PLTian College of Nursing

1. The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:
A. poor nursing practice because a registered nurse should work with this client.
B. reasonable nursing practice because one-to-one requires the total attention of a staff member.
C. outside the responsibility of an aide.
D. illegal to delegate to an aide.
Rationale: A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn't illegal to delegate observation to an aide.
2. Nursing care for a client after electroconvulsive therapy (ECT) should include:
A. nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B. bed rest for the first 8 hours after a treatment.
C. assessment of short-term memory loss.
D. no special care.
Rationale: The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
3. The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?
A. "I'm not permitted to discuss her progress."
B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."
Rationale: The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital.
4. A nurse is working with a dying client and his family. Which communication technique is most important to use?
A. Reflection
B. Interpretation
C. Clarification
D. Active listening
Rationale: When working with a dying client and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client on the defensive.
5. Which clinical condition meets the criteria for involuntary commitment?
A. A single parent who leaves her minor children unattended and stays out all night drinking
B. A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution
C. A man who threatens to kill his wife
D. A person with depression who says he's tired of living but doesn't have a suicide plan
Rationale: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
6. A client in the emergency department complains of suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is assessing the client to determine treatment recommendations. The most important factor to consider is:
A. an active suicide plan and the means to carry it out.
B. a previous suicide attempt.
C. the client's religion and social status.
D. social support and marital status.
Rationale: The presence of an actual plan would require a restrictive environment for the client. Although a previous suicide attempt, marital status, and social support can affect the rate of suicide, a serious plan is of primary concern for the nurse.
7. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?
A. Restating
B. Making observations
C. Exploring
D. Focusing
Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation.
8. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:
A. check the client's medical record for an order for an I.M. as needed dose of medication for agitation.
B. place the client in full leather restraints.
C. call the physician and report the behavior.
D. remove all other clients from the day room.
Rationale: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals.
9. The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
A. Inadequate diet
B. Divorce
C. Job promotion
D. Adopting a child
Rationale: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.
10. A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which of the following techniques?
A. A broad opening statement
B. Reassurance
C. Clarifying
D. Making observations
Rationale: The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (clarifying) and she didn't reassure the client.
11. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
A. Has perceptions based on reality
B. Assumes responsibility for actions
C. Generates new levels of awareness
D. Has maximum ability to solve problems and learn new skills
Rationale: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
12. Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:
A. antisocial behavior.
B. manipulation.
C. poor boundaries.
D. passive-aggressive behavior.
Rationale: The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
13. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
Rationale: The nurse has a responsibility to observe continuously the acutely suicidal client — not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects such as belts, razors, suspenders, glass, and knives.
14. Silence in therapeutic communication is:
A. a means of disapproval.
B. to be avoided as it indicates intolerance and anger.
C. a means of allowing the client space in which to respond and communicates patience.
D. not therapeutic.
Rationale: Silence conveys acceptance and gives the client an opportunity to reflect. It doesn't convey disapproval unless accompanied by hostile gestures. It's one of the most difficult therapeutic communication techniques.
15. The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which of the following statements best describes the nurse's response?
A. Correct because she didn't give out information about the client
B. A violation of confidentiality because she informed the officer that the client wasn't there
C. A breech of the principle of veracity because the nurse is misleading the officer
D. Illegal because she's withholding information from law enforcement agents
Rationale: The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
16. Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which of the following accusations?
A. Assault
B. Battery
C. Neglect
D. Breach of confidentiality
Rationale: Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
17. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?
A. Assess and stabilize the client’s medical needs.
B. Assess and stabilize the client’s psychological needs.
C. Attempt to locate the nearest family member to get an accurate history.
D. Arrange a transfer to the nearest medical facility.
Rationale: The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don’t address the client’s immediate medical needs.
18. Sedative-hypnotic drugs are used to treat which of the following disorders?
A. Obsessive-compulsive disorder (OCD)
B. Attention deficit hyperactivity disorder (ADHD)
C. Hallucinations and delusions
D. Anxiety and insomnia
Rationale: Sedative-hypnotic drugs aren't linked to the treatment of a specific disorder. They're used to treat anxiety and insomnia, which can occur in a range of psychiatric disorders. Antidepressants are used to treat OCD. Psychostimulants are used to treat ADHD. Hallucinations and delusions are treated with antipsychotics.
19. Assertive behavior involves which of the following elements?
A. Saying what is on your mind at the expense of others
B. Expressing an air of superiority
C. Avoiding unpleasant situations and circumstances
D. Standing up for your rights while respecting the rights of others
Rationale: The basic element of assertive behavior includes the ability to express your feelings and thoughts while respecting the rights of others. Options A and B describe aggressive behavior, and option C describes passive behavior.
20. Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?
A. Hyperpyrexia, slow pulse, and weight gain
B. Tachycardia, weight loss, and mood swings
C. Hypotension, weight gain, and listlessness
D. Increased appetite, slowing of sensorium, and arrhythmias
Rationale: Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.
21. A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. an increased response to a medication.
B. a diminished response to a drug so that more is required to reach the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods of time.
Rationale: Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.
22. The third major health problem in the United States is which of the following disorders?
A. Cancer
B. Heart disease
C. Alcoholism
D. Bipolar illness
Rationale: Alcoholism is the third major health problem in the United States. Between 9 and 10 million people are "problem" drinkers. In addition, alcoholism adversely affects the mental health of 30 million friends and relatives of alcoholics. Heart disease and cancer are the number one and two health problems, respectively, in the United States. Bipolar illness isn't a major illness.
23. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:
A. structured limit setting.
B. supportive environment.
C. abuse and neglect.
D. direction and attention.
Rationale: Abuse and neglect lead to poor self-concept and role confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive limits and attention.
24. A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be best?
A. "You sure did. You're going to have a scar now."
B. "How many times have you done this before?"
C. "What were you feeling before you hurt yourself?"
D. "It seems to me you are trying to get attention in a negative way."
