A client is being admitted to the medical unit to rule out cardiac issues related to valve malfunction. Which question should the nurse ask the client during the admission interview to support this diagnosis?

“Did you have rheumatic fever as a child?”

“Do you have a family history of valve problems?”

“Do you have a history of MRSA?”

“What over-the-counter medications do you take?”

Answer and Explanation

The Correct Answer is A

A. "Did you have rheumatic fever as a child?"

Rheumatic fever is an inflammatory condition that can affect the heart, especially the heart valves. Rheumatic fever is a known risk factor for the development of valvular heart disease. Asking about a history of rheumatic fever helps identify a potential cause for valve malfunction.

B. "Do you have a family history of valve problems?"

Family history can be relevant in understanding genetic predispositions to certain cardiac conditions. While it may contribute to the overall assessment of cardiac risk, it may not be as directly linked to valve malfunction as a history of rheumatic fever.

C. "Do you have a history of MRSA?"

MRSA (Methicillin-resistant Staphylococcus aureus) is a type of bacterial infection and is not directly associated with valve malfunction. This question may be relevant for other aspects of the client's health but is not specific to ruling out cardiac issues related to valve malfunction.

D. "What over-the-counter medications do you take?"

While knowing the medications a client takes is important for a comprehensive assessment, asking about over-the-counter medications may not be as directly related to ruling out cardiac issues related to valve malfunction. It is more relevant for assessing potential interactions or effects on cardiovascular health.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Retinal Hemorrhage

Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.

B. Ventricular Hypertrophy

Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.

C. Cerebrovascular Disease

Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.

D. Venous Insufficiency

Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.

E. Transient Ischemic Attacks (TIAs)

Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.

A. Lie in a low Fowler’s or supine position B. Increase oral fluids unless contraindicated C. Increase activity D. Call the nurse for oral suctioning as needed

Correct Answer is D

Explanation

A. Lie in a low Fowler’s or supine position:

Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.

B. Increase oral fluids unless contraindicated:

Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.

C. Increase activity:

Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.

D. Call the nurse for oral suctioning as needed:

This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.

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A client is being admitted to the medical unit to rule out cardiac issues related to valve malfunction. Which question should the nurse ask the client during the admission interview to support this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer is D

Explanation

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