convert PSVT to normal sinus rhyme (PP) A. IV adenosine B. IV β-blockers C. Amiodarone D. Calcium channel blockers

A. IV adenosine

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply. A. Planning for future safety B. Normalizing victimization C. Validating the experiences D. Promoting access to community services E. Providing housing for the victim

A. Planning for future safety C. Validating the experiences D. Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.

How do ACE-inhibitors, such as enalapril work to reduce HF? A. Prevent the conversion of angiotensin I to II B. Cause systemic vasodilation C. Promote the excretion of sodium and water D. Block the sympathetic nervous system stimulation of the heart E. Increase cardiac contractility F. Reduce preload and afterload

A. Prevent the conversion of angiotensin I to II B. Cause systemic vasodilation D. Block the sympathetic nervous system stimulation of the heart F. Reduce preload and afterload

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery? A. Promote pain relief B. Increase activity tolerance C. Prevent cardiac dysrhythmias D. Maintain potassium and sodium intake

A. Promote pain relief The major goal is to manage pain. Pain relief helps increase the oxygen supply and decrease myocardial oxygen demand, decreasing the workload of the heart. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. While preventing dysrhythmia is important, it is not the priority. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? A. Raise the client to high-Fowler position B. Obtain the apical pulse and blood pressure C. Call the primary healthcare provider immediately D. Monitor the pulse oximeter to ascertain the oxygen level

A. Raise the client to high-Fowler position Raising the client to high-Fowler position will decrease orthopnea by using gravity to keep fluid in lower extremities, putting less stress on the heart. Obtaining a full set of vital signs would be the next priority after changing the client position. Calling the primary healthcare provider immediately would not be useful without having a full set of vital signs. The vital signs should include the oxygen saturation, which the healthcare provider would expect the nurse to provide.

A nurse is assessing a toddler and the dynamics of the child's family, in which abuse is suspected. What behaviors are expected? Select all that apply. A. The child cringes when approached. B. The child has unexplained healed injuries. C. The parents are overly affectionate toward the child. D. The child lies still while surveying the environment. E. The parents give detailed accounts of the child's injuries.

A. The child cringes when approached. B. The child has unexplained healed injuries. D. The child lies still while surveying the environment. The child cringes when approached because past experiences with adults have resulted in pain rather than comfort. Evidence of past injuries may exist, but the parents do not discuss it, because this would be an admission of child abuse. Abused children are always on the alert for potential abuse. Lying motionless is an attempt to avoid attention; also, in the past the abused child's attempts to resist abuse have often precipitated more abuse. Abusive parents are unable to provide any emotional support and will not exhibit overly affectionate behavior. Because abusive parents try to hide the fact of abuse, explanations about injuries are usually fabricated, inconsistent, and vague.

Ventricular remodeling is changes in (select all that apply) A. size of the ventricle B. only the right ventricle C. shape of the ventricle D. mechanical performance of the ventricle

A. size C. shape D. mechanical performance of the ventricle

The HCP ordered Sertaline (Zoloft) after 3 days, the patient says the med is not working. The RN should respond: A. "Cheer up, you have so much to be happy about." B. "Sometimes its takes 4-6 weeks to see improvements in symptoms." C. "Give it 2 days and you should see improvements in your symptoms." D. "I'll call the HCP and get an order to change the medication."

B. "Sometimes its takes 4-6 weeks to see improvements in symptoms."

Women taking estrogen replacement therapy need how much calcium a day? A. 500mg B. 1000mg C. 1250 mg D. 1500mg

B. 1000mg

Patients with heart failure can experience episodes of exacerbation. All of the patients below have a history of heart failure. Which of the following patients are at MOST risk for heart failure exacerbation? A. A 55 year old female who limits sodium and fluid intake regularly. B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation. C. A 67 year old female who is being discharged home from heart valve replacement surgery. D. A 78 year old male who has a health history of eczema and cystic fibrosis.

B. A 73 year old male who reports not taking Amiodarone for one month and is experiencing atrial fibrillation. Option B is the correct answer. Patients who are in an arrhythmia (especially a-fib) are at risk for developing heart failure because the heart is not contracting properly and blood is pooling in the chambers.

