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The triage nurse in the ED assesses an adult client who presents with reports of
midsternal chest pain that has lasted for the last 5 hours. If the client's symptoms
are due to an MI, what will have happened to the myocardium?
A. It may have developed an increased area of infarction during the time without
treatment.
B. It will probably not have more damage than if the client came in immediately.
C. It may be responsive to restoration of the area of dead cells with proper
treatment.
D. It has been irreparably damaged, so immediate treatment is no longer
necessary. - ANSWERS-A
Family members bring a client to the ED with pale cool skin, sudden midsternal
chest pain unrelieved with rest, and a history of CAD. How should the nurse best
interpret these initial data?
A. The symptoms indicate angina and should be treated as such.
B. The symptoms indicate a pulmonary etiology rather than a cardiac etiology.
C. The symptoms indicate an acute coronary episode and should be treated as
such.
D. Treatment should be determined pending the results of an exercise stress test.
- ANSWERS-C
,The nurse is caring for a client who has been diagnosed with an elevated
cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is
composed chiefly of what?
A. Lipids and fibrous tissue
B. White blood cells
C. Lipoproteins
D. High-density cholesterol - ANSWERS-D
The nurse is caring for an adult client who had symptoms of unstable angina upon
admission to the hospital. What nursing diagnosis underlies the discomfort
associated with angina?
A. Ineffective breathing pattern related to decreased cardiac output
B. Anxiety related to fear of death
C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease
(CAD)
D. Impaired skin integrity related to CAD - ANSWERS-C
A client with angina has been prescribed nitroglycerin. Before administering the
drug, the nurse should inform the client about what potential adverse effects?
A. Nervousness or paresthesia
B. Throbbing headache or dizziness
C. Drowsiness or blurred vision
D. Tinnitus or diplopia - ANSWERS-B
, The nurse is providing an educational workshop about coronary artery disease
(CAD) and its risk factors. The nurse explains to participants that CAD has many
risk factors, some that can be controlled and some that cannot. Which risk factors
should the nurse list that can be controlled or modified?
A. Gender, obesity, family history, and smoking
B. Inactivity, stress, gender, and smoking
C. Cholesterol levels, hypertension, and smoking
D. Stress, family history, and obesity - ANSWERS-C
A client presents to the ED reporting severe substernal chest pain radiating down
the left arm. The client is admitted to the coronary care unit (CCU) with a
diagnosis of myocardial infarction (MI). What nursing assessment activity is a
priority on admission to the CCU?
A. Begin ECG monitoring.
B. Obtain information about family history of heart disease.
C. Auscultate lung fields.
D. Determine if the client smokes. - ANSWERS-A
The nurse is working with a client who had an MI and is now active in
rehabilitation. The nurse should teach this client to cease activity if which of the
following occurs?
A. The client experiences chest pain, palpitations, or dyspnea.
B. The client experiences a noticeable increase in heart rate during activity.