Rationale: Self-mutilation is the client's way of defending herself against feelings she isn't able to express. It's important to shift focus from the mutilation and to help the client express feelings in a more acceptable manner. All other answers are judgmental.
25. Which of the following statements is a guideline to help nurses avoid liability?
A. Follow every physician's order.
B. Do what the client desires even though you may disagree.
C. Practice within the scope of the Nurse Practice Act.
D. Obtain malpractice insurance.
Rationale: The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. The client doesn't know standards of care and isn't responsible for the nurse's actions. Physicians may not be aware of guidelines for nurses and delegate inappropriate treatment or practice for the nurse. Insurance won't prevent a liability suit, but only assist the nurse if a suit would be filed.
26. What is the nurse's most important role in caring for a client with a mental health disorder?
A. To offer advice
B. To know how to solve the client's problems
C. To establish trust and rapport
D. To set limits with the client
Rationale: It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important but not as important as developing trust and rapport.
27. A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?
A. False imprisonment
B. Limit setting
C. Slander
D. Violation of confidentiality
Rationale: Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
28. A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which of the following techniques?
A. Presenting reality
B. Making observations
C. Restating
D. Exploring
Rationale: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
29. The goal of crisis intervention is:
A. to solve the client's problems for him.
B. psychological resolution of the immediate crisis.
C. to establish a means for long-term therapy.
D. to provide a means for admission to an acute care facility.
Rationale: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy isn't the goal of crisis intervention.
30. The nurse's goal in crisis intervention is to provide:
A. problem-solving techniques and structured activities.
B. an insight-oriented analytic approach.
C. medication to sedate the client.
D. nondirective techniques such as free association.
Rationale: Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful.
31. Additive central nervous system (CNS) depression can occur when combining a sedative-hypnotic with which of the following drugs?
A. methylphenidate (Ritalin)
B. cocaine
C. amitriptyline (Elavil)
D. amphetamine (Adderall)
Rationale: Additive effects occur with concomitant use of CNS depressants, antihistamines, antidepressants, and antipsychotics. Elavil is an antidepressant and the only correct answer. All the other drugs are classified as stimulants.
32. A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which of the following actions?
A. Administering the medication by injection
B. Omitting the dose and trying again the next day
C. Crushing the medication and putting it in his food
D. Consulting with the physician about a plan of care
Rationale: To determine plans of care for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, medications can't be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving or misleading a client violates the therapeutic relationship.
33. Which of the following statements accurately describes therapeutic communication?
A. Offering advice and your opinion
B. Refraining from verbalizing your feelings
C. Avoiding advice, judgment, false reassurance, and approval
D. Telling the client how to cope
Rationale: The goal of therapeutic communication is to help the client develop insight and skills to solve his own problems. This is done by avoiding advice, judgment, false reassurance, and approval. Pointing out mistakes can make a client defensive. The client-nurse relationship isn't the place for the nurse to offer advice or an opinion. It also isn't the place for the nurse to verbalize her own feelings. The client needs assistance in developing coping skills, not someone to solve problems for him.
34. Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which of the following adverse reactions?
A. Extrapyramidal reaction
B. Tardive dyskinesia
C. Reye's syndrome
D. Agranulocytosis
Rationale: The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.
35. A therapeutic nurse-client relationship begins with the nurse’s:
A. sincere desire to help others.
B. acceptance of others.
C. self-awareness and understanding.
D. sound knowledge of psychiatric nursing.
Rationale: Although all of the choices are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding and helping clients.
36. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
A. Once per hour
B. Once per shift
C. Every 10 to 15 minutes
D. Every 2 hours
Rationale: Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.
37. A woman seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include:
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem.
Rationale: All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.
38. An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is the nurse's best response to the client?
A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them."
B. "You have the right to see your chart. Please discuss this with your primary care provider."
C. "You may see your chart after you're discharged."
D. "Please discuss this matter with your attorney."
Rationale: The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might be detrimental to the client, the primary care provider should be informed of the client's request. The client doesn't need an attorney to view her chart. She also doesn't need to wait until after discharge to view it.
39. Emergency restraints or seclusion may be implemented without a physician's order under which of the following conditions?
A. When a written order will be obtained from the primary physician within 1 hour
B. Never
C. If a voluntary client wants to leave against medical advice
D. When a minor child is out of control
Rationale: The primary physician in charge of a client's care must write an order for the restraint within 1 hour. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.
40. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:
A. encourage verbalizations about fears and stressful life situations.
B. agree with the client because she feels a specific physical feature is awful.
C. ignore the comment and talk about less threatening issues.
D. compliment the client on her appearance.
Rationale: Encouraging the client to discuss stressful life situations helps focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem.
41. In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be:
A. "Will you briefly summarize your point because others need time also?"
B. "Your behavior is obnoxious and drains the group."
C. To ignore the behavior and allow him to vent.
D. "I'm so frustrated with your behavior."
Rationale: Option A redirects the client to focus his comments and allows him to make his point. Option B is judgmental, and option C doesn't help facilitate communication. Option D focuses more on the nurse than on the client's need.
42. The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this?
A. Interpreting proverbs
B. Spelling words backward
C. Counting by serial sevens
D. Discussing hypothetical ethical situations
Rationale: Hypothetical ethical situations — such as "What would you do if you found a wallet containing credit cards and identification?" — are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration.
43. Which of the following statements describes how elderly clients react to medications?
A. At risk for increased adverse effects
B. Tolerate medication better because they're less active
C. Metabolize medications quickly
D. Need higher doses to respond to the same medication
Rationale: As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower doses not higher. Level of activity typically doesn't affect a person's reaction to medication.
44. Which of the following indications is the primary use for electroconvulsive therapy (ECT)?
A. Severe agitation
B. Antisocial behavior
C. Noncompliance with treatment
D. Major depression with psychotic features
Rationale: ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance.
45. Conditions necessary for the development of a positive sense of self-esteem include:
A. consistent limits.
B. critical environment.
C. inconsistent boundaries.
D. physical discipline.
Rationale: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.

