The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

Frequent change of position

Antibiotics

Oxygen humidification

Chest physiotherapy

Answer and Explanation

The Correct Answer is A

A. Frequent change of position:

Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.

B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.

C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.

D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.

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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. “Did you have rheumatic fever as a child?” B. “Do you have a family history of valve problems?” C. “Do you have a history of MRSA?” D. “What over-the-counter medications do you take?”

Correct Answer is A

Explanation

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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The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

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 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?

Correct Answer is A

Explanation

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