NUR 213 Health Exam

Correct Answer: (d) Sit the client up with a pillow to lean forward on.

Explanation:

Acute pericarditis is characterized by inflammation of the pericardium, leading to sharp, substernal precordial pain that often worsens with lying flat and deep inspiration. Sitting up and leaning forward relieves pericardial pain by reducing pressure on the inflamed pericardium, making (d) the best choice.

Why the Other Options Are Wrong:

(a) Apply an ice pack to the client's chest.

Pericarditis pain is inflammatory, not musculoskeletal, so ice will not provide relief. Instead, anti-inflammatory medications (e.g., NSAIDs) are used for pain management.

(b) Provide a neck rub, especially on the left side.

Pericarditis pain is not due to muscle tension in the neck. A neck rub won't relieve the inflammation-related pain.

(c) Allow the client to lie in bed with the lights down.

Lying flat can worsen pericarditis pain, making this an incorrect intervention. While a calm environment is beneficial, it does not address the underlying pain.

Summary:

For clients with acute pericarditis, sitting upright and leaning forward reduces pericardial friction and pain, making (d) the correct answer.

Correct Answers:

✅ (a) Pulmonary crackles

✅ (b) Confusion, restlessness

✅ (e) Cough that worsens at night

Explanation:

Left-sided heart failure (HF) occurs when the left ventricle cannot pump blood effectively, leading to pulmonary congestion and decreased oxygenation. The nurse should assess for symptoms related to fluid accumulation in the lungs and decreased cardiac output:

• (a) Pulmonary crackles – Correct
  
  
  
  
  • Blood backs up into the pulmonary circulation, causing fluid accumulation in the alveoli, leading to crackles (rales) on auscultation.
  
  
  
  


• (b) Confusion, restlessness – Correct
  
  
  
  • Reduced cardiac output decreases oxygen delivery to the brain, leading to confusion, restlessness, and anxiety, especially in older adults.
  
  
  
  


• (e) Cough that worsens at night – Correct
  
  
  
  • Pulmonary congestion worsens in a supine position, leading to paroxysmal nocturnal dyspnea (PND) and a worsening cough at night.
  
  
  
  

Why the Other Options Are Wrong:

• (c) Pulmonary hypertension – Incorrect
  
  
  
  
  • Pulmonary hypertension is more directly linked to right-sided heart failure and chronic lung diseases (e.g., COPD, pulmonary fibrosis). Left-sided HF can contribute to pulmonary hypertension, but it is not an early or primary manifestation.
  
  
  
  


• (d) Dependent edema – Incorrect
  
  
  
  • Dependent edema (swelling in the legs and feet) is a hallmark sign of right-sided heart failure, not left-sided HF.
  
  
  
  

Summary:

Left-sided heart failure primarily causes pulmonary congestion and reduced oxygenation, leading to pulmonary crackles (a), confusion/restlessness (b), and a worsening cough at night (e). Right-sided heart failure is responsible for dependent edema (d) and pulmonary hypertension (c).

Correct Answers: 

 (a) "Are your bedroom and bathroom on the first floor?"

 (b) "What social support do you have at home?"

 (c) "Will you be able to afford your oxygen therapy?"

(e) "Are you able to accurately weigh yourself at home?"

Explanation:

Before discharging a client with heart failure (HF), the nurse must ensure the client can safely manage their condition at home. The focus should be on mobility, social support, financial ability to afford necessary treatments, and self-monitoring.

(a) "Are your bedroom and bathroom on the first floor?"

Heart failure patients often experience fatigue and dyspnea, making it difficult to climb stairs. If the bedroom/bathroom is upstairs, the nurse may need to coordinate home modifications or assistive devices.

(b) "What social support do you have at home?" 

Heart failure requires lifestyle modifications and ongoing monitoring. The client may need assistance with daily tasks, medication management, and transportation to follow-up appointments. A lack of social support may require additional resources, such as home health care.

(c) "Will you be able to afford your oxygen therapy?"

Oxygen therapy may be required for some HF patients. If the client cannot afford it, the nurse may need to consult a social worker or case manager to assist with insurance coverage, financial aid, or alternative resources.

(e) "Are you able to accurately weigh yourself at home?" 

Daily weight monitoring is crucial for HF management to detect fluid retention early. The client should have a scale, understand how to use it, and know when to report weight changes. A weight gain of 2-3 lbs in 24 hours or 5 lbs in a week should be reported to a healthcare provider.

Why the Other Option Is Incorrect:

(d) "What spiritual beliefs may impact your recovery?"

While spiritual beliefs are important in holistic care, they do not directly impact the client’s physical safety at home. This question would be more appropriate for emotional and psychosocial assessment, but not as a primary discharge safety question.

Summary:

The correct answers are (a), (b), (c), and (e). These questions help assess mobility, support systems, financial barriers, and self-monitoring abilities, ensuring the client can safely manage their heart failure at home.

