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Hesi rn adult health II (wgu)
Total Questions : 56
Showing 10 questions, Sign in for moreAn older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and reports a dry mouth. Which intervention should the nurse implement?
An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as lightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO once daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment:
Neurological: Alert and oriented. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+ Capillary refill 2 seconds
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral Jungs
Gastrointestinal: Within normal limits (WNL)
Genitourinary: WNL
Musculoskeletal: WNL
Pain Reported 7 on a 0 to 10 scale, lightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest
1230
Vital signs
Temperature 98.1° F (38.7° C), orally
Heart rate: 121 beats/minute
Respirations: 21 breaths/minute
Blood pressure: 162/98 mm Hg
Oxygen saturation: 92% on room air
Body mass index (BMI) 32 kg/m2 (normal 18 to 24.9 kg/m2)
Pain: 7 on a scale of 0 to 10, tightness and pressure in chest
The healthcare provider places prescriptions for further diagnostics.
Click to indicate if the listed symptoms are consistent with angina, myocardial infarction, or both. Each column must have at least one response option selected.
Explanation
Myocardial Infarction (MI):
- Occurring without cause
- Feelings of fear
- Pain only relieved by opioids
- Epigastric distress
- Chest pain radiating down arm
Angina:
- Feelings of fear
- Pain relieved by nitroglycerin
- Chest pain radiating down arm
Rationale:
- Occurring without cause: MI pain often develops spontaneously without obvious exertional triggers. It may strike during rest or sleep due to complete blockage of a coronary artery, which differentiates it from angina that is typically exertion-induced.
- Feelings of fear: Both MI and angina can provoke intense feelings of fear or a sense of impending doom. The body's sympathetic response to chest pain and hypoxia can trigger anxiety and a heightened emotional reaction in both conditions.
- Pain relieved by nitroglycerin: Stable angina pain usually responds well to nitroglycerin because it reduces myocardial oxygen demand by dilating coronary vessels. Relief after nitroglycerin suggests the pain is related to transient ischemia rather than infarction.
- Pain only relieved by opioids: In MI, the ischemic injury is severe and prolonged, causing chest pain that is often refractory to nitroglycerin. Opioids like morphine are typically needed to manage the intense, persistent discomfort caused by myocardial tissue death.
- Epigastric distress: Epigastric pain or discomfort may occur especially with inferior wall MIs, mimicking indigestion or gastrointestinal upset. This atypical presentation can delay diagnosis, particularly in older adults and women.
- Chest pain radiating down arm: Radiation of chest pain to the left arm, jaw, neck, or back is common in both MI and angina. It occurs because the same spinal segments supply sensory nerves to the heart and these other areas, causing referred pain.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO once daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment:
Neurological Alert and oriented. Agitated. Denies headaches.
Cardiovascular Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+ Capillary refill 2 seconds
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs
Gastrointestinal Within normal limits (WNL)
Genitourinary: WNL
Musculoskeletal: WNL
Pain Reported 7 on a 0 to 10 scale, lightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest
1230
Vital signs
Temperature 98.1° F (38.7 ° C), orally
Heart rate: 121 beats/minute
Respirations: 21 breaths/minute
Blood pressure: 162/98 mm Hg
Oxygen saturation: 92% on room air
Body mass index (BMI) 32 kg/m2 (normal 18 to 24.9 kg/m2)
Pain: 7 on a scale of 0 to 10, tightness and pressure in chest
The client was given oxygen, sublingual nitroglycerin, and aspirin. After one dose of nitroglycerin, the client's pain decreased to a reported 2 on a 0 to 10 scale with squeezing pain. The client was admitted for observation and percutaneous coronary intervention (PCI) to be completed later within the evening. The client asks the nurse to explain why a PCI is being completed.
select word choices to complete the sentence.
If healthcare providers see a narrowed heart vessel while performing a percutaneous coronary intervention (PCI), they may perform a balloon angioplasty to compress the plaque against the vessel wall and hold it there with a stent, which will lessen
Explanation
- Heart blocks: Heart blocks result from conduction abnormalities in the electrical pathways of the heart and are typically managed with pacemakers or medications, not directly corrected by PCI. PCI targets mechanical obstructions in the coronary arteries and does not primarily address conduction delays.
- Dysrhythmias: Restoring blood flow through PCI improves oxygen delivery to the myocardium, stabilizing the heart’s electrical activity. Ischemia often triggers dysrhythmias, and by relieving this ischemia, PCI reduces the risk of abnormal heart rhythms, particularly ventricular arrhythmias.
- Vasospasms: While vasospasms can cause transient coronary artery narrowing, they are usually managed with medications like calcium channel blockers. PCI is not typically used to treat vasospastic events unless they result in a fixed lesion or underlying atherosclerosis.
- Pain: Chest pain in this client is likely ischemic in nature due to reduced coronary perfusion. PCI relieves this ischemia by opening narrowed arteries, thereby reducing myocardial oxygen demand mismatch and leading to a significant reduction in chest pain symptoms.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as lightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO once daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment:
Neurological: Alert and oriented. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+ Capillary refill 2 seconds
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral Jungs
Gastrointestinal: Within normal limits (WNL)
Genitourinary: WNL
Musculoskeletal: WNL
Pain Reported 7 on a 0 to 10 scale, lightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest
1230
Vital signs
Temperature 981 F (38.7 C), orally
Heart rate: 121 beats/minute
Respirations: 21 breaths/minute
Blood pressure: 162/98 mm Hg
Oxygen saturation: 92% on room air
Body mass index (BMI) 32 kg/m2 (normal 18 to 24.9 kg/m2)
Pain: 7 on a scale of 0 to 10, tightness and pressure in chest
The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?