What area of the heart is responsible for the delay of conduction between the artrium and ventricles? A. Bachmann's Bundle B. AV node C. Right bundle branch D. Bundle of His

B. AV node

A patient with heart failure has +1 ankle edema and feeling too tires to go to the BR. Which nursing dx is correct? A. Fluid volume excess r/t edema B. Activity intolerance r/t altered preload C. Alterations in gas exchange r/t imbalance between oxygen D. Knowledge deficit r/t subjective data

B. Activity intolerance r/t altered preload

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.

B. Assess the client's heart and lung sounds. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

You are assisting a patient up from the bed to the bathroom. The patient has swelling in the feet and legs. The patient is receiving treatment for heart failure and is taking Hydralazine and Isordil. Which of the following is a nursing priority for this patient while assisting them to the bathroom? A. Measure and record the urine voided. B. Assist the patient up slowing and gradually. C. Place the call light in the patient's reach while in the bathroom. D. Provide privacy for the patient.

B. Assist the patient up slowing and gradually.

Which of the following would be the best recommendation for osteoporosis prevention? A. Taking vitamin E B. cycling every day C. Include more dairy and green leafy vegetables D. Limit caffeine

C. Include more dairy and green leafy vegetables

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

B. Auscultate breath sounds Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore, assessing the effectiveness of furosemide therapy as it relates to the respiratory system is most important. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis; as diuresis occurs fluid moves out of the vascular compartment, thereby reducing pulmonary edema and the bilateral crackles. Although a liter of fluid weighs approximately 2.2 pounds (1 kilogram) and weight loss will reflect the amount of fluid lost, it will take time before a change in weight can be measured. Although identifying a greater output versus intake indicates the effectiveness of furosemide, it is the client's pulmonary status that is most important with acute pulmonary edema. Although the lessening of a client's dependent edema reflects effectiveness of furosemide therapy, it is the client's improving pulmonary status that is most important.

A 74 year old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure? A. K+ 5.6 B. BNP 820 C. BUN 9 D. Troponin <0.02

B. BNP 820 The answer is option B. BNP (b-type natriuretic peptide) is a biomarker released by the ventricles when there is excessive pressure in the heart due to heart failure. <100 no failure, 100-300 present, >300 pg/mL mild, >600 pg/mL >moderate, 900 pg/mL severe

Which of the following are physical signs that a child was abused physically A. Withdrawing behavior in class B. Cigarette burns on arms C. Acting out sexual interactions when playing D. poor hygiene and dirty clothes

B. Cigarette burns on arms

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. A. Collapsed neck veins B. Distended abdomen C. Dependent edema D. Urinating at night E. Cool extremities

B. Distended abdomen C. Dependent edema D. Urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.

What is the hallmark for left sided HF with systolic dysfunction A. Pitting edema B. EF less than 45% C. Distended neck veins D. EF greater than 50%

B. EF less than 45%

Priority labs/diagnostics suspect for acute MI A. CBC B. EKG C. troponin, CK, CKMB D. Coronary angiography E. BMP

B. EKG C. troponin, CK, CKMB D. Coronary angiography

Which of the following is a common side effect of Spironolactone? A. Renal failure B. Hyperkalemia C. Hypokalemia D. Dry cough

B. Hyperkalemia

A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz (4167 g). The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply. A. Stranger anxiety B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions E. Adequate personal hygiene

B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment. The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.

A nurse teaches the parents of an infant with a cardiac defect how to detect impending heart failure. What should the parents be taught to identify as an early sign? A. Slowed respiration B. Increased heart rate C. Distended neck veins D. Increased urine output

B. Increased heart rate Tachycardia results from sympathetic stimulation in the setting of heart failure; it is the body's attempt to increase cardiac output and increase oxygen supply to the body's cells. The respirations will increase, not decrease, when heart failure occurs. Distended neck veins occur only in adults when heart failure has progressed to systemic congestion. Urinary output is decreased as a result of sodium and water retention.

