Question

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

Answer 1

Correct Answers:

Lack of sufficient oxygen to the myocardium.

Rationale :

🟨 Coronary artery disease (CAD) occurs when plaque buildup in the coronary arteries reduces blood flow to the myocardium, especially during exertion or stress.

🟨 The myocardial cells require oxygen to function, and when oxygen supply is insufficient (ischemia), the result is angina pectoris, or chest pain.

🟨 This pain is the heart's response to hypoxia, which leads to the accumulation of lactic acid and other metabolites, stimulating nerve endings and producing a squeezing or pressure-like chest discomfort.

🟨 Although increased workload and nutrient demand contribute, the critical issue causing pain is the lack of oxygenated blood reaching cardiac tissue.

🟨 Understanding this helps patients grasp the importance of medications (like nitrates, beta-blockers) and lifestyle changes aimed at improving oxygen delivery and reducing demand.

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Answer 2

Correct Answers:

Lack of sufficient oxygen to the myocardium.

Rationale :

🟨 Coronary artery disease (CAD) occurs when plaque buildup in the coronary arteries reduces blood flow to the myocardium, especially during exertion or stress.

🟨 The myocardial cells require oxygen to function, and when oxygen supply is insufficient (ischemia), the result is angina pectoris, or chest pain.

🟨 This pain is the heart's response to hypoxia, which leads to the accumulation of lactic acid and other metabolites, stimulating nerve endings and producing a squeezing or pressure-like chest discomfort.

🟨 Although increased workload and nutrient demand contribute, the critical issue causing pain is the lack of oxygenated blood reaching cardiac tissue.

🟨 Understanding this helps patients grasp the importance of medications (like nitrates, beta-blockers) and lifestyle changes aimed at improving oxygen delivery and reducing demand.

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Answer 3

Correct Answers:

The client can undergo electroconvulsive therapy without giving informed consent.

Rationale :

🟩 Even under involuntary admission, a client retains the right to refuse treatment, including medications, unless they are deemed a danger to themselves or others, or a court order overrides that right.

🟩 Informed consent is a fundamental legal and ethical principle in mental health care. The use of medication must be voluntary, unless in emergency situations or with legal approval.

🟩 Clients under involuntary admission are still protected by the Patient's Bill of Rights, which includes the right to participate in treatment decisions and refuse care, except in specific emergency or legal circumstances.

🟩 Nurses must advocate for and respect patient autonomy, even when admission is involuntary, and must follow proper procedures to document refusals and report concerns to the healthcare team.

🟩 Actions such as forced ECT, sharing information without consent, or applying restraints PRN violate ethical and legal care standards unless explicitly justified and documented under proper authority.

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Answer 4

Correct Answers:

Measure the client's apical pulse.

Rationale :

🟦 Digoxin slows the heart rate and increases cardiac contractility, so it's essential to assess the apical pulse for 1 full minute before administration.

🟦 If the apical pulse is below 60 bpm in adults (or age-appropriate threshold in children), the nurse should withhold the dose and notify the provider.

🟦 Monitoring the apical pulse helps prevent digoxin toxicity, which can cause bradycardia, arrhythmias, nausea, and visual disturbances.

🟦 This step ensures safe administration and protects the client from adverse cardiac effects due to digoxin’s narrow therapeutic range.

🟦 While weight and blood pressure are important for general heart failure monitoring, they are not the priority check before digoxin administration.

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Answer 5

Correct Answers:

I will have my potassium level checked.

Rationale :

🟨 Furosemide (Lasix) is a loop diuretic that promotes urinary excretion of sodium, potassium, and water, which can lead to hypokalemia—a potentially serious electrolyte imbalance.

🟨 Monitoring serum potassium levels is essential because low potassium increases the risk of cardiac arrhythmias, especially in clients taking digoxin or antihypertensives.

🟨 Patients should also be educated to report symptoms like muscle weakness, cramps, or palpitations, which may indicate electrolyte disturbances.

🟨 While furosemide can also affect calcium and sodium, potassium is the priority electrolyte due to its vital role in cardiac conduction and muscle function.

🟨 Prothrombin time (PT) is unrelated to furosemide’s mechanism, and urine sodium is not routinely used for outpatient diuretic monitoring.

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Answer 6

Correct Answers:

"You seem to be very upset about something. Tell me about it."

Rationale :

🟩 This response uses therapeutic communication by acknowledging the client’s emotions and inviting them to express their concerns, which helps de-escalate agitation and promotes emotional safety.

🟩 Clients with bipolar disorder, especially during manic or agitated phases, may exhibit increased demands and decreased impulse control. Responding with empathy rather than dismissal is critical.

🟩 By focusing on the underlying emotional need rather than the immediate demand, the nurse provides a calm, non-confrontational redirection that builds rapport and trust.

🟩 The response avoids confrontation, respects the client’s feelings, and supports client-centered care, which is essential in psychiatric nursing.

🟩 Other responses may seem dismissive or directive without addressing the emotional distress, potentially escalating the situation.

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Answer 7

Correct Answers:

Administer daily stool softener.
Provide bedside commode.
Advocate for rest periods with no visitors.

Rationale :

✅ Administer daily stool softener

🔷 Straining during bowel movements can trigger the Valsalva maneuver, which may cause sudden changes in heart rate and blood pressure, increasing cardiac workload.