Posted by UNDERGROUND at 10:54 PM | Permalink | Comments

Case of Cerebrovascular Accident

07-10-06 7am-3pm
7:05 > Received on bed, asleep c D5LRs 1L @ KVO, 400 cc level
>c SD of D5W ½ L + amps hydralazine and 4amps clonidine, regulated @ 10 ugtts/min, 450 cc level received
>incoherent, restless, BP 80/50
>Obtunded, GCS 11/15; patient always attended to prevent fall
>muscle strength 4/5, hypoactive reflex; always assisted
>c slurred speech, sometimes inappropriate
> Morning care done
8:30am>seen and examined by Dr. Dumlao c orders made and carried out
>discussion given on the nature of disease, possible complications of the disease process and fall prevention measures
>SD of D5W + 4amps clonidine and 4amps hydralazine on standby due to decreased BP
>Patient on close watch
>Still on low fat, low salt diet, able to consume half of the served meal
>Latest v/s taken and recorded BP= 90/60 PR=68
3:00pm>endorsed accordingly
Zena Yelena Shimmery, SN

Diagnosis: R/O Prostate CA

07-10-06 7am-3pm
7:05am >received on semi-fowler’s position, awake
>complained of tolerable Low Back Pain, 5/10 on Numerical Pain Intensity Scale
>Hot Compress applied on lower back for 15 min, reported relief
>no report of hematuria and dysuria
>c tender hypogastric area
8:30am>Seen and examined by Resident on duty with new orders made and carried out
8:55am>Result of BUN, Crea attached to chart, ROD notified
1:00pm>IVF of D5LRs 1 L inserted aseptically on L hand regulated @ KVO
>for Transrectal Biopsy c UTZ guidance of Prostate tomorrow (11-23-04)
>Surgery Resident on duty/Anesthesiologist on duty notified of the procedure
>for KUB-IVP tomorrow
>Health teachings given to patient/SO about the nature of disease, the procedure and the need for biopsy
>NPO post midnight instructed
>KUB-IVP preparation instructed
>Latest BP taken, 110/90
> endorsed accordingly to NOD
Zena Yelena Shimmery, SN

Posted by UNDERGROUND at 7:53 AM | Permalink | Comments

Rm # : Date:
Name of Patient:
Diagnosis:
Name of IVF:
Volume:
No of hour/s to infuse:
Regulation:
Additives:

SD:

Name of Student:
________________

Posted by UNDERGROUND at 9:19 PM | Permalink | Comments

MYOCARDIAL INFARCTION
Myocardial infarction (MI) is caused by marked reduction/loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia and necrosis.
CARE SETTING
Inpatient acute hospital, step-down, or medical unit.
RELATED CONCERNS
Angina
Dysrhythmias
Heart failure: chronic
Psychosocial aspects of care
Thrombophlebitis: deep vein thrombosis
Patient Assessment Database
ACTIVITY/REST
May report: Weakness, fatigue, loss of sleep
Sedentary lifestyle, sporadic exercise schedule
May exhibit: Tachycardia, dyspnea with rest/activity
CIRCULATION
May report: History of previous MI, CAD, HF, hypertension, diabetes mellitus
May exhibit: BP may be normal, increased, or decreased; postural changes may be noted from lying to sitting/standing
Pulse may be normal, full/bounding, or have a weak/thready quality with delayed capillary refill; irregularities (dysrhythmias) may be present
Heart sounds S3/S4 may reflect a pathological condition (e.g., cardiac failure, decreased ventricular contractility or compliance)
Murmurs may reflect valvular insufficiency or papillary muscle dysfunction
Friction rub (suggests pericarditis)
Heart rate regular or irregular; tachycardia/bradycardia may be present
Edema: Jugular vein distention, peripheral/dependent edema, generalized edema
Color: Pallor or cyanosis/mottling of skin, nailbeds, mucous membranes, and lips may be noted
EGO INTEGRITY
May report: Denial of significance of symptoms/presence of condition
Fear of dying, feelings of impending doom
Anger at inconvenience of illness/”unnecessary” hospitalization
Worry about family, job, finances
May exhibit: Denial, withdrawal, anxiety, lack of eye contact
Irritability, anger, combative behavior
Focus on self/pain
ELIMINATION
May exhibit: Normal or decreased bowel sounds
FOOD/FLUID
May report: Nausea, loss of appetite, belching, indigestion/heartburn
May exhibit: Poor skin turgor; dry or diaphoretic skin
Vomiting
HYGIENE
May report/exhibit: Difficulty in performing self-care tasks
NEUROSENSORY
May report: Dizziness, fainting spells in or out of bed (upright or at rest)
May exhibit: Changes in mentation
Weakness
PAIN/DISCOMFORT
May report: Sudden onset of chest pain unrelieved by rest or nitroglycerin (although most pain is deep and visceral, 20% of MIs are painless)
Location: Typically anterior chest (substernal, precordium); may radiate to arms, jaw, face; may have atypical location such as epigastrium/abdomen; elbow, jaw, back, neck, between shoulder blades, severe sore throat; throat fullness (females)
Quality: Crushing, constricting, viselike, squeezing, heavy, steady
Intensity: Usually 10 on a scale of 0–10 or “worst pain ever experienced.” Note: Pain is sometimes absent in females, postoperative patients, those with prior stroke or heart failure, diabetes mellitus or hypertension, or the elderly. Studies indicate that up to one-third of persons experiencing MI do not have typical chest pain.
Precipitating factor: May/may not be associated with activity
May exhibit: Facial grimacing, changes in body posture, may place clenched fist on midsternum when describing pain
Crying, groaning, squirming, stretching
Withdrawal, lack of eye contact
Autonomic responses: Changes in heart rate/rhythm, BP, respirations, skin color/moisture, level of consciousness
RESPIRATION
May report: Dyspnea with/without exertion, nocturnal dyspnea
Cough with/without sputum production
History of smoking, chronic respiratory disease
May exhibit: Increased respiratory rate, shallow/labored breathing
Pallor or cyanosis
Breath sounds clear or crackles/wheezes
Sputum clear, pink-tinged
SOCIAL INTERACTION
May report: Recent stress, e.g., work, family
Difficulty coping with recent/current stressors, e.g., money, work, family problems made worse by this illness/hospitalization
May exhibit: Difficulty resting quietly, overemotional responses (intense anger, fear)
Withdrawal from family
TEACHING/LEARNING
May report: Family history of heart disease/MI, diabetes, stroke, hypertension, peripheral vascular disease
Use of tobacco
Discharge plan DRG projected length of inpatient stay: 4.9–7.0 days (2–4 days/critical care unit [CCU])
considerations: May require assistance with food preparation, shopping, transportation, homemaking/maintenance tasks; physical layout of home
DIAGNOSTIC STUDIES
ECG: ST elevation signifying ischemia; peaked upright or inverted T wave indicating injury; development of Q waves signifying prolonged ischemia or necrosis.
Cardiac enzymes and isoenzymes: CPK-MB (isoenzyme in cardiac muscle): Elevates within 4–8 hr, peaks in 12–20 hr, returns to normal in 48–72 hr.
LDH: Elevates within 8–24 hr, peaks within 72–144 hr, and may take as long as 14 days to return to normal. An LDH1 greater than LDH2 (flipped ratio) helps confirm/diagnose MI if not detected in acute phase.
Troponins: Troponin I (cTnI) and troponin T (cTnT): Levels are elevated at 4–6 hr, peak at 14–18 hr, and return to baseline over 6–7 days. These enzymes have increased specificity for necrosis and are therefore useful in diagnosing postoperative MI when MB-CPK may be elevated related to skeletal trauma.
Myoglobin: A heme protein of small molecular weight that is more rapidly released from damaged muscle tissue with elevation within 2 hr after an acute MI, and peak levels occurring in 3–15 hr.
Electrolytes: Imbalances of sodium and potassium can alter conduction and compromise contractility.
WBC: Leukocytosis (10,000–20,000) usually appears on the second day after MI because of the inflammatory process.
ESR: Rises on second or third day after MI, indicating inflammatory response.
Chemistry profiles: May be abnormal, depending on acute/chronic abnormal organ function/perfusion.
ABGs/pulse oximetry: May indicate hypoxia or acute/chronic lung disease processes.
Lipids (total lipids, HDL, LDL, VLDL, total cholesterol, triglycerides, phospholipids): Elevations may reflect arteriosclerosis as a cause for coronary narrowing or spasm.
Chest x-ray: May be normal or show an enlarged cardiac shadow suggestive of HF or ventricular aneurysm.
Two-dimensional echocardiogram: May be done to determine dimensions of chambers, septal/ventricular wall motion, ejection fraction (blood flow), and valve configuration/function.
Nuclear imaging studies: Persantine or Thallium: Evaluates myocardial blood flow and status of myocardial cells, e.g., location/extent of acute/previous MI.
Cardiac blood imaging/MUGA: Evaluates specific and general ventricular performance, regional wall motion, and ejection fraction.
Technetium: Accumulates in ischemic cells, outlining necrotic area(s).
Coronary angiography: Visualizes narrowing/occlusion of coronary arteries and is usually done in conjunction with measurements of chamber pressures and assessment of left ventricular function (ejection fraction). Procedure is not usually done in acute phase of MI unless angioplasty or emergency heart surgery is imminent.
Digital subtraction angiography (DSA): Technique used to visualize status of arterial bypass grafts and to detect peripheral artery disease.
Magnetic resonance imaging (MRI): Allows visualization of blood flow, cardiac chambers/intraventricular septum, valves, vascular lesions, plaque formations, areas of necrosis/infarction, and blood clots.
Exercise stress test: Determines cardiovascular response to activity (often done in conjunction with thallium imaging in the recovery phase).
NURSING PRIORITIES
1. Relieve pain, anxiety.
2. Reduce myocardial workload.
3. Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.
4. Promote cardiac health, self-care.
DISCHARGE GOALS
1. Chest pain absent/controlled.
2. Heart rate/rhythm sufficient to sustain adequate cardiac output/tissue perfusion.
3. Achievement of activity level sufficient for basic self-care.
4. Anxiety reduced/managed.
5. Disease process, treatment plan, and prognosis understood.
6. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Pain, acute
May be related to
Tissue ischemia (coronary artery occlusion)
Possibly evidenced by
Reports of chest pain with/without radiation
Facial grimacing
Restlessness, changes in level of consciousness
Changes in pulse, BP
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Verbalize relief/control of chest pain within appropriate time frame for administered medications.
Display reduced tension, relaxed manner, ease of movement.
Pain Control (NOC)
Demonstrate use of relaxation techniques.

ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Monitor/document characteristics of pain, noting verbal reports, nonverbal cues (e.g., moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing), and hemodynamic response (BP/heart rate changes).

Obtain full description of pain from patient including location, intensity (0–10), duration, characteristics(dull/crushing), and radiation. Assist patient to quantify pain by comparing it to other experiences.

Review history of previous angina, anginal equivalent, or MI pain. Discuss family history if pertinent.

Instruct patient to report pain immediately.

Provide quiet environment, calm activities, and comfort measures (e.g., dry/wrinkle-free linens, backrub). Approach patient calmly and confidently. RATIONALE

Variation of appearance and behavior of patients in pain may present a challenge in assessment. Most patients with an acute MI appear ill, distracted, and focused on pain. Verbal history and deeper investigation of precipitating factors should be postponed until pain is relieved. Respirations may be increased as a result of pain and associated anxiety; release of stress-induced catecholamines increases heart rate and BP.

Pain is a subjective experience and must be described by patient. Provides baseline for comparison to aid in determining effectiveness of therapy, resolution/progression of problem.

May differentiate current pain from preexisting patterns, as well as identify complications such as extension of infarction, pulmonary embolus, or pericarditis.

Delay in reporting pain hinders pain relief/may require increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain.

Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation.

ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Assist/instruct in relaxation techniques, e.g., deep/slow breathing, distraction behaviors, visualization, guided imagery.

Check vital signs before and after narcotic medication.

Collaborative
Administer supplemental oxygen by means of nasal cannula or face mask, as indicated.

Administer medications as indicated:
Antianginals, e.g., nitroglycerin (Nitro-Bid, Nitrostat, Nitro-Dur), isosorbide denitrate (Isordil), mononitrate (Imdur)

Beta-blockers, e.g., atenolol (Tenormin), pindolol(Visken), propranolol (Inderal), nadolol (Corgard), metoprolol (Lopressor)

Analgesics, e.g., morphine, meperidine (Demerol) RATIONALE

Helpful in decreasing perception of/ response to pain. Provides a sense of having some control over the situation, increase in positive attitude.

Hypotension/respiratory depression can occur as a result of narcotic administration. These problems may increase myocardial damage in presence of ventricular insufficiency.

Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia.

Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand.

Important second-line agents for pain control through effect of blocking sympathetic stimulation, thereby reducing heart rate, systolic BP, and myocardial oxygen demand. May be given alone or with nitrates. Note: beta-blockers may be contraindicated if myocardial contractility is severely impaired, because negative inotropic properties can further reduce contractility.

Although intravenous (IV) morphine is the usual drug of choice, other injectable narcotics may be used in acute-phase/recurrent chest pain unrelieved by nitroglycerin to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible, because they can alter the CPK diagnostic indicator and are not well absorbed in underperfused tissue.

NURSING DIAGNOSIS: Activity intolerance
May be related to
Imbalance between myocardial oxygen supply and demand
Presence of ischemia/necrotic myocardial tissues
Cardiac depressant effects of certain drugs (beta-blockers, antidysrhythmics)
Possibly evidenced by
Alterations in heart rate and BP with activity
Development of dysrhythmias
Changes in skin color/moisture
Exertional angina
Generalized weakness
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Activity Tolerance (NOC)
Demonstrate measurable/progressive increase in tolerance for activity with heart rate/rhythm and BP within patient’s normal limits and skin warm, pink, dry.
Report absence of angina with activity.

