Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?
A. "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it."
"It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." is wrong because it is dismissive of the client's feelings and does not address his concern or provide any education.
B. "Exercise is good for you and good for your heart."
"Exercise is good for you and good for your heart." is wrong because it is too simplistic and vague, and does not explain how cardiac rehabilitation can help the client specifically.
C. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."
The nurse should respond with empathy and honesty, and provide factual information about the benefits of cardiac rehabilitation. Cardiac rehabilitation can help the client improve his cardiovascular fitness, reduce his risk factors, prevent further complications, and enhance his quality of life.
D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
"Your doctor is the expert here, and I'm sure he would only recommend what is best for you." is wrong because it is deferential and does not empower the client or encourage his participation in his own care.
This question is an excerpt from Nurse Dive's nursing test bank - College Proctored Exam 2 perfusion euro pm. Take the full exam now
Full Explanation
Choice A reason:
This statement is incorrect because it trivializes the patient's concerns and implies that enjoyment is the primary goal, which is not the case. The main purpose of cardiac rehabilitation is to improve health outcomes, not just to make the routine enjoyable.
Choice B reason:
While exercise is beneficial for heart health, this statement is too general and does not address the specific benefits of cardiac rehabilitation for someone who has had a myocardial infarction.
The correct answer is C:
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Cardiac rehabilitation is crucial for patients who have experienced a myocardial infarction. It provides a structured program that includes exercise, education, and support to help patients improve their cardiovascular health and prevent future cardiac events.
Choice D reason:
Deferring to the doctor's expertise does not educate the patient about the benefits of cardiac rehabilitation. It's important for patients to understand why they are participating in the program.
Similar Questions
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
A. Request a dietitian consult.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
B. Suggest that the client rests before eating the meal.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
C. Request an order for an antiemetic.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
D. Check the client's vital signs.
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Full Explanation
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
A. Thick, deformed toenails
Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.
B. Edema
Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.
C. Dependent rubor
Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
D. Hair loss
Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.
Full Explanation
Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.
a. Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.
c. Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
d. Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
A. Peripheral edema
Peripheral edema is a common finding in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
B. Chest pain
Chest pain is not a typical finding of right-sided heart failure, unless there is an underlying cause such as coronary artery disease or pulmonary hypertension.
C. Heart murmur
Heart murmur is not a specific finding of right-sided heart failure, but it may indicate a valvular disorder that can contribute to or result from heart failure.
D. Crackles in lungs
Crackles in lungs are more likely to be seen in clients who have left-sided heart failure, due to the pulmonary congestion and impaired gas exchange.