The nurse is caring for a client with heart failure and knows that an increase in myocardial oxygen demand is likely the result of which finding?
1. Temperature of 98.6ºF
2. Respirations of 26
3. Blood pressure of 154/98
4. Heart rate of 95
Correct Answer: 3
Rationale 1: A normal temperature does not increase myocardial demand.
Rationale 2: Respirations do not increase myocardial demand.
Rationale 3: High blood pressure requires a higher force of contraction, increasing the heart's myocardial demand.
Rationale 4: High heart rates do increase myocardial demand, but this client's rate is normal.
Global Rationale: High blood pressure requires a higher force of contraction, increasing the heart's myocardial demand. A normal temperature and respirations do not increase myocardial demand. High heart rates do increase myocardial demand, but this client's rate is normal at 95 beats per minute.
You might also like to view...
An older adult may become uncooperative during a mental competency assessment. Reasons for this would not include
a. Feeling defensive b. Having a poor attention span c. Having the nurse focus entirely on the adult d. Feeling he or she is being forced to cooperate
Values clarification can assist the client to clarify his or her own values to facilitate effective decision making. Which of the following nursing activities is incorporated into this intervention?
a. Avoid the use of open-ended questions. b. Use multiple sessions to cross-examine the client to ensure he or she is clear about personal values. c. Use appropriate questions to assist the client in reflecting on the situation and what is personally important. d. Encourage members of the health care team to relate how they would make the decision.
The client is scheduled for a biopsy of a lung lesion. The nurse realizes this type of surgery is classified as being:
a. exploratory. b. reconstructive. c. curative. d. palliative.
A newborn has a hemangioma on the face. What would be important for the nurse to include in patient teaching?
A) Will need surgery to remove B) Will become smaller over the first year of life C) Is made of epithelial cells that form caverns and fill with blood D) Will usually resolve by age 9 years