A patient is admitted for treatment of aortic stenosis. What findings should the nurse expect when collecting data from this patient? (Select all that apply.)
a. Chest pain
b. Orthopnea
c. Heart murmur
d. Dyspnea on exertion
e. Oxygen saturation 80%
ANS: A, B, C, D
Angina pectoris (chest pain) is the primary symptom that occurs as a result of a lack of oxygen to the myocardium. Other signs and symptoms include a murmur, syncope from dysrhythmias or decreased cardiac output, and heart failure signs and symptoms. Orthopnea, dyspnea on exertion, and fatigue are indicators of left ventricular failure, resulting in pulmonary edema and right sided heart failure. E. A change in oxygen saturation level is not a manifestation of aortic stenosis.
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A nurse is educating a client with peptic ulcer disease (PUD) regarding Helicobacter pylori and its role in PUD. Which statements by the nurse are appropriate to include in the teaching session?
Select all that apply. A) "The bacteria produces enzymes that improves the efficacy of mucous gel in protecting the gastric mucosa." B) "Helicobacter pylori infection is found in about 25% of individuals with PUD." C) "Your inflammatory response to H. pylori contributes to gastric cell damage." D) "H. pylori infection increases production of gastric acids." E) "H. pylori infection is spread by droplets in the air."
The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)
a. Reassessments b. Incident reports c. Initial assessments d. Nursing care provided e. Patient's response of care provided
The nurse is conducting a family counseling session. Which comment made by a parent might indicate psychological abuse?
1) "I just don't know how to help you anymore." 2) "I am having trouble trusting you because you continually lie." 3) "I don't understand why you are so dumb." 4) "I just wish I was able to understand why you are acting this way."