A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?
While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?
A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?
A client with a gram positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% sodium chloride with daptomycin 500 mg/100 mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only.)
Explanation
Calculation:
Total volume to be infused = 100 mL
Infusion time in hours:
Infusion time (hours) = Infusion time (minutes) / 60 minutes/hour
= 30 minutes / 60 minutes/hour
= 0.5 hours
Calculate the infusion rate in mL/hour:
Infusion rate (mL/hour) = Total volume (mL) / Infusion time (hours)
= 100 mL / 0.5 hours
= 200 mL/hour
A 68-year-old male client is 24 hours postoperative from left hip surgery on the orthopaedic floor. The surgery was due to a fall. No surgical complications were noted. Total right knee surgery was done due to osteoarthritis 18 months ago, and the client has a significant history of tobacco use, smoking half a pack per day for 25 years.
Postoperative
Day 1, 0730
The client reports tenderness and a pain rating of 4 on a 0 to 10 scale located in left calf area. Assessment of the left calf shows moderate redness with edema noted. The circumference measurement of left calf is 15 in (38.1 cm) and right calf is 13 in (33 cm) Pedal pulses bilaterally are 2+ Capillary refill bilaterally is less than 2 seconds. The dressing to the left hip is clean, dry, and intact. The client is noted to have ambulated for 10 minutes once after surgery with physical therapy (PT)
Day 1, 0800
The client is given ibuprofen 200 mg 2 tablets PO with morning breakfast. Measurement for compression stockings is performed. The left leg is slightly elevated. Enoxaparin 30 mg is given deep SUBQ in the outer abdomen area.
Day 1, 0830
The client reports a pain rating of 2 on a 0 to 10 scale in the left calf area. Compression stockings are applied to both legs. The client is instructed on proper use of stockings.
Day 1, 0900
The healthcare provider (HCP) is at the bedside to do the morning assessment. The nurse reports concerns regarding the left calf findings. Pain level is at 6 on a 0 to 10 scale. Mild redness and edema are noted in the left calf. The dressing on the left hip has a small amount of dark red blood. The nurse circles dates and times the drainage on the dressing and prepares the client for a STAT Doppler ultrasound of the lower left leg.
Postoperative
Day 1, 0730
Vital signs
Temperature: 100.1 F (37.8° C), orally Heart rate: 98 beats/minute
Respirations: 20 breaths/minute
Blood pressure: 138/84 mm Hg
Oxygen saturation: 96% on room air
Pain: 4 on a 0 to 10 scale, left calf
|
Laboratory Test |
Results |
Reference Range |
|
Partial thromboplastin time (PTT) |
26 seconds
|
20 to 30 seconds |
|
D-dimer |
0.26 mg/L (1.4 nmol/L) |
Less than 0.5 mg/L (Less than 3 nmol/L) |
Postoperative
Day 1, 0745
Apply compression stockings to both legs
Enoxaparin 30 mg SUBQ every 12 hours
Ibuprofen 200 mg 2 tablets PO for pain every 4 to 6 hours
Day 1, 9000
D-dimer and complete blood count (CBC) STAT
Partial thromboplastin time (PTT)
Doppler ultrasound lower left leg area STAT
Keep left leg elevated on 2 pillows
Data is evaluated to determine possible condition and appropriate interventions.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
- Deep vein thrombosis (DVT): The client presents with classic signs of DVT, including calf tenderness, unilateral edema and redness, increased calf circumference, low-grade fever, and a history of immobility following surgery—all of which increase thrombotic risk. A STAT Doppler and D-dimer were appropriately ordered, both of which help confirm or rule out DVT.
- Begin anticoagulation therapy: Anticoagulants like enoxaparin reduce clot propagation and the risk of pulmonary embolism, the most serious complication of DVT. This is a standard first-line treatment following a positive diagnosis or high clinical suspicion.
- Early ambulation: After stabilization and with provider clearance, early ambulation is encouraged to enhance venous return and prevent further thrombus formation. It must be done cautiously to avoid dislodging a clot if DVT is still untreated or unstable.
- Massage the calf area: This is contraindicated, as it may dislodge a clot and cause embolization to the lungs. It is strictly avoided in suspected or confirmed cases of DVT.
- Prep for return to surgery / Culture hip wound: These are not relevant to the current clinical concern. The surgical wound has minimal drainage, with no signs of infection or dehiscence.
- Development of pulmonary embolus: Clients with DVT are at high risk for PE. Monitoring for chest pain, shortness of breath, decreased oxygen saturation, and respiratory distress is essential for early detection and intervention.
- Laboratory values: Ongoing assessment of coagulation labs (PT, aPTT, platelet count) and renal function is critical to safely manage anticoagulation and ensure therapeutic response.
- Wound drainage / Nutritional intake / I&O: These are important for general postoperative care but are not specific to monitoring progress related to DVT or anticoagulation therapy.
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