Hurst Module 2 Cardiac Q bank questions

A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? 1. Hypotension 2. Cool extremities 3. Bradycardia 4. CVP readng of 8 mm/Hg 5. Radial pulses 4+/4+

1. & 2. Correct: These are signs and symptoms of FVD due to 3rd spacing and shock is what you are afraid of. 3. Incorrect: We would expect the heart rate to increase in FVD in an effort to move what little volume you have left through the system. 4. Incorrect: This is a high CVP, and with FVD you would expect it to be low. 5. Incorrect: Pulses are evaluated on a 4 point scale, so 4 would be a bounding pulse which would indicate fluid volume excess.

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."

1., 2., 3. & 4. Correct: The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.5. Incorrect: These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure. The nurse in this question wants to determine if the client is having anxiety. First you need to understand what anxiety looks like. The symptoms depend on what type of anxiety disorder a client has, however general symptoms include: feelings of panic, fear, and uneasiness; problems sleeping; cold or sweaty hands or feet; shortness of breath; heart palpitations; not being able to be still and calm; dry mouth; numbness or tingling in the feet or hands; nausea; muscle tension; dizziness So, what statements by the client would validate that the client is experiencing anxiety? Look at option 1: "I do not think I can continue working." True. The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. What about option 2: "My husband has taken over the house cleaning and cooking." True. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Option 3: "I fear I am dying." True. Fear. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Option 4: "I have an "uneasy" feeling most of the time." True. Clients with anxiety often report feeling uneasy or on edge. That leaves option 5: "Most of the time I feel very 'down and blue'." This one is false. These comments are more indicative of a depressed mood than anxiety. Depression may also occur in the client who has chronic renal failure

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1., 2., 3., & 4. Correct: Because lymphedema is a lifelong threat, teach the client hand and arm precautions to minimize the risk of injury, infection, and impaired circulation. All of these options are correct options to minimize these risks. Even a minor injury such as a pin prick or sunburn can cause painful swelling after lymph node removal. 5. Incorrect: The client may wear jewelry that does not inhibit lymph drainage. They should avoid jewelry that constricts the affected arm.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1., 2., 3., 5., & 6. Correct: Classic features of RA include joint pain, swelling, and tenderness worsened by movement and stress placed on joint. Morning stiffness that often lasts for one hour or more and limited movement in joints are common manifestations as well. The Rheumatoid Factor is present in 80% of adults who have rheumatoid arthritis. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body. The cyclic citrullinated peptide antibody, if present, helps to confirm the diagnosis of RA and may indicate the risk of having severe symptoms. Levels that are at a moderate to high level may indicate that the client is at increased risk for damage to the joints. 4. Incorrect: Dupuytren's contractures are a type of hand deformity where a layer of tissue under the skin in the palms of the hands is affected. Hard knots form in the palm areas and eventually create a thick cord that can pull one or more of the fingers into a bent position. However, this is not associated with RA.

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.

1.,2., & 4 Correct: The client is placed on the right side and a pillow placed under the costal margin. The pillow will place additional pressure on the rib cage which will assist with applying pressure to the liver capsule. By positioning the client on the right side, the liver capsule at the site of the biopsy is compressed against the chest wall. If the puncture site is not compressed, there is the possibility that blood or bile will leak from the puncture site. The vital signs are measured at 10 - 15 minute intervals for the first hour. Variations of the vital signs will indicate complications such as bleeding, severe hemorrhage, and bile leakage. 3. Incorrect: Passive range of motion exercises is not correct. The shoulder is not placed in a position during and after the biopsy to warrant passive exercises to the shoulder. 5. Incorrect: The client should be instructed to avoid strenuous exercise for 1 week not 1 month. The strenuous exercise is restricted to 1 week to prevent the possibility of liver bleeding.

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial line BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.

4. Correct. When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. Excessive positive pressure can result in lung complications, including a pneumothorax. This could quickly progress to a tension pneumothorax. Therefore, the nurse should consider any sudden changes in oxygen saturations and signs of respiratory distress as life threatening. Immediate assessment of the client is warranted with actions taken based on the findings. 1. Incorrect. Depending on the assessment findings, this action may be necessary. Check the ventilator after checking the client. The ventilator is checked following the client assessment to assure that it is working properly and that the settings are appropriate. 2. Incorrect. Depending on the assessment findings, this action may be necessary. The goal of mechanical ventilation is optimal gas exchange by maintaining oxygen delivery and alveolar ventilation. The lowered oxygen saturation could be the result of the underlying illness, but since there was an abrupt change, mechanical factors should be considered as well. The nurse would need to institute other measures to promote gas exchange in addition to consideration of increasing the fraction of inspired oxygen. 3. Incorrect. Depending on the assessment findings, this action may be necessary. Ventilation use increases the production of secretions, regardless of the initial reason for ventilating support. The client must be assessed first for the presence of secretions by auscultating the lungs bilaterally. If excessive secretions are present, suctioning should be performed with caution to prevent damage to the airway mucosa.