Most characteristic symptom of menopause? A. Hot flahses B. It varies from woman to woman C. Mood swings D. Vaginal dryness and painful intercourse

B. It varies from woman to woman

You initially suspect he has an ACS, which symptom is not a typical manifestation? (Kahoot) A. Pressure-like chest pain B. Palpitations C. Dyspnea D. Nausea

B. Palpitations

Select all the correct statements about educating the patient with heart failure: A. It is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week. B. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. C. Heart failure patients should limit sodium intake to 2-3 grams per day. D. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. E. Patients with heart failure should limit exercise because of the risks.

B. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine. C. Heart failure patients should limit sodium intake to 2-3 grams per day. D. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias. The answers are B, C, and D. Option A is wrong because heart failure patients should notify their doctor if they gain 2-3 pounds in a day or 5 pounds in a week, and option E is wrong because exercise is important for heart failure patients to help strengthen the heart muscle...so they should exercise as tolerated.

The pt was dx with MI yesterday. Which of the data would be most important to report (Kahoot) A. Hyperglycemia B. bilateral crackles C. Q waves on EKG D. elevated troponin

B. bilateral crackles

Which assessment data suggest that his chest pain is caused by an acute MI? (Kahoot) A. pain increases with deep breathing B. pain last lasted longer than 30 minutes C. pain is relieved after the patient take Nitro D. pain resolved when patient raises his arm

B. pain last lasted longer than 30 minutes

The nurse knows that cardiac specific troponin will increase ____ hours after onset of MI (Kahoot) A. Immediately B. 2-3 C. 4-6 D. 10-12

C. 4-6

What part of the heart's electrical system is known as the "gatekeeper"? A. SA node B. Tetany C. AV node D. Gap Junction

C. AV node

A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? A. Providing information about a local support group B. Explaining that it is normal to feel depressed after childbirth C. Asking the client questions, using a postpartum depression scale D. Suggesting that the client find someone who can take care of the baby for 24 hours

C. Asking the client questions, using a postpartum depression scale A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Although providing community resources of a local support group may be helpful, it is not useful in assessing the client's current emotional status. Although postpartum blues caused by hormonal changes soon after pregnancy might be common, feelings of depression and fatigue 6 weeks after childbirth is a matter of concern. The client may not have anyone else who can provide child care, or the client may not follow through on the recommendation. In addition, this intervention does not provide any information on the client's current emotional status.

A patient with left-sided heart failure is having difficulty breathing. Which of the following is the most appropriate nursing intervention? A. Encourage the patient to cough and deep breathe. B. Place the patient in Semi-Fowler's position. C. Assist the patient into High Fowler's position. D. Perform chest percussion therapy.

C. Assist the patient into High Fowler's position. The answer is C. Due to the patient being in fluid overload (especially with left-sided heart failure...remember the lungs are majorly affected in this type of heart failure), it is most appropriate to place the patient in High Fowler's position to help make breathing easier

You dx STEMI with W.R the closest hospital with cardiac cath lab is 4 hours away. You... A. Transfer the patient to the cath lab 4 hours away B. Forego re-perfusion tx as chest pain began 6 hours ago C. Begin administering a fibrotic agent D. Start heparin drop

C. Begin administering a fibrotic agent

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.

C. Client has increased plasma hydrostatic pressure. In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.

A patient taking Digoxin is experiencing severe bradycardia, nausea, and vomiting. A lab draw shows that their Digoxin level is 4 ng/mL. What medication do you anticipate the physician to order for this patient? A. Narcan B. Aminophylline C. Digibind D. No medication because this is a normal digoxin level.

C. Digibind The patient is experiencing Digoxin toxicity...therefore the physician will order the antidote for Digoxin which is Digibind.

A pt is thinking about using HRT during menopause. Which statement is correct by the nurse? A. Vaginal estrogen creams are as effective as oral estrogen B. Increased risk of colon cancer in women taking HRT C. HRT decreases osteoporosis risk but increases breast cancer risk D. Use of HRT up to 10 years helps symptoms

C. HRT decreases osteoporosis risk but increases breast cancer risk

An older adult presents with a fx arm, multiple bruises, which action should the RN do first A. Notify elder protective services B. Make a referral for a nursing home assessment C. Have the family member stay in the waiting room when the RN assesses the patient D. Ask the patient how injury occurred and watch the family's response

C. Have the family member stay in the waiting room when the RN assesses the patient

A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5 ng/mL. Which of the following is the correct nursing action? A. Hold this dose and administer the second dose at 1800. B. Administer the dose as ordered. C. Hold the dose and notify the physician of the digoxin level. D. Hold this dose until the patient's potassium level is normal.

