A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?

"You should not have sexual intercourse while the monitor is in place."

"You can bathe while wearing the electrodes."

"You should remove the electrodes when you go to bed."

"You will need to record daily activities in a diary."

Answer and Explanation

The Correct Answer is D

A. "You should not have sexual intercourse while the monitor is in place.": This is incorrect because sexual activity is generally not restricted while wearing a Holter monitor. The main focus is on ensuring the monitor remains attached.
B. "You can bathe while wearing the electrodes.": This is incorrect because bathing or getting the electrodes wet can interfere with the monitor's functionality and potentially lead to inaccurate readings.
C. "You should remove the electrodes when you go to bed.": This is incorrect because the electrodes should remain in place for the full 24-hour period to ensure continuous monitoring.
D. "You will need to record daily activities in a diary.": This is correct as recording activities in a diary is crucial for correlating symptoms with the Holter monitor data.

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Correct Answer is A

Explanation

A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.

A. Heart rate B. Respiratory effort C. Pain D. Blood pressure E. Mentation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.

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A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

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