Question

What is the best indication if the client with congestive heart failure is holding excess fluid?

Answer 1

Correct Answers:

Daily weights

Rationale :

🎀Daily weight is the most accurate indicator of fluid gain or loss in clients with CHF.

🎀A 1 kg (2.2 lb) weight gain equals ~1 liter of fluid, which helps detect early fluid overload.

🎀 Other signs like edema or crackles may appear later, making weight a more sensitive measure.

🎀 Weighing at the same time daily (with same clothing) ensures consistency.

🎀 Important for evaluating effectiveness of diuretics or fluid restrictions.

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Answer 2

Correct Answers:

“Did you have rheumatic fever as a child?”

Rationale :

💠 Rheumatic fever is a common cause of valve disease, particularly mitral stenosis.

💠 Post-streptococcal autoimmune reaction damages valves, sometimes decades later.

💠 Asking about childhood history helps support diagnosis, especially in undiagnosed adults.

💠 Mitral valve is most commonly affected, but other valves may also be involved.

💠 Important to screen for endocarditis risk and auscultate for murmurs.

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Answer 3

Correct Answers:

“A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.”

Rationale :

🔹 Hypertension diagnosis requires multiple readings over time under standardized conditions.

🔹 Transient BP elevations can occur from stress, anxiety, or physical activity.

🔹 Encouraging follow-up and re-checks helps avoid unnecessary treatment.

🔹 This educates the patient while promoting evidence-based decision-making.

🔹 Preventing mislabeling avoids overtreatment and anxiety.

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Answer 4

Correct Answers:

“The test will provide a detailed profile of the heart’s electrical activity.”

Rationale :

♦ Transesophageal echocardiography (TEE) assesses cardiac structure, not electrical activity.

♦ It uses ultrasound via the esophagus to view heart valves and chambers.

♦ Electrophysiology is assessed via ECG, not TEE.

♦ Correct prep includes NPO status, sedation, and IV access.

♦ Miscommunication may cause confusion and mistrust in patients.

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Answer 5

Correct Answers:

Intermittent claudication

Rationale :

💙Pain during walking relieved by rest is classic for intermittent claudication, caused by PAD.

💙 Hairless skin and cool extremities suggest poor perfusion.

💙 Ischemic muscles cramp during exertion, resolving with rest.

💙This symptom warrants ankle-brachial index testing.

💙Left untreated, it can progress to critical limb ischemia.

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Answer 6

Correct Answers:

Shortness of breath
Anxiety
Unusual fatigue
Back pain
Chest pain

Rationale :

💠 Women with MI often present atypically, not just with chest pain.

💠 Symptoms like fatigue, anxiety, or back pain are commonly under-recognized.

💠 Dyspnea may be the only symptom, especially in diabetic or elderly women.

💠 Full symptom assessment is critical to avoid missed diagnosis.

💠 Prompt ECG and troponin testing are necessary in suspected MI.

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Answer 7

Correct Answers:

normal sinus rhythm that becomes sinus tachycardia
Onset of a cough with pink, frothy sputum
presence of dyspnea at rest
falls asleep when not disturbed

Rationale :

😉Sinus tachycardia signals increased cardiac workload, often due to worsening HF.

😉 Pink frothy sputum indicates pulmonary edema, an emergency finding.

😉 Dyspnea at rest suggests progression to decompensated HF.

😉 Lethargy or somnolence may indicate low oxygenation and cerebral hypoperfusion.

😉All these findings require immediate intervention, often including diuretics and oxygen.

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Answer 8

Correct Answers:

Relieve the patient’s symptoms
Extend survival
Improve functional status

Rationale :

✳ HF treatment goals focus on symptom control and quality of life.

✳ Improving function (e.g., activity tolerance) is essential for independence.

✳ Optimizing therapy extends survival, especially with beta-blockers and ACE inhibitors.

✳ Limiting activity may be short-term, but not an overall goal.

✳ Preventing endocarditis is not a primary HF goal, though important in valve disease.

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Answer 9

Correct Answers:

Retinal Hemorrhage
Ventricular hypertrophy
Cerebrovascular Disease
Transient Ischemic Attacks (TIAs)

Rationale :

🎗️Chronic high BP damages blood vessels, including those in the brain and retina.

🎗️ Retinal hemorrhages can lead to vision loss, often seen in fundoscopic exams.

🎗️ Left ventricular hypertrophy (LVH) is a compensatory mechanism for pressure overload.

🎗️TIAs and stroke are common complications, linked to vessel rupture or atherosclerosis.

🎗️ Venous insufficiency is not caused by hypertension, but by valve dysfunction.

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Answer 10

Correct Answers:

Encourage increased oral fluid intake
Early mobilization after surgery
Frequent turning of the patient
Use of incentive spirometry

Rationale :

🟪 Atelectasis is the collapse of alveoli, often post-op due to immobility and shallow breathing.

🟪 Mobilization and repositioning help lung expansion and drainage.

🟪 Incentive spirometry encourages deep breaths, preventing collapse.

🟪 Hydration keeps secretions thin, aiding expectoration.

🟪 Antibiotics are not preventative, but treatment if infection develops.

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Ivytech community college Med Surg II exam

No.

1 :
What is the best indication if the client with congestive heart failure is holding excess fluid?

2 :
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?

4 :
A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

5 :
The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

6 :
An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

7 :
The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

8 :
The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

9 :
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)

10 :
The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

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Ivytech community college Med Surg II exam

No.

1 : What is the best indication if the client with congestive heart failure is holding excess fluid?

2 : 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?

4 : A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

5 : The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

6 : An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

7 : The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

8 : The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

9 : 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)

10 : The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

1 :
What is the best indication if the client with congestive heart failure is holding excess fluid?

2 :
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?

4 :
A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

5 :
The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

6 :
An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

7 :
The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

8 :
The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)

9 :
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)

10 :
The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)