C. Hold the dose and notify the physician of the digoxin level.

The family of a client with right ventricular heart failure expresses concern about the client's increasing abdominal girth. What physiologic change should the nurse consider when explaining the client's condition? A. Loss of cellular constituents in blood B. Rapid osmosis from tissue spaces to cells C. Increased pressure within the circulatory system D. Rapid diffusion of solutes and solvents into plasma

C. Increased pressure within the circulatory system Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure, fluid moves into the tissues, causing edema, and into the abdominal cavity, causing ascites; ascites leads to an increased abdominal girth. There is no loss of the cellular constituents in blood with right ventricular heart failure. Ascites is the accumulation of fluid in an extracellular space, not intracellular. The opposite of rapid diffusion of solutes and solvents into plasma results when there is a pressure increase in the systemic circulation.

A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5

C. K+ 8.0 Losartan and Spironolactone can both cause an increased potassium level (hyperkalemia). Losartan is an ARB and Spironolactone is a potassium-sparing diuretic. Therefore, the EKG changes are a sign of a high potassium level (normal potassium level is 3.5-5.1).

On an EKG the P-wave represents what area of the heart? A. Left bundle branch B. AV node C. SA node D. Bachmann's Bundle

C. SA node

What area of the heart's electrical conduction is known as the "pacemaker" of the heart? A. Bundle of His B. AV node C. SA node D. Purknije Fibers

C. SA node

A 6-year-old child with a leg fracture of suspicious origin is brought into the emergency department by the mother and the mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, a nurse anticipates that the healthcare provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool? A. The exact location and extent of the fracture will be pinpointed. B. Three separate x-ray films of the leg and hip should be ordered, making it more cost-effective. C. The skeletal history of the current fracture and any previous healing or healed fractures are identified. D. It is the first step toward a complete assessment before computed tomography and magnetic resonance imaging are done.

C. The skeletal history of the current fracture and any previous healing or healed fractures are identified. Abusive parents may "shop" for hospitals that do not have a previous record of their child; the skeletal survey will provide a revealing injury history if abuse has occurred. Pinpointing the exact location of a fracture is necessary to plan appropriate treatment and can be done with a single x-ray film of the area; a skeletal survey is more extensive and helpful when abuse is suspected. Cost-effectiveness is not the primary concern if abuse is suspected. Computed tomography and magnetic resonance imaging are not required unless internal injuries are suspected.

During the administration of the thrombolytic, the nurse should stop the transfusion if that pt has (Kahoot) A. Bleeding gums B. increased BP C. a decrease in LOC D. a non-sustained arrhythmia

C. a decrease in LOC

A patient is taking digoxin, apical pulse 61, digoxin is 5. Which is correct A. hold dose now and administer the dose in the evening B. administer the dose as ordered C. hold the dose and notify the Dr. of the digoxin level D. Administer the dose and repeat a digoxin level in 6 hours

C. hold the dose and notify the Dr. of the digoxin level

A patient diagnosed with ACS is on Nitro drip. Which nursing action could the RN delegate to the LPN? A. teach the pt about nitro B. change the peripheral IV site C. monitor the patient BP every hour D. titrate the drip as ordered

C. monitor the patient BP every hour

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A. "My ankles are swollen." B. "I am tired at the end of the day." C. "When I eat a large meal, I feel bloated." D. "I have trouble breathing when I walk rapidly."

D. "I have trouble breathing when I walk rapidly." Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.

You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals."

D. "I will limit my consumption of frozen meals." The answer is D. Patients with heart failure should limit sodium intake to 2 to 3 grams per day (not 5-6 grams), avoid canned vegetable/fish, and avoid sandwich meats and cheeses because of their high sodium content. Frozen meals are high in sodium, therefore the patient is correct in saying they should limit their consumption of them.

A patient is being discharged home after hospitalization of left ventricular systolic dysfunction. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition? A. "Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain." B. "It is important to monitor your daily weights, fluid and salt intake." C. "Left-sided heart failure can lead to right-sided heart failure, if left untreated." D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."