ACTIONS/INTERVENTIONS
Energy Management (NIC)
Independent
Record/document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain/shortness of breath. (Refer to ND: Cardiac Output, risk for decreased.)

Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide nonstress diversional activities.

Instruct patient to avoid increasing abdominal pressure, e.g., straining during defecation.

Explain pattern of graded increase of activity level, e.g., getting up to commode or sitting in chair, progressive ambulation, and resting after meals.

Review signs/symptoms reflecting intolerance of present activity level or requiring notification of nurse/physician.

Collaborative

Refer to cardiac rehabilitation program. RATIONALE

Trends determine patient’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level/return to bedrest, changes in medication regimen, or use of supplemental oxygen.

Reduces myocardial workload/oxygen consumption, reducing risk of complications (e.g., extension of MI). Note: American Heart Association/American College of Cardiology guidelines (1996) suggest that patients with cardiac conditions should not be kept in bed longer than 24 hr. Patients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hr after incident.

Activities that require holding the breath and bearing down (Valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardia with elevated BP.

Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion.

Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication.

Provides continued support/additional supervision and participation in recovery and wellness process.

NURSING DIAGNOSIS: Anxiety [specify level]/Fear
May be related to
Threat to or change in health and socioeconomic status
Threat of loss/death
Unconscious conflict about essential values, beliefs, and goals of life
Interpersonal transmission/contagion
Possibly evidenced by
Fearful attitude
Apprehension, increased tension, restlessness, facial tension
Uncertainty, feelings of inadequacy
Somatic complaints/sympathetic stimulation
Focus on self, expressions of concern about current and future events
Fight (e.g., belligerent attitude) or flight behavior
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Anxiety/Fear Control (NOC)
Recognize feelings.
Identify causes, contributing factors.
Verbalize reduction of anxiety/fear.
Demonstrate positive problem-solving skills.
Identify/use resources appropriately.

ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
Identify and acknowledge patient’s perception of threat/situation. Encourage expressions of, and do not deny feelings of, anger, grief, sadness, fear.

Note presence of hostility, withdrawal, and/or denial (inappropriate affect or refusal to comply with medical regimen).

Maintain confident manner (without false reassurance).

Observe for verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient displays destructive behavior.

RATIONALE

Coping with the pain and emotional trauma of an MI is difficult. Patient may fear death and/or be anxious about immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended/unresolved, and effects of illness on family) may be present in varying degrees for some time and may be manifested by symptoms of depression.

Research into survival rates between type A and type B individuals and the impact of denial has been ambiguous; however, studies show some correlation between degree/
expression of anger or hostility and an increased risk for MI.

Patient and SO can be affected by the anxiety/uneasiness displayed by health team members. Honest explanations can alleviate anxiety.

Patient may not express concern directly, but words/actions may convey sense of agitation, aggression, and hostility. Intervention can help patient regain control of own behavior.

ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
Accept but do not reinforce use of denial. Avoid confrontations.

Orient patient/SO to routine procedures and expected activities. Promote participation when possible.

Answer all questions factually. Provide consistent information; repeat as indicated.

Encourage patient/SO to communicate with one another, sharing questions and concerns.

Provide privacy for patient and SO.

Provide rest periods/uninterrupted sleep time, quiet surroundings, with patient controlling type, amount of external stimuli.

Support normality of grieving process, including time necessary for resolution.

Encourage independence, self-care, and decision making within accepted treatment plan.

Encourage discussion about postdischarge expectations.

Collaborative

Administer antianxiety/hypnotics as indicated, e.g., alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), flurazepam (Dalmane).
RATIONALE

Denial can be beneficial in decreasing anxiety but can postpone dealing with the reality of the current situation. Confrontation can promote anger and increase use of denial, reducing cooperation and possibly impeding recovery.

Predictability and information can decrease anxiety for patient.

Accurate information about the situation reduces fear, strengthens nurse-patient relationship, and assists patient/SO to deal realistically with situation. Attention span may be short, and repetition of information helps with retention.

Sharing information elicits support/comfort and can relieve tension of unexpressed worries.

Allows needed time for personal expression of feelings; may enhance mutual support and promote more adaptive behaviors.

Conserves energy and enhances coping abilities.

Can provide reassurance that feelings are normal response to situation/perceived changes.

Increased independence from staff promotes self-confidence and reduces feelings of abandonment that can accompany transfer from coronary unit/discharge from hospital.

Helps patient/SO identify realistic goals, thereby reducing risk of discouragement in face of the reality of limitations of condition/pace of recuperation.

Promotes relaxation/rest and reduces feelings of anxiety.

NURSING DIAGNOSIS: Cardiac Output, risk for decreased
Risk factors may include
Changes in rate, rhythm, electrical conduction
Reduced preload/increased SVR
Infarcted/dyskinetic muscle, structural defects, e.g., ventricular aneurysm,
septal defects
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cardiac Pump Effectiveness (NOC)
Maintain hemodynamic stability, e.g., BP, cardiac output within normal range, adequate urinary output, decreased frequency/absence of dysrhythmias.
Report decreased episodes of dyspnea, angina.
Demonstrate an increase in activity tolerance.

ACTIONS/INTERVENTIONS
Cardiac Care: Acute (NIC)
Independent
Auscultate BP. Compare both arms and obtain lying, sitting, and standing pressures when able.

Evaluate quality and equality of pulses, as indicated.

Auscultate heart sounds:
Note development of S3, S4;

Presence of murmurs/rubs.

Auscultate breath sounds.

RATIONALE

Hypotension may occur related to ventricular dysfunction, hypoperfusion of the myocardium, and vagal stimulation. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and/or preexisting vascular problems. Orthostatic (postural) hypotension may be associated with complications of infarct, e.g., HF.

Decreased cardiac output results in diminished weak/thready pulses. Irregularities suggest dysrhythmias, which may require further evaluation/monitoring.

S3 is usually associated with HF, but it may also be noted with the mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. S4 may be associated with myocardial ischemia, ventricular stiffening, and pulmonary or systemic hypertension.

Indicates disturbances of normal blood flow within the heart, e.g., incompetent valve, septal defect, or vibration of papillary muscle/chordae tendineae (complication of MI). Presence of rub with an infarction is also associated with inflammation, e.g., pericardial effusion and pericarditis.