Correct Answer:

B) Bag-valve-mask device

Why It Is Correct:

• Competitive neuromuscular blocking agents (NMBAs) cause paralysis, including the diaphragm and respiratory muscles, leading to respiratory arrest if ventilatory support is not provided.


• A bag-valve-mask (BVM) device ensures that the nurse can provide manual ventilation if the client is not adequately ventilated until mechanical ventilation is established or in case of emergency.


• Examples of competitive (non-depolarizing) NMBAs include rocuronium, vecuronium, and pancuronium.

Why the Other Choices Are Incorrect:

1. Central Venous Catheterization Tray
   
   
   
   
   • Incorrect because:
     
     
     
     
     • While central venous access may be used for administering medications, it is not specifically required for neuromuscular blocking agents.
     
     
     • NMBAs can be given through a peripheral IV in most cases.
     
     
     
     
   
   
   
   


2. Urinary Catheter Insertion Tray
   
   
   
   • Incorrect because:
     
     
     
     • While clients receiving long-term paralysis and sedation may require a urinary catheter, it is not an immediate priority when administering an NMBA.
     
     
     • The most critical concern is airway management and ventilation.
     
     
     
     
   
   
   
   


3. Temporary Pacemaker
   
   
   
   • Incorrect because:
     
     
     
     • NMBAs do not directly affect cardiac conduction or rhythm; they work only on skeletal muscles.
     
     
     • A temporary pacemaker is used for conditions like bradyarrhythmias or heart block, which are not caused by neuromuscular blockade.
     
     
     
     
   
   
   
   

Summary:

• Correct Answer: Bag-valve-mask device—ensures manual ventilation in case of respiratory paralysis.


• A central venous catheter is not required for NMBA administration.


• A urinary catheter may be needed later but is not an immediate priority.


• A pacemaker is unnecessary since NMBAs do not affect the heart's electrical activity.

Correct Answer:

A) Providing thorough oral care before and after meals

Explanation:

In stage 3 HIV (AIDS), candidiasis (thrush) is a common opportunistic infection that affects the oral mucosa, skin folds, and genital areas. Proper oral care helps reduce fungal overgrowth, prevent discomfort, and maintain skin integrity by preventing irritation and secondary infections. Brushing with a soft toothbrush, using antifungal mouth rinses (like nystatin), and avoiding irritating foods are key interventions.

Why the Other Choices Are Incorrect:

• B) Administering prophylactic antibiotics:
  
  
  
  
  • Incorrect. Candidiasis is a fungal infection, not a bacterial one, so antibiotics are not effective. In fact, excessive antibiotic use can increase the risk of fungal overgrowth by killing beneficial bacteria.
  
  
  
  


• C) Promoting nutrition and adequate fluid intake:
  
  
  
  • Partially correct but not the best choice. Good nutrition and hydration support immune function and tissue repair, but they do not directly prevent skin breakdown from candidiasis like proper oral care does.
  
  
  
  


• D) Applying skin emollients as needed:
  
  
  
  • Incorrect. While moisturizing the skin can help with dryness and irritation, it does not specifically address candidiasis-related skin breakdown. Antifungal treatments (such as clotrimazole or nystatin) are more appropriate for managing fungal infections.
  
  
  
  

Summary:

For HIV/AIDS patients with candidiasis, thorough oral care (A) is the best nursing intervention to prevent impaired skin integrity, reduce fungal overgrowth, and maintain oral and skin health. Antibiotics are not useful, and while nutrition and skin hydration are helpful, they are not the most direct intervention for candidiasis-related skin risks.

Correct Answers: 

Methylprednisolone

Ciprofloxacin

Golimumab

Explanation:

Methylprednisolone

Methylprednisolone is a corticosteroid used to reduce inflammation during acute flare-ups of ulcerative colitis (UC). It helps suppress the immune response and reduce bowel inflammation, leading to symptom relief. Corticosteroids are generally used short-term due to side effects like osteoporosis, hyperglycemia, and adrenal suppression

Ciprofloxacin

Ciprofloxacin is an antibiotic sometimes used in combination with metronidazole to treat infections or complications such as toxic megacolon, abscesses, or perianal disease in UC. Though not a primary treatment for UC, it can help control bacterial overgrowth and secondary infections.

Golimumab

Golimumab is a TNF-alpha inhibitor (biologic therapy) used in moderate to severe UC when other treatments (like corticosteroids or aminosalicylates) are ineffective. It helps reduce inflammation and maintain remission by blocking tumor necrosis factor-alpha (TNF-α), a key cytokine in inflammation.

Explanation of Incorrect Answers:

Buprofen

NSAIDs like ibuprofen are NOT recommended for ulcerative colitis because they can worsen inflammation and increase the risk of flare-ups. They may also increase the risk of gastrointestinal bleeding in UC patients.