D. "This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema." Option D is the answer. This is a description of right-sided heart failure NOT left ventricular systolic dysfunction. Left-sided systolic dysfunction is where the left side of the heart is unable to CONTRACT efficiently which causes blood to back-up into the lungs...leading to pulmonary edema.

What can a women do to decrease the vasomotor effect of menopause? A. Perform aerobic exercise B. increase the amount of calcium and vitamin D in the diet C. Increase caffeinated beverages D. Dress in layers of cotton clothing

D. Dress in layers of cotton clothing

A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse? A. "Maybe it was your husband's fault, too." B. "I can't agree with that—no one should be beaten." C. "Tell me why you believe that you deserve to be beaten." D. "You say that it was your fault—help me understand that."

D. "You say that it was your fault—help me understand that." Paraphrasing and clarifying are interviewing techniques that promote communication between the nurse and client and help the client hear and explore her words and gain insight into her behavior. "Maybe it was your husband's fault, too" is a declarative statement that is closed, will limit dialog, and is not therapeutic. When the nurse voices her opinion saying, "I can't agree with that—no one should be beaten", the nurse is shutting off communication with the client. Nurses are to be nonjudgmental and not offer an opinion, and should ask open-ended questions to facilitate communication with the client. Asking a "why" question is generally not therapeutic because most clients cannot respond to these questions with logical explanations.

The SA node fires at a rate of? A. 80-90 bpm B. 60-80 bpm C. 40-60 bpm D. 60-100 bpm

D. 60-100 bpm

On the third postpartum day, the nurse enters the room of a client who had an unexpected cesarean birth and finds her crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" What should the nurse consider when responding? A. The client's feelings will pass after she has bonded with her infant. B. The client is probably suffering from postpartum depression and needs special care. C. A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome. D. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this.

D. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this. The client's response is appropriate to the situation, reflecting disappointment in not achieving her goal; in addition, this is the time when "postpartum blues" occurs. The client's feelings may or may not pass after she has bonded with her infant; there is no indication that the feeling will pass or that bonding is involved. The client's statement is not indicative of depression. With rising cesarean rates across the United States, most women know that a cesarean birth is a real possibility. However, knowing this does not negate the disappointment a client may feel over not reaching her goal.

What area of the heart forms the PR segment on the EKG? A. Apex of heart B. Purkinje fibers C. Bundle of His D. AV node and Right and Left Bundles

D. AV node and Right and Left Bundles

On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? A. Synchronized cardioversion B. CPR and immediate defibrillation C. Administration of IV amiodarone (Cordarone) and dextrose D. Administration of oxygen and observation of the heart rhythm

D. Administration of oxygen and observation of the heart rhythm Rationale: Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.

Which of the following is a late sign of heart failure? A. Shortness of breath B. Orthopnea C. Edema D. Frothy-blood tinged sputum

D. Frothy-blood tinged sputum Shortness of breath, orthopnea, and edema are EARLY signs and symptoms. Frothy-blood tinged sputum is a late sign.

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party? A. The client B. The client's spouse C. The client's primary healthcare provider D. Adult Protective Services

D. Adult Protective Services The nurse has a legal responsibility to report suspicions of abuse to the appropriate agency, which in this instance is Adult Protective Services. The client will not be able to understand the discussion. It is not the nurse's responsibility to directly challenge the spouse's behavior in this situation; the nurse may act as a client advocate by interrupting the spouse's behavior and providing immediate physical and emotional care. The nurse should then report suspicions of abuse to Adult Protective Services. Although the nurse may report suspicions about the spouse's behavior to the healthcare provider, the law requires that Adult Protective Services be notified.

These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the work load of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes? A. Beta-blockers B. Vasodilators C. Angiotensin II receptor blockers D. Angiotensin-converting-enzyme inhibitors

D. Angiotensin-converting-enzyme inhibitors This is a description of ACE inhibitors.

A teacher's aide in a kindergarten class informs the school nurse that a male student said that his mother beat him and that he has bruises on the back and shoulders. What is the priority nursing action? A. Notifying Child Protective Services B. Reporting this information to the principal C. Calling the parents to arrange a conference D. Assessing the child for the presence of bruises

D. Assessing the child for the presence of bruises The nurse must validate the presence of physical injury and potential abuse before initiating other interventions. Child Protective Services, the school principal, and the parents should not be notified until signs of possible abuse are verified.

