The nurse is caring for a male patient, age 54, who had a myocardial infarction 2 days ago. His wife, who is very talkative, has remained at his bedside. Which of these interventions should the nurse implement to reduce the workload of the heart? (Select all that apply.)

Administer daily stool softener.

Provide bedside commode.

Advocate for rest periods with no visitors.

Provide regular diet.

Ambulate four times a day.

Maintain bedrest.

Answer and Explanation

Correct Answer : A,B,C,F

Choice A reason: Administering a daily stool softener can help prevent straining during bowel movements, which can increase cardiac workload.

Choice B reason: Providing a bedside commode reduces the effort required to go to the bathroom, thus reducing cardiac workload.

Choice C reason: Advocating for rest periods with no visitors can help reduce emotional stress and physical exertion, which can increase cardiac workload.

Choice D reason: A regular diet is not specifically an intervention to reduce cardiac workload and may not be appropriate immediately following a myocardial infarction.

Choice E reason: Ambulating four times a day is not recommended immediately following a myocardial infarction as it can increase cardiac workload.

Choice F reason: Maintaining bedrest can help reduce the workload on the heart by minimizing physical activity.

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Correct Answer is C

Explanation

Choice A reason: Respiratory alkalosis is typically associated with hyperventilation, which is not common in acute pulmonary edema.

Choice B reason: Metabolic acidosis can occur in pulmonary edema due to tissue hypoxia and lactic acid production, but respiratory acidosis is more directly related to the primary problem of gas exchange.

Choice C reason: Respiratory acidosis is likely in acute pulmonary edema due to impaired gas exchange and CO2 retention.

Choice D reason: Metabolic alkalosis is not typically associated with acute pulmonary edema and is less likely than respiratory acidosis in this context.

A. Difficulty concentrating B. Paranoia C. Feelings of grandeur D. Flight of ideas

Correct Answer is A

Explanation

Choice A reason: Difficulty concentrating is a common symptom of depression, particularly in individuals with a spinal cord injury, where the change in lifestyle and physical abilities can lead to cognitive overload and reduced focus.

Choice B reason: While paranoia can be associated with other mental health conditions, it is not a typical sign of depression. Depression is more commonly associated with symptoms like hopelessness and low self-esteem.

Choice C reason: Feelings of grandeur are not typically associated with depression. This symptom is more indicative of mania or other psychiatric conditions such as bipolar disorder.

Choice D reason: Flight of ideas is a symptom often seen in manic episodes and is characterized by rapidly changing or disjointed thoughts. It is not a common symptom of depression.

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The nurse is caring for a male patient, age 54, who had a myocardial infarction 2 days ago. His wife, who is very talkative, has remained at his bedside. Which of these interventions should the nurse implement to reduce the workload of the heart? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

Correct Answer is C

Explanation

A nurse is caring for a client who has a spinal cord injury and is at risk for depression. Which of the following findings should the nurse identify as an indication that the client is developing depression?

Correct Answer is A

Explanation

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