Rationale #1 Fundamentals of Nursing

1. d Rationale: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
2. b Rationale: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike, and sputum that varies in color. A client in cardiogenic shock would show signs of hypotension and tachycardia.
3. d Rationale: Clinical signs of right-sided heart failure include jugular vein distention, dependent peripheral edema, hepatomegaly, splenomegaly, ascites, nausea, vomiting, weakness, dizziness, and syncope. Respiratory acidosis, hypertension, and dyspnea are associated with left-sided heart failure.
4. c Rationale: Failure to progress is an example of noncompliance. Undesirable drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.
5. d Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation, thereby reducing cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date APTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid narcotic; therefore, an opioid antagonist such as naloxone doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab
6. a Rationale: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase social interaction or to participate in social activities at least weekly. The other options aren't goals that address this nursing diagnosis.
7. d Rationale: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty nest crisis.
8. d Rationale: The nursing diagnosis of Acute pain takes highest priority because pain increases the client's pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body's response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern — pain.
9. b Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.
10. a Rationale: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact the problem is only a potential one, not an actual one, making the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If disturbed body image were a problem, interventions would focus on the client's feelings about himself and the disease.
11. d Rationale: CAD develops when fatty deposits line the walls of the coronary arteries, impeding blood flow and therefore decreasing cardiac output. Thermoregulatory disturbances aren't usually associated with CAD unless accompanied by heart failure. Impaired gas exchange may occur if the blood's oxygen-carrying capacity were altered, as in anemia, chronic obstructive pulmonary disease, or carbon monoxide poisoning. There would be a risk of injury if the client had sensory or motor deficits.
12. d Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
13. c Rationale: Cardiac output is the total amount of blood ejected by the heart per minute. It's determined by multiplying the client's heart rate by his stroke volume. Stroke volume is the amount of blood ejected with each beat. Ejection fraction is the percent of left ventricular end-diastolic volume ejected during systole. Heart rate is the number of beats per minute.
14. b Rationale: To relieve anginal pain, the client should place nitroglycerin tablets under the tongue (sublingually) and shouldn't consume fluids with the medication. All other statements made by this client reflect an accurate understanding of nitroglycerin use.
15. b Rationale: The client should avoid consuming large amounts of vitamin K because it can interfere with anticoagulation. The client may need to report diarrhea, but it isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen (Tylenol) should be used for pain relief.
16. d Rationale: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn't caused by vestibular (inner ear) dysfunction, vascular fluid shifting, or postural hypotension.
17. a Rationale: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
18. c Rationale: The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively, but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.
19. c Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. d Rationale: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing or widening complexes and amplitude increase aren't expected on the ECG of an individual with cardiac tamponade.
21. d Rationale: Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
22. a Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Retrospective or summative evaluation occurs at the conclusion of teaching and learning sessions. Informative isn't a type of evaluation.
23. a Rationale: Pitting edema is documented as +1 when depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
24. b Rationale: When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
25. a Rationale: Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock would cause a decrease in cardiac output. Tissue perfusion would be altered if hypovolemic shock occurred, but this wouldn't be the primary nursing diagnosis.
26. b Rationale: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy isn't effective.
27. b Rationale: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
28. d Rationale: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
29. b Rationale: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.
30. a Rationale: A murmur that indicates heart disease is commonly accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and periorbital edema aren't associated with murmurs and heart disease.