Which are modifiable risk factors for MI? (Kahoot) A. Age B. HTN C. Smoking D. Both B and C

D. Both B and C

During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue?* A. Lisinopril B. Losartan C. Lasix D. Digoxin

D. Digoxin Yellowish-green halos/vision changes are classic signs of Digoxin toxicity.

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? A. Repression B. Manipulation C. Transference D. Displacement

D. Displacement Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on those who are less threatening. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse.

The physician's order says to administered Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0, and BUN 10. Which of the following is a nursing priority?* A. Administer the Lasix as ordered B. Notify the physician of the BNP level C. Assess the patient for edema D. Hold the dose and notify the physician about the potassium level

D. Hold the dose and notify the physician about the potassium level

Which of the following tests/procedures are NOT used to diagnose heart failure? A. Echocardiogram B. Brain natriuretic peptide blood test C. Nuclear stress test D. Holter monitoring

D. Holter monitoring The answer is D. Options A, B, and C are all used to diagnose heart failure...however a holter monitor is not. A holter monitor is used to monitor a patient's heart rate and rhythm.

What is the best room assignment for a 5-year-old child admitted with injuries that may be related to abuse? A. In an isolation room B. With a friendly older child C. With a child of the same age D. In a room near the nurses' desk

D. In a room near the nurses' desk A child who exhibits signs of abuse needs close supervision, especially when members of the family visit. The child requires close monitoring and should not be left alone. There is no indication that this child needs to be placed in an isolation room for the sake of infection control. An older child who exhibits signs of friendliness may be threatening to this child. Placement with a child of the same age may be desirable from a developmental level, but it does not meet the child's safety needs.

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse? A. Encouraging him to express his feelings about the situation B. Telling him to schedule an appointment with the gynecologist C. Asking whether he can afford a home health aide for several weeks D. Informing him that he should seek emergency intervention for his wife

D. Informing him that he should seek emergency intervention for his wife The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiologic, problem at this time. Asking whether the family can afford a home health aide for several weeks is not the priority at this time; the wife's emotional condition is the priority.

A patient is diagnosed with left-sided systolic dysfunction heart failure. Which of the following are expected findings with this condition? A. Echocardiogram shows an ejection fraction of 38%. B. Heart catheterization shows an ejection fraction of 65%. C. Patient has frequent episodes of nocturnal paroxysmal dyspnea. D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure.

D. Options A and C are both expected findings with left-sided systolic dysfunction heart failure. The answer is D. Both Options A and C are correct. Option B is a finding expected in left-sided DIASTOLIC dysfunction heart failure because the issue is with the ability of the ventricle to FILL properly...therefore a patient usually has a normal ejection fraction. Remember a normal EF is >60% in a healthy heart.

A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed? A. Getting her involved with a rape therapy group B. Remaining available and supportive to limit destructive anger C. Exploring her feelings about men to promote future relationships D. Providing a safe environment that permits the ventilation of feelings

D. Providing a safe environment that permits the ventilation of feelings

An 8-year-old girl visits the school nurse frequently with vague ailments. The nurse spends time listening to the girl, takes her temperature, and always sends her back to class. One Thursday the girl tells the nurse that she no longer wants to visit her grandfather in his home because he "hugs me too tight and touches me down there" (pointing to her genitals). She has told her mother that she does not want to spend the weekend with her grandparents, but her mother says that she has no choice. What is the most appropriate action by the nurse? A. Planning a home visit to discuss with the mother what her child has shared with the nurse B. Advising the child to tell her mother why she does not want to go to her grandfather's house C. Arranging a meeting with the principal and the mother to discuss the possibility of child molestation D. Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit

D. Reporting the alleged abuse to the local child protective agency and encouraging an investigation before the weekend visit

During a therapy group session, after several members relate traumatic incidents that happened during the week, a client says with a smile, "Things haven't gone well in my life this week either." It is most appropriate for the nurse to: A. Ask the client to share what has happened this week. B. Make a note of the incongruity of the client's message but remain silent. C. Comment, "This seems to have been a bad week for several of our members." D. Say to the client, "You say things have been bad this week, but you're smiling."

