Nursing Elites

1. A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?

• A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
• B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
• C. I will avoid physical activity until the pain subsides completely.
• D. I will take nitroglycerin 30 minutes before any physical activity.

Correct answer: B

Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.

2. A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?

• A. Encourage the client to increase physical activity.
• B. Instruct the client to take rest breaks during walking.
• C. Apply warm compresses to the legs to improve circulation.
• D. Massage the affected leg to relieve the pain.

Correct answer: B

Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.

3. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?

• A. Administer antiemetics to reduce nausea.
• B. Obtain a list of the client's cardiac medications.
• C. Perform an ECG to evaluate heart function.
• D. Review the client's dietary intake for possible causes.

Correct answer: B

Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.

4. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?

• A. Instruct the client to drink clear fluids and avoid solid foods.
• B. Administer antidiarrheal medication as prescribed.
• C. Encourage a high-fiber diet and regular physical activity.
• D. Restrict fluid intake and monitor electrolytes.

Correct answer: C

Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.

5. The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading?

• A. Frequent syncope
• B. Muscle rigidity
• C. Gait instability
• D. Fine motor tremors

Correct answer: A

Rationale: The correct answer is A: 'Frequent syncope.' Orthostatic hypotension, common in Parkinson's disease, often causes syncope (fainting) when blood pressure drops upon standing. This information is critical for planning safe blood pressure measurements, ensuring readings are taken in both lying and standing positions to assess for sudden drops in pressure. Muscle rigidity, tremors, or gait instability are important symptoms in Parkinson's disease but are not directly related to blood pressure assessment.

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