A nurse is collecting data on a client who has coronary artery disease. Which of the following manifestations should the nurse anticipate? (Select All that Apply.)

Varicose veins

Chest pain

Palpitations

Shortness of breath

Heart murmur

Answer and Explanation

Correct Answer : B,C,D

A. Varicose veins are typically associated with venous insufficiency rather than coronary artery disease.
B. Chest pain, or angina, is a common symptom of coronary artery disease due to reduced blood flow to the heart muscle.
C. Palpitations can occur in clients with coronary artery disease as the heart compensates for decreased perfusion.
D. Shortness of breath can result from decreased cardiac output and oxygenation due to coronary artery disease.
E. A heart murmur is not a typical manifestation of coronary artery disease; it is more associated with valvular heart disease.

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Correct Answer is B

Explanation

A. While travel can expose individuals to various pathogens, Guillain-Barré syndrome (GBS) is more commonly linked to recent infections rather than overseas travel.
B. GBS is often preceded by an acute viral or bacterial infection, particularly an upper respiratory or gastrointestinal infection. This makes it essential for the nurse to inquire about a recent upper respiratory infection.
C. Taking multivitamins does not have a direct connection to the development of GBS.
D. While some vaccines are associated with GBS, the MMR vaccine is not typically a cause of concern in this context.

A. Prevent bladder distention. B. Elevate the client's head. C. Provide analgesia for headaches. D. Monitor for elevated blood pressure.

Correct Answer is A

Explanation

A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.

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A nurse is collecting data on a client who has coronary artery disease. Which of the following manifestations should the nurse anticipate? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is A

Explanation

A nurse is reinforcing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

A nurse is collecting data from a client who has heart failure prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

A nurse is reinforcing teaching with a newly licensed nurse about coup and contrecoup injuries. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is collecting data on a client who has a heart rate of 56/min. Which of the following findings should the nurse expect?

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?