D. Say to the client, "You say things have been bad this week, but you're smiling." Say to the client, "You say things have been bad this week, but you're smiling.""You say things have been bad this week, but you're smiling" is an open-ended, nonjudgmental response that points out incongruity between the client's verbal and nonverbal communication. Asking the client to share, remaining silent but making a note of the incongruity, or noting that it has been a bad week for several of the group's members will not help the client recognize the incongruity.

4 hours after a difficult labor and birth, the patient refer uses to feed her baby, stating she needs to rest. the nurse should A. Tell the women she can rest after she feeds her baby B. Reorganize this as a behavior as postpartum C. Recognize the behavior as ineffective material-newborn attachment D. Take the baby back to the nurse, reassure the patient that her rest is priority

D. Take the baby back to the nurse, reassure the patient that her rest is priority

The school nurse is conducting a teacher's in-service on signs that may indicate that a child is a victim of bullying. Which sign should the nurse include in the teaching session? A. The child wants to try out for the basketball team. B. The child asks for extra work to make better grades. C. The child is participating in several extracurricular activities after school. D. The child asks to go to the nurse's office frequently with vague complaints.

D. The child asks to go to the nurse's office frequently with vague complaints.

A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation? A. "I've noticed that I've gain 6 lbs in one week." B. "While I sleep I have to prop myself up with a pillow so I can breathe." C. "I haven't noticed any swelling in my feet or hands lately." D. Options B and C are correct. E. Options A and B are correct. F. Options A, B, and C are all correct.

E. Options A and B are correct. The answer is E. Options A and B are classic signs and symptoms a patient may experience with heart failure exacerbation.

What factors can cause premature menopause? A. smoking B. autoimmune disorders C. a women mother had early D. menopause E. all of the above

E. all of the above

A​ 52-year-old woman complains of hot​ flashes, night​ sweats, irritability, decreased vaginal​ lubrication, and no menstrual period in the past 15 months. Over the past several​ weeks, the hot flashes and night sweats have increased in​ frequency, and she has noticed that she is more irritable. Laboratory values reveal increased​ follicle-stimulating hormone and luteinizing hormone levels. Which intervention should the nurse​ initiate?​ (Select all that​ apply.) a Asking​ open-ended questions about the​ client's body image b Instructing the client to avoid​ over-the-counter vaginal lubricants c Explaining such physiological manifestations of menopause as hot flashes and night sweats d Providing information about medications that might be prescribed to help with menopausal symptoms e Encouraging discussion of how menopausal symptoms are affecting sexual functioning

a Asking​ open-ended questions about the​ client's body image c Explaining such physiological manifestations of menopause as hot flashes and night sweats d Providing information about medications that might be prescribed to help with menopausal symptoms e Encouraging discussion of how menopausal symptoms are affecting sexual functioning The client is undergoing menopause. The client with menopause may have problems understanding the natural female aging​ process, sexual​ dysfunction, low​ self-esteem, or disturbed body image. Interventions to help the client with these problems include explaining the physiological manifestations of​ menopause; providing information about medications that might be prescribed to help with menopausal​ symptoms; encouraging discussion of how menopausal symptoms are affecting sexual​ functioning; and instructing the client to use vaginal lubricants if experiencing decreased lubrication. Asking​ open-ended questions will further explore the client​'s thoughts and feelings about body image in a therapeutic manner.)

The nurse is preparing to examine a client who is experiencing menopause. What information should the nurse obtain when performing a health​ history? ​(Select all that​ apply.) a Posture b Menstrual history c Medications d Sleep pattern e Vital signs

b Menstrual history c Medications d Sleep pattern When performing a health history on a client experiencing​ menopause, the nurse should obtain information on the client​'s menstrual​ history, medications, and sleep pattern. Posture and vital signs are assessments that the nurse will include when completing the physical examination.