🔷 A stool softener helps the patient pass stool without bearing down, minimizing the risk of triggering cardiac stress or arrhythmias.

🔷 It supports safe elimination, which is important in the immediate post-MI period when the heart muscle is still recovering.

🔷 Prevents constipation, which is a common side effect of opioids and decreased mobility often used in post-MI care.

🔷 This intervention is a simple and effective way to reduce unnecessary physical stress on the myocardium.

✅ Provide bedside commode

🔷 Using a bedside commode allows the patient to urinate or defecate without walking far, thereby reducing exertion and oxygen demand.

🔷 Early post-MI, even short walks to the bathroom may cause tachycardia or chest pain due to increased cardiac workload.

🔷 It prevents falls or orthostatic hypotension, which can result from sudden position changes or walking unaided.

🔷 Supports safe toileting while allowing the patient to maintain a level of independence.

🔷 This intervention helps balance the need for rest with the need to prevent complications from complete immobility.

✅ Advocate for rest periods with no visitors

🔷 Continuous interaction, even with well-meaning family members, can lead to emotional overstimulation, raising heart rate and blood pressure.

🔷 Patients recovering from a myocardial infarction need calm, uninterrupted rest to allow the heart muscle to heal effectively.

🔷 Limiting visitors during specific periods helps establish a therapeutic environment that supports physiologic recovery.

🔷 Rest periods minimize sympathetic nervous system stimulation, reducing the likelihood of ischemic episodes.

🔷 This approach promotes hemodynamic stability and reduces mental and emotional stress, both of which affect cardiac recovery.

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Answer 8

Correct Answers:

A chronic mood disorder of at least 2 years.

Rationale :

🟪 Cyclothymic disorder is a chronic mood disorder characterized by fluctuating periods of hypomanic symptoms and depressive symptoms that do not meet full criteria for hypomanic or major depressive episodes.

🟪 The mood instability must be present for at least 2 years in adults (or 1 year in children/adolescents), with symptoms present for at least half the time and not absent for more than 2 months at a time.

🟪 It is considered a milder form of bipolar disorder, but still significantly impacts functioning and emotional stability.

🟪 Clients with cyclothymic disorder experience alternating low-grade depression and hypomania, without ever having full-blown manic or major depressive episodes.

🟪 Diagnosis requires long-term symptom tracking, as symptoms are often less severe but more persistent and unpredictable.

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Answer 9

Correct Answers:

Escort the client to her room when she is observed trying to interact with other clients.

Rationale :

🟦 Clients in the manic phase of bipolar disorder often exhibit excessive talking, impulsivity, and boundary issues, which can disturb or overstimulate others in the environment.

🟦 Escorting the client gently and non-punitively to her room helps reduce environmental stimulation, promote calmness, and protect the therapeutic environment for all clients.

🟦 This action supports the client’s need for structure and limits, which are essential during manic episodes, without using threats or isolation as punishment.

🟦 It helps prevent escalation of disruptive behavior, while maintaining the client’s dignity and safety.

🟦 The nurse must set clear, firm, and therapeutic boundaries to manage behaviors in a way that promotes safety and recovery.

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Answer 10

Correct Answers:

Exertion and anxiety can trigger the pain.

Rationale :

🟥 Angina pectoris is chest pain caused by myocardial ischemia, typically occurring when oxygen demand exceeds supply due to narrowed coronary arteries.

🟥 Physical exertion, emotional stress, and anxiety increase heart rate and oxygen consumption, which can trigger anginal episodes.

🟥 Pain is usually relieved by rest or nitroglycerin and does not last longer than 20 minutes—this helps distinguish stable angina from more serious events like myocardial infarction.

🟥 The pain is not related to respiratory movement, and if it persists despite rest and nitrates, it may indicate unstable angina or MI, which is an emergency.

🟥 Teaching clients to recognize triggers allows them to implement preventive strategies such as pacing activities, stress management, and carrying nitrates for relief.

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QLexNursing

1 :
The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

2 :
The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

3 :
A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?

4 :
A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

5 :
The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding medication teaching if the patient states that which of the following laboratory tests will be monitored as ordered?

6 :
A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

7 :
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.)

8 :
What is cyclothymic disorder?

9 :
A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

10 :
A nurse is reinforcing teaching with a client who has a new diagnosis of angina pectoris. Which of the following information about anginal pain should the nurse include in the teaching?

QLexNursing

1 : The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

2 : The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

3 : A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?

4 : A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

5 : The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding medication teaching if the patient states that which of the following laboratory tests will be monitored as ordered?

6 : A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

7 : 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.)

8 : What is cyclothymic disorder?

9 : A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

10 : A nurse is reinforcing teaching with a client who has a new diagnosis of angina pectoris. Which of the following information about anginal pain should the nurse include in the teaching?

1 :
The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

2 :
The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

3 :
A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?

4 :
A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

5 :
The patient is being discharged on furosemide (Lasix). The nurse evaluates the patient as understanding medication teaching if the patient states that which of the following laboratory tests will be monitored as ordered?

6 :
A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

7 :
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.)

8 :
What is cyclothymic disorder?

9 :
A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

10 :
A nurse is reinforcing teaching with a client who has a new diagnosis of angina pectoris. Which of the following information about anginal pain should the nurse include in the teaching?