Nursing Elites

1. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsened with breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.

2. A nurse is assessing a male adolescent client who has heart failure. Based on the client’s chart, which of the following actions should the nurse plan to take?

• A. Withhold spironolactone
• B. Administer ferrous sulfate
• C. Administer furosemide
• D. Withhold digoxin

Correct answer: C

Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.

3. A nurse is assessing a client for signs of heart failure. Which of the following findings should the nurse monitor?

• A. Decreased heart rate
• B. Peripheral edema
• C. Increased energy levels
• D. Hyperglycemia

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. Peripheral edema, the accumulation of fluid causing swelling in the extremities, is a classic sign of heart failure due to fluid overload. This occurs because the heart's reduced pumping efficiency leads to fluid backup in the circulatory system. Choices A, C, and D are incorrect. Decreased heart rate is not typically associated with heart failure; instead, tachycardia or an increased heart rate may be observed. Increased energy levels are not an expected finding in heart failure, as this condition often causes fatigue and weakness. Hyperglycemia is not a direct sign of heart failure; however, it can be present in individuals with uncontrolled diabetes or as a result of certain treatments, but it is not a specific indicator of heart failure.

4. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, 'I never should have let him take the car. It's all my fault!' Which of the following responses by the nurse is appropriate?

• A. You had no way of knowing this would happen.
• B. Most parents blame themselves when losing a child.
• C. Tell me why you feel this is your fault.
• D. You appear to be feeling overwhelmed.

Correct answer: C

Rationale: Choice C is the most appropriate response because it encourages the mother to express her feelings and explore the reasons behind her guilt. This approach allows the mother to process her emotions effectively and address her grief. Choices A and B do not directly address the mother's feelings of guilt and may not help her work through her emotions. Choice D acknowledges the mother's emotional state but does not delve into the underlying issues causing her guilt and grief.

5. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?

• A. Monitor for liver function
• B. It can cause muscle pain
• C. It is safe to take during pregnancy
• D. Both A and B

Correct answer: D

Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.

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