Go on. Explore!

lvl 0 • 0 xp

lvl 1

Home Market Decks Interests

NCLEX Style Nursing 102

memorize.ai (lvl 286)

(0)

15 cards

()

Section 1

Preview this deck

25] If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: a. Explaining how the old behavior leads to poor health b. Withholding praise until the new behavior is well established c. Rewarding the client whenever the acceptable behavior is performed d. Instilling mild fear into the client to extinguish the behavior

Front

1 / 15

CSS

0.0

0 reviews

5			0
4			0
3			0
2			0
1			0

Active users

All-time users

Favorites

Last updated

6 years ago

Date created

Mar 14, 2020

Cards (15)

Section 1

(15 cards)

25] If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: a. Explaining how the old behavior leads to poor health b. Withholding praise until the new behavior is well established c. Rewarding the client whenever the acceptable behavior is performed d. Instilling mild fear into the client to extinguish the behavior

Front

c. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

Back

43] Sublingual nitroglycerine tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pains stops b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes c. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician

Front

c. The correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes.

Back

31] Crackles heard on lung auscultation indicate which of the following? a. Cyanosis b. Bronchospasm c. Airway narrowing d. Fluid-filled alveoli

Front

d. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

Back

33] The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? a. cancer b. hypertension c. Liver disease d. Myocardial damage

Front

d. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction. Myoglobin does not help diagnose cancer, hypertension, or liver disease.

Back

20] Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? a. Increased blood pressure b. Increased urine output c. Decreased pain d. Decreased premature ventricular contractions

Front

b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias

Back

41] As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a. Antispasmodic effects on the pericardium b. Causing an increased myocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium

Front

c. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

Back

34] An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: a. Left ventricular atrophy b. Irregular heartbeats c. Peripheral vascular occlusion d. Pacemaker placement

Front

a. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

Back

36] The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet? a. Hamburger, salad, and milkshake b. Baked liver, green beans, and coffee c. Spaghetti with tomato sauce, salad, and coffee d. Fried chicken, green beans, and skim milk

Front

c. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

Back

32] A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. b. Administer oxygen via nasal cannula c. Offer pain medication for the chest heaviness d. Inform the physician of the chest heaviness

Front

a. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.

Back

7] The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive highest priority? a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles b. Confusion, urine output 15mL over the last 2 hours, orthopnea. c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.

Front

b. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable

Back

40] Which of the following is not a risk factor for the development of atherosclerosis? a. Family history of early heart attack b. Late onset of puberty c. Total blood cholesterol level greater than 220 mg/dL d. Elevated fasting blood glucose concentration

Front

b. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity

Back

24] A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." b. "The triglycerides are elevated and will not return to normal without these medications." c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." d. "The medications are not indicated since your lab values are all normal."

Front

c. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, post-menopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

Back

23] The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. b. a 43-year-old male with a family history of CAD and cholesterol level of 158 c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor) d. A 65-year-old female who is obese with an LDL of 188

Front

d. The woman who is 65-years-old, over weight and has an elevated LDL is at greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women, men 45-years and older, women 55-years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity and high LDL cholesterol places this client at greatest risk.

Back

21] After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help: a. Prepare the client for ambulation b. Promote urinary and intestinal elimination c. Prevent thrombophlebitis and blood clot formation d. Decrease the likelihood of pressure ulcer formation

Front

c. This type of exercise is a preventive strategy taught to all clients who are hospitalized and on bed rest. This activity is taught to the client to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. It is venous stasis that increases one's risk for thrombophlebitis and blood clot formation. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation.

Back

10] A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first: a. Administer the morphine b. Obtain a 12-lead ECG c. Obtain the blood work d. Order the chest radiograph

Front

a. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.

Back