Crackles reflecting pulmonary congestion may develop because of depressed myocardial function.

ACTIONS/INTERVENTIONS
Cardiac Care: Acute (NIC)
Independent
Monitor heart rate and rhythm. Document dysrhythmias via telemetry.

Note response to activity and promote rest appropriately. (Refer to ND: Activity intolerance.)

Provide small/easily digested meals. Limit caffeine intake, e.g., coffee, chocolate, cola.

Have emergency equipment/medications available.

Collaborative

Administer supplemental oxygen, as indicated.

Measure cardiac output and other functional parameters as appropriate.

Maintain IV/Hep-Lock access as indicated.

Review serial ECGs.

Review chest x-ray.

Monitor laboratory data, e.g., cardiac enzymes, ABGs, electrolytes. RATIONALE

Heart rate and rhythm respond to medication, activity, and developing complications. Dysrhythmias (especially premature ventricular contractions or progressive heart blocks) can compromise cardiac function or increase ischemic damage. Acute or chronic atrial flutter/fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathological.

Overexertion increases oxygen consumption/demand and can compromise myocardial function.

Large meals may increase myocardial workload and cause vagal stimulation, resulting in bradycardia/ectopic beats. Caffeine is a direct cardiac stimulant that can increase heart rate. Note: New guidelines suggest no need to restrict caffeine in regular coffee drinkers.

Sudden coronary occlusion, lethal dysrhythmias, extension of infarct, and unrelenting pain are situations that may precipitate cardiac arrest, requiring immediate life-saving therapies/transfer to CCU.

Increases amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation/dysrhythmias.

Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively with thoracic electrical bioimpedance (TEB) technique. Useful in evaluating response to therapeutic interventions and identifying need for more aggressive/emergency care.

Patent line is important for administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain.

Provides information regarding progression/resolution of infarction, status of ventricular function, electrolyte balance, and effects of drug therapies.

May reflect pulmonary edema related to ventricular dysfunction.

Enzymes monitor resolution/extension of infarction. Presence of hypoxia indicates need for supplemental oxygen. Electrolyte imbalance, e.g., hypokalemia/hyperkalemia, adversely affects cardiac rhythm/contractility.

ACTIONS/INTERVENTIONS
Cardiac Care: Acute (NIC)
Collaborative
Administer antidysrhythmic drugs as indicated. (Refer to CP: Dysrhythmias.)

Assist with insertion/maintain pacemaker, when used. RATIONALE

Dysrhythmias are usually treated symptomatically, except for PVCs, which are often treated prophylactically. Early inclusion of ACE inhibitor therapy (especially in presence of large anterior MI, ventricular aneurysm, or HF) enhances ventricular output, increases survival, and may slow progression of HF. Note: Use of routine lidocaine is no longer recommended.

Pacing may be a temporary support measure during acute phase or may be needed permanently if infarction severely damages conduction system, impairing systolic function. Evaluation is based on echocardiography or radionuclide ventriculography.

NURSING DIAGNOSIS: Tissue Perfusion, ineffective
Risk factors may include
Reduction/interruption of blood flow, e.g., vasoconstriction, hypovolemia/shunting, and thromboembolic formation
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Cardiac Pump Effectiveness (NOC)
Demonstrate adequate perfusion as individually appropriate, e.g., skin warm and dry, peripheral pulses present/strong, vital signs within patient’s normal range, patient alert/oriented, balanced I&O, absence of edema, free of pain/discomfort.

ACTIONS/INTERVENTIONS
Hemodynamic Regulation (NIC)
Independent
Investigate sudden changes or continued alterations in mentation, e.g., anxiety, confusion, lethargy, stupor.

Inspect for pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse. RATIONALE

Cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/acid-base variations, hypoxia, and systemic emboli.

Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses. (Refer to ND: Cardiac Output, risk for decreased, p. 000.)

ACTIONS/INTERVENTIONS
Hemodynamic Regulation (NIC)
Independent
Monitor respirations, note work of breathing.

Monitor intake, note changes in urine output. Record urine specific gravity as indicated.

Assess GI function, noting anorexia, decreased/absent bowel sounds, nausea/vomiting, abdominal distension, constipation.

Circulatory Care: Venous Insufficiency (NIC)

Encourage active/passive leg exercises, avoidance of isometric exercises.

Assess for Homans’ sign (pain in calf on dorsiflexion), erythema, edema.

Instruct patient in application/periodic removal of antiembolic hose, when used.

Hemodynamic Regulation (NIC)
Collaborative
Monitor laboratory data, e.g., ABGs, BUN, creatinine, electrolytes, coagulation studies (PT, aPTT, clotting times).

Administer medications as indicated:
Antiplatelet agents, e.g., aspirin, abciximab (ReoPro), clopidogrel (Plavix);

Anticoagulants, e.g., heparin/enoxaparin (Lovenox);

Oral anticoagulants, e.g., anisindione (Miradon), warfarin (Coumadin);

Cimetidine (Tagamet), ranitidine (Zantac), antacids; RATIONALE

Cardiac pump failure and/or ischemic pain may precipitate respiratory distress; however, sudden/continued dyspnea may indicate thromboembolic pulmonary complications.

Decreased intake/persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function.

Reduced blood flow to mesentery can produce GI dysfunction, e.g., loss of peristalsis. Problems may be potentiated/aggravated by use of analgesics, decreased activity, and dietary changes.

Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption.

Indicators of deep vein thrombosis (DVT), although DVT can be present without a positive Homans’ sign.

Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis in patient who is limited in activity.

Indicators of organ perfusion/function. Abnormalities in coagulation may occur as a result of therapeutic measures (e.g., heparin/Coumadin use and some cardiac drugs).

Reduces mortality in MI patients, and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). ReoPro is an IV drug used as an adjunct to PTCA for prevention of acute ischemic complications.

Low-dose heparin is given during PTCA and may be given prophylactically in high-risk patients (e.g., atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis) to reduce risk of thrombophlebitis or mural thrombus formation.

Used for prophylaxis and treatment of thromboembolic complications associated with MI.

Reduces or neutralizes gastric acid, preventing discomfort and gastric irritation, especially in presence of reduced mucosal circulation.