Aspirin

Aspirin is also an NSAID and can worsen UC symptoms by irritating the gastrointestinal mucosa. While some anti-inflammatory drugs are used for UC (e.g., aminosalicylates like mesalamine), aspirin is not one of them.

Sumatriptan

Sumatriptan is a migraine medication (a serotonin receptor agonist) that has no role in treating ulcerative colitis. It does not affect gut inflammation or immune response.

Summary:

Appropriate medications for acute ulcerative colitis flare-ups include methylprednisolone (corticosteroid), ciprofloxacin (antibiotic for infections), and golimumab (biologic therapy for severe cases).

NSAIDs like ibuprofen and aspirin should be avoided as they can worsen symptoms, and sumatriptan is unrelated to UC treatment.

Correct Answer: B. "My shoes fit really tight lately."

Explanation:

Right-sided heart failure (HF) occurs when the right ventricle cannot effectively pump blood to the lungs, leading to systemic venous congestion. This results in fluid retention and peripheral edema, which commonly causes swelling in the feet, ankles, and legs—making shoes feel tighter.

Why the Other Options Are Incorrect:

A. "I sleep with four pillows at night." – This suggests orthopnea, a symptom of left-sided HF, where fluid accumulates in the lungs and worsens when lying flat.

C. "I wake up coughing every night." – Paroxysmal nocturnal dyspnea (PND) and nocturnal coughing are classic signs of left-sided HF, caused by pulmonary congestion.

D. "I have trouble catching my breath." – While shortness of breath (dyspnea) can occur in both left- and right-sided HF, it is more commonly associated with left-sided HF, where fluid backs up into the lungs.

Summary:

Right-sided heart failure primarily leads to systemic congestion, causing symptoms like peripheral edema, weight gain, ascites, and jugular vein distention (JVD). Tight-fitting shoes due to swelling is a key indicator. Left-sided HF, on the other hand, causes pulmonary symptoms like dyspnea, coughing, and orthopnea.

Correct Answer: b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg

Explanation:

This client is the highest priority because hypertension after a coronary artery bypass graft (CABG) can put excessive pressure on the new grafts, increasing the risk of graft failure, bleeding, or even myocardial infarction. The nurse should intervene immediately to prevent complications such as suture line rupture or stroke.

Why the other options are incorrect:

a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours

While nitroglycerin is used to manage chest pain and hypertension, a stable dose with no recent titration suggests the client is stable. This client does not require immediate attention compared to option b.

c. Client who is 1 day post percutaneous coronary intervention (PCI), going home this morning

A discharge-ready client is not a priority, as they are stable and do not require urgent intervention.

d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Dizziness is concerning, but it is not as critical as uncontrolled hypertension in a CABG patient. The nurse can assess this client after addressing the immediate risk of complications in option b.

Summary:

The hypertensive client post-CABG is at the highest risk for serious complications, making them the nurse’s first priority.

Correct Answer:

c. "What do you understand about what happened to you?"

Explanation:

The client’s statement about indigestion could indicate a lack of understanding of their condition. Clients who have experienced a myocardial infarction (MI) may sometimes mistake symptoms of a heart attack (e.g., chest discomfort, indigestion-like pain) for something less serious, like indigestion. By asking "What do you understand about what happened to you?", the nurse can assess the client’s knowledge of their condition and provide the necessary education about symptoms of a heart attack and the importance of managing their diet, risk factors, and overall heart health.

Why the Other Choices Are Incorrect:

a. "Chili is high in fat and calories; it would be a good idea to stop eating it."

While it is true that chili (especially with fatty meats or rich ingredients) may be high in fat and calories, which can affect heart health, simply telling the client to stop eating chili may not address the underlying issue. The nurse should first assess the client’s understanding of their condition and explain the relationship between diet and heart health in a more comprehensive manner.

b. "The provider has prescribed an antacid for you to take every morning."

If the client is experiencing gastrointestinal symptoms like indigestion, an antacid might help. However, the underlying concern is to ensure that the client is not confusing heart-related symptoms (such as chest discomfort) with gastrointestinal issues. This response could mislead the client into thinking that indigestion is the primary cause, rather than considering the potential link to their cardiac event.

d. "When did you start experiencing this indigestion?"

While it’s important to assess the client’s symptoms, this response does not address the client’s potential misunderstanding of their symptoms. It focuses only on the timing of symptoms without directly exploring the client’s understanding of the situation and their knowledge of MI-related symptoms.

Summary:

The correct answer is c. "What do you understand about what happened to you?" This response helps the nurse assess the client’s understanding of their myocardial infarction and provides an opportunity to educate the client about distinguishing between heart attack symptoms and other conditions like indigestion, as well as offering more detailed guidance on managing diet and heart health going forward.