A nurse is caring for a client with a myocardial infarction. The client questions the need for cardiac rehabilitation since "my heart is already damaged." Which of the following is the appropriate nursing response?
"Diet and exercise is good for you and good for your heart."
"It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it."
"Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely."
"Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
The Correct Answer is C
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypertension is a manifestation of increased intracranial pressure, as it reflects the body's attempt to maintain adequate cerebral perfusion pressure (CPP) and blood flow to the brain. CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). When ICP rises, MAP must also rise to keep CPP constant and prevent cerebral ischemia. Hypertension is part of the Cushing's triad, which is a classic sign of increased ICP that also includes bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure, as it does not affect the auditory system. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors, such as ear infections, noise exposure, medications, or aging. Tinnitus may be associated with other neurological conditions, such as Meniere's disease, acoustic neuroma, or multiple sclerosis, but not with increased ICP.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure, as it indicates a decrease in MAP and CPP, which can lead to cerebral ischemia and infarction. Hypotension can be caused by various factors, such as blood loss, dehydration, shock, or medications. Hypotension may worsen the outcome of increased ICP by reducing the oxygen and nutrient delivery to the brain.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure, as it contradicts Cushing's triad. Tachycardia is an increase in heart rate that can be caused by various factors, such as anxiety, pain, fever, dehydration, or medications. Tachycardia may increase the oxygen demand and metabolic rate of the brain, which can exacerbate the effects of increased ICP.
Correct Answer is B
Explanation
Choice A reason: Mitral valve disease is not a disorder that makes clients especially vulnerable to ozone effects, as it does not affect the respiratory system. Mitral valve disease is a condition that affects the mitral valve, which is the valve that separates the left atrium and the left ventricle of the heart. Mitral valve disease can cause the valve to become narrow (stenosis) or leaky (regurgitation), affecting the blood flow and oxygen delivery to the body. Mitral valve disease can cause symptoms such as shortness of breath, fatigue, chest pain, palpitations, and swelling of the legs.
Choice B reason: Asthma is a disorder that makes clients especially vulnerable to ozone effects, as it affects the respiratory system. Asthma is a chronic inflammatory condition that causes the airways to become narrow, swollen, and sensitive to triggers such as allergens, irritants, infections, or exercise. Asthma can cause symptoms such as wheezing, coughing, chest tightness, and difficulty breathing. Ozone is a gas that is formed when sunlight reacts with pollutants in the air. Ozone can irritate the lungs and worsen asthma symptoms by causing inflammation, bronchoconstriction, and mucus production. Ozone can also reduce lung function and increase the risk of respiratory infections.
Choice C reason: Nasal polyps are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Nasal polyps are benign growths that form in the lining of the nose or sinuses. Nasal polyps can cause symptoms such as nasal congestion, runny nose, postnasal drip, loss of smell or taste, headache, and snoring. Nasal polyps are usually associated with chronic inflammation or allergies, but their exact cause is unknown.
Choice D reason: Seasonal allergies are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Seasonal allergies are allergic reactions that occur during certain times of the year when pollen or mold spores are high in the air. Seasonal allergies can cause symptoms such as sneezing, itching, watery eyes, runny nose, and sore throat. Seasonal allergies are caused by an overreaction of the immune system to harmless substances in the environment.
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