ACTIONS/INTERVENTIONS
Hemodynamic Regulation (NIC)
Collaborative
Assist with reperfusion therapy:
Administer thrombolytic agents, e.g., alteplase (Activase, rt-PA), reteplase (Retavase), streptokinase (Streptase), anistreplase (Eminase), urokinase, (Abbokinase);

Prepare for PTCA (balloon angioplasty), with/without intracoronary stents;

Transfer to critical care. RATIONALE

Thrombolytic therapy is the treatment of choice (when initiated within 6 hr) to dissolve the clot (if that is the cause of the MI) and restore perfusion of the myocardium.

This procedure is used to open partially blocked coronary arteries before they become totally blocked. The mechanism includes a combination of vessel stretching and plaque compression. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery and improve the odds of long-term patency.

More intensive monitoring and aggressive interventions are necessary to promote optimum outcome.

NURSING DIAGNOSIS: Fluid Volume, risk for excess
Risk factors may include
Decreased organ perfusion (renal)
Increased sodium/water retention
Increased hydrostatic pressure or decreased plasma proteins (sequestering of fluid in interstitial space/tissues)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Fluid Balance (NOC)
Maintain fluid balance as evidenced by BP within patient’s normal limits.
Be free of peripheral/venous distension and dependent edema, with lungs clear and weight stable.

ACTIONS/INTERVENTIONS
Fluid Management (NIC)
Independent

Auscultate breath sounds for presence of crackles.

Note JVD, development of dependent edema. RATIONALE

May indicate pulmonary edema secondary to cardiac decompensation.

Suggests developing congestive failure/fluid volume excess.

ACTIONS/INTERVENTIONS
Fluid Management (NIC)
Independent
Measure I&O, noting decrease in output, concentrated appearance. Calculate fluid balance.

Weigh daily.

Maintain total fluid intake at 2000 mL/24 hr within cardiovascular tolerance.

Collaborative

Provide low-sodium diet/beverages.

Administer diuretics, e.g., furosemide (Lasix), spironolactone with hydrochlorothiazide (Aldactazide), hydralazine (Apresoline).

Monitor potassium as indicated. RATIONALE

Decreased cardiac output results in impaired kidney perfusion, sodium/water retention, and reduced urine output.

Sudden changes in weight reflect alterations in fluid balance.

Meets normal adult body fluid requirements, but may require alteration/restriction in presence of cardiac decompensation.

Sodium enhances fluid retention and should therefore be restricted during active MI phase and/or if heart failure is present.

May be necessary to correct fluid overload. Drug choice is usually dependent on acute/chronic nature of symptoms.

Hypokalemia can limit effectiveness of therapy and can occur with use of potassium-depleting diuretics.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding cause/treatment of condition, self-care, and discharge needs
May be related to
Lack of information/misunderstanding of medical condition/therapy needs
Unfamiliarity with information resources
Lack of recall
Possibly evidenced by
Questions; statement of misconception
Failure to improve on previous regimen
Development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of condition, potential complications, individual risk factors, and function of pacemaker (if used).
Relate signs of pacemaker failure.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic regimen.
List desired action and possible adverse side effects of medications.
Correctly perform necessary procedures and explain reasons for actions.

ACTIONS/INTERVENTIONS
Teaching: Individual (NIC)
Independent
Assess patient/SO level of knowledge and ability/desire to learn.

Be alert to signs of avoidance, e.g., changing subject away from information being presented or extremes of behavior (withdrawal/euphoria).

Present information in varied learning formats, e.g., programmed books, audiovisual tapes, question-and-answer sessions, group activities.

Cardiac Care: Rehabilitation (NIC)
Independent
Reinforce explanations of risk factors, dietary/activity restrictions, medications, and symptoms requiring immediate medical attention.

Encourage identification/reduction of individual risk factors, e.g., smoking/alcohol consumption, obesity.

Warn against isometric activity, Valsalva maneuver, and activities requiring arms positioned above head.

Review programmed increases in levels of activity. Educate patient regarding gradual resumption of activities, e.g., walking, work, recreational and sexual activity. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking, as appropriate.

Identify alternative activities for “bad weather” days, such as measured walking in house or shopping mall.

Review signs/symptoms requiring reduction in activity and notification of healthcare provider. Differentiate between increased heart rate that normally occursduring various activities and worsening signs of cardiac stress (e.g., chest pain, dyspnea, palpitations, increased heart rate lasting more than 15 min after cessation of activity, excessive fatigue the following day).

RATIONALE

Necessary for creation of individual instruction plan.
Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.

Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s response and ability to assimilate information. Changing to a less formal/structured style may be more effective until patient/SO is ready to accept/deal with current situation.

Using multiple learning methods enhances retention of material.

Provides opportunity for patient to retain information and to assume control/participate in rehabilitation program.
Note: Routine use of supplements/herbal remedies (e.g., ginkgo biloba, garlic, vitamin E) can result in alterations in blood clotting, especially when anticoagulant/ASA therapy is prescribed.

These behaviors/chemicals have direct adverse effects on cardiovascular function and may impede recovery, increase risk for complications.

These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect
myocardial contractility/output.

Gradual increase in activity increases strength and prevents overexertion, may enhance collateral circulation, and allows return to normal lifestyle. Note: Sexual activity can be safely resumed once patient can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects.

Provides for continuing daily activity program.

Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen.

ACTIONS/INTERVENTIONS
Cardiac Care: Rehabilitation (NIC)
Independent
Stress importance of follow-up care, and identify community resources/support groups, e.g., cardiac rehabilitation programs, “coronary clubs,” smoking cessation clinics.

Emphasize importance of contacting physician if chest pain, change in anginal pattern, or other symptoms recur.

Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural, pericardial) and joint pain.

Encourage patient/SO to share concerns/feelings. Discuss signs of pathological depression versus transient feelings frequently associated with major life events. Recommend seeking professional help if depressed feelings persist. RATIONALE

Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. Note: After discharge, patients encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support.

Timely evaluation/intervention may prevent complications.

Post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation/intervention.

Depressed patients have a greater risk of dying 6–18 mo following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), e.g., paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.

POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)

Activity intolerance —imbalance between myocardial oxygen supply/demand.
Grieving, anticipatory—perceived loss of general well-being, required changes in lifestyle, confronting mortality.
Decisional Conflict (treatment)—multiple/divergent sources of information, perceived threat to value system, support system deficit.
Family Processes, interrupted—situational transition and crisis.
Home Management, impaired—altered ability to perform tasks, inadequate support systems, reluctance to request assistance.

