A 68-year-old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
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Solution
Use hand roll and extend the left upper extremity on a pillow to prevent contractions
Option B: The left side of the body will be affected in a right-sided brain attack.
During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
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Solution
Able to perform self-care activities without pain
Option A: By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
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Solution
Obtaining infusion pump for the medication
Option D: Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
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Solution
Abdominal cramps
Option C: The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
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Solution
Extension of the extremities after a stimulus
Option C: Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
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Solution
Increase cardiac output
Option B: The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.
Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
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Solution
Prevents sleep disturbances during night
Option C: When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
Which of the following should the nurse teach the client about the signs of digitalis toxicity?
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Solution
Visual disturbances such as seeing yellow spots
Option D: Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
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Solution
Prevents shock and relieves pain
Option B: Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
Mrs. Chua a 78-year-old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
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Solution
Crackles
Option B: Left-sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.