Which medication is used​ off-label to reduce the occurrence of hot flashes associated with​ menopause? a Raloxifene​ (Evista) b Venlafaxine​ (Effexor) c Levothyroxine​ (Synthroid) d Triphenylethylene​ (Tamoxifen)

b Venlafaxine​ (Effexor)

Perpetrators of domestic violence tend to: Select all that apply. a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

Which problem is observed in children who regularly witness acts of violence in their family? Select all that apply. a. Phobias b. Low self-esteem c. Major depressive disorder d. Narcissistic personality disorder e. Post-traumatic stress disorder

a. Phobias b. Low self-esteem c. Major depressive disorder e. Post-traumatic stress disorder

The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? Select all that apply. a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter e. The hospital emergency department

a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter

4. When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. b. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. c. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. d. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate.

a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation.

8. When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by a. dysrhythmias. b. heart murmurs. c. gallop rhythms. d. pericardial friction rubs.

a. dysrhythmias.

Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work."

b. "I think the baby cries just to make me angry."

The nurse is providing education to a client who has been diagnosed with menopause. Which health promotion intervention should the nurse discuss with the​ client?​ (Select all that​ apply.) a. Wearing tight clothing b. Eating a balanced diet that includes​ fruits, vegetables, and​ high-fiber foods c. Doing Kegel exercises d. Avoiding alcohol and cigarette use e. Participating in yoga classes

b. Eating a balanced diet that includes​ fruits, vegetables, and​ high-fiber foods c. Doing Kegel exercises d. Avoiding alcohol and cigarette use e. Participating in yoga classes Exercise can help manage the anxiety and mood swings associated with perimenopause. Dressing in loose layers of clothing that can be added or removed will increase comfort during hot flashes. Keeping the bedroom cool will help control and provide comfort during night sweats. Caffeine intake should be decreased during perimenopause because it can trigger hot flashes. Sexual intercourse does not have to be avoided during​ perimenopause, but lubricants may be used to decrease discomfort from vaginal dryness.

7. Which heart valve sound is heard best at the left midclavicular line at the level of the fifth ICS? a. Aortic b. Mitral c. Tricuspid d. Pulmonic

b. Mitral

5. A P wave on an ECG represents an impulse arising at the a. SA node and repolarizing the atria. b. SA node and depolarizing the atria. c. AV node and depolarizing the atria. d. AV node and spreading to the bundle of His.

b. SA node and depolarizing the atria.

6. Which subjective data related to the cardiovascular system should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies

b. Smoking history c. Religious preference d. Number of pillows used to sleep

What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with the elderly.

b. The caregiver was neglected as a child.

An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: a. A decrease in family interaction so that there are fewer opportunities for abuse to occur. b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. c. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. d. A triad of treatment modalities, including medication, counseling, and role-playing opportunities.

b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses.

9. An expected finding in the assessment of an 81-year-old patient is a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty isolating the apical pulse. d. an increased heart rate in response to stress.

c. difficulty isolating the apical pulse.

You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply) a. increases SVR. b. produces diuresis. c. improves contractility. d. dilates renal blood vessels. e. works on the β1-receptors in the heart.

c. improves contractility. e. works on the β1-receptors in the heart.

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a. ventricular dilation. b. ventricular hypertrophy. c. neurohormonal response. d. sympathetic nervous system activation.

c. neurohormonal response

1. A patient with a tricuspid valve disorder has impaired blood flow between the a. vena cava and right atrium. b. left atrium and left ventricle. c. right atrium and right ventricle. d. right ventricle and pulmonary artery.

c. right atrium and right ventricle.

The nurse is interviewing Melinda Britt during her annual gynecologic exam. Which statement by Melinda would cause you to believe she is experiencing​ perimenopause? a ​"I am so cold​ lately." b ​"I feel that my appetite is really​ increasing."​ c "I have problems with​ constipation."​ d "I often experience sweating at​ night."

d "I often experience sweating at​ night." Sweating at night is a manifestation during perimenopause. Cold​ intolerance, increased​ appetite, and constipation are not symptoms manifested with perimenopause.

A​ 34-year-old client presents to the family practice clinic with complaints of not having a menstrual period in the past 14 months. What data should the nurse obtain when performing a physical examination on the​ client? a Drug and alcohol use b Sexual history c Menstrual history d Weight and height

d Weight and height When performing a physical examination on a perimenopausal​ client, the nurse needs to obtain the client​'s weight and height. The client​'s sexual and menstrual history and use of alcohol and drugs are data obtained when performing the health history.