-jt_21-

Posted by UNDERGROUND at 9:44 AM | Permalink | Comments

ANSWER ME IF U CAN!
The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. What is the primary rationale for tube feedings in this situation?
(1) Prevent pain from swallowing.
(2) Ensure adequate intake.
(3) Prevent fistula development.
(4) Allow for adequate suture line healing.

Posted by UNDERGROUND at 9:31 AM | Permalink | Comments

sample charting, NCP, sample patho...

Posted by UNDERGROUND at 12:33 PM | Permalink | Comments

While inspecting the client's chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. From this assessment, she suspects:
A. hemothorax.
B. flail chest.
C. pneumothorax.
D. tension pneumothorax.

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30 Q Rationale - MS
1. d Rationale: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: CAD develops when fatty deposits line the walls of the coronary arteries, impeding blood flow and therefore decreasing cardiac output. Thermoregulatory disturbances aren't usually associated with CAD unless accompanied by heart failure. Impaired gas exchange may occur if the blood's oxygen-carrying capacity were altered, as in anemia, chronic obstructive pulmonary disease, or carbon monoxide poisoning. There would be a risk of injury if the client had sensory or motor deficits.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively, but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.

Posted by UNDERGROUND at 8:34 AM | Permalink | Comments

MS Q's (Cardiovascular)
* Answers w/ Rationale to be posted after 2-3 days...

1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain worsened when I took a deep breath."
D. "The pain occurred while I was mowing the lawn."

2. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.

3. A client with a history of chronic obstructive pulmonary disease (COPD) develops right-sided heart failure. Which symptom is common in this disorder?
A. Respiratory acidosis
B. Hypertension
C. Dyspnea
D. Jugular vein distention

4. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms

5. A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
A. negative history of tonic-clonic seizures.
B. ampule of naloxone (Narcan) at the bedside.
C. continuous electrocardiogram (ECG) monitoring.
D. up-to-date activated partial thromboplastin time (APTT) result in his record.

6. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence

7. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength

8. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain

9. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.

10. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility

11. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)?
A. neffective thermoregulation
B. Impaired gas exchange
C. Risk for injury
D. Decreased cardiac output

12. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
A. hypertension.
B. high urine output.
C. dry mucous membranes.
D. pulmonary crackles.

13.A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.

14. Which statement from a client who takes nitroglycerin (Nitrostat) as needed for anginal pain indicates that further teaching is necessary?
A. "I store the tablets in a dark bottle."
B."I take the tablet with a full glass of water."
C. "I check for my tongue to tingle when I take a tablet."
D. "I'll go to the hospital if three tablets, 5 minutes apart, don't relieve the pain."

15. The nurse is caring for a client taking an anticoagulant. The nurse should teach the client to:
A. report incidents of diarrhea.
B. avoid foods high in vitamin K.
C. use a straight razor when shaving.
D. take aspirin for pain relief.


16. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:
A. vestibular dysfunction.
B. sudden vascular fluid shifting.
C. postural hypotension.
D. bradyrhythmia.

17. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
A. realize the surgeon has the right to refuse to care for the client.
B. advise the surgeon to arrange for an alternate cardiac surgeon.
C. tell the client that she can donate her own blood for the procedure.
D. inform the client that her decision could shorten her life.

18. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
A. administer oxygen.
B. have the client take deep breaths and cough.
C. place the client in high Fowler's position.
D. perform chest physiotherapy.

19. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.

20. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex.
B. widening complex.
C. amplitude increase.
D. amplitude decrease.

21. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia

22. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative

23. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
C. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling

24. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A. Oral
B. Rectal
C. Axillary
D. Tympanic

25. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion

26. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.

27. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.

28. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly

29. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis

30. Murmurs that indicate heart disease are commonly accompanied by other symptoms such as:
A. dyspnea on exertion.
B. subcutaneous emphysema.
C. thoracic petechiae.
D. periorbital edema.

Posted by UNDERGROUND at 5:35 PM | Permalink | Comments

1. D. Evaluation
Rationale: The nursing actions described constitute evaluation of expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action.
2. B. Analysis
Rationale: The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step the nurse systematically collects data about the client or family. During the planning step the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step the nurse determines the effectiveness of the plan of care.
3. A. Formative
Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
4. A. pH
Rationale: The pH in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (Pao2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (Paco2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3_) value indicates the amount of bicarbonate or base in the blood.
5. C. walk from his room to the end of the hall and back before discharge.
Rationale: Walking from his room to the end of the hall and back before discharge is a specific measurable, attainable, and timed goal as well as a client oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
6. D. Risk for aspiration related to anesthesia
Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
7. B. Risk for injury
Rationale: A sensory deficit such as blindness puts the client at risk for injury from the environment. To prevent an injury that could further complicate the client's stay, the nurse should assign highest priority to this nursing diagnosis. Although Anxiety, Activity intolerance, or Impaired physical mobility also may be relevant, these nursing diagnoses don't take precedence over client safety.
8. B. documenting drugs given.
Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
9. A. By discharge, the client correctly identifies three potassium-rich foods.
Rationale: A client outcome must be measurable, concise, realistic for the client, and obtainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.
10. D. Acute pain
Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
11. B. "Infuse I.V. fluids at 83 ml/hr"
Rationale: Because shock signals a severe fluid volume loss (700 to 1300 ml) its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
12. A. Risk for impaired skin integrity related to immobility
Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
13. A. Deficient fluid volume
Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
14. D. Inability to speak clearly
Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
15. B. Administering a measles, mumps, and rubella immunization to an infant
Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
16. A. Identifying one way to increase social interaction
Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
17. C. Failure to progress
Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
18. D. Evaluation
Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.
19. B. Current health promotion activities
Rationale: Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.
20. C. Nurse-client relationship
Rationale: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.
21. D. 5 cm H20.
Rationale: Usually CVP ranges from 4 to 10 cm H20 or 3 to 7 mm Hg. The other options are outside this range.
22. C. Man, environment, health, and nursing
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
23. B. Elimination
Rationale: According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client's first level needs have been satisfied.
24. B. keeping the bed at the lowest position possible.
Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
25. C. "What were you doing when the pain started?"
Rationale: Subjective data (data from the client) about the chest pain help determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Options A and D wouldn't elicit information related to a cardiac problem. Option B presumes a particular diagnosis and asks a "why" question, which is a nontherapeutic communication technique.
26. D. Adjusting to retirement, deaths of family members, and decreased physical strength
Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.

Posted by UNDERGROUND at 1:00 PM | Permalink | Comments