A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

"Everything will be fine. Your family is here for you."

"Don't cry: you have the best team of doctors."

"Tell me what concerns you most."

"Would you like something to calm your nerves?"

Answer and Explanation

The Correct Answer is C

A. "Everything will be fine. Your family is here for you.": This response offers reassurance but does not address or validate the client's specific fears. It may feel dismissive of their emotional distress.
B. "Don't cry: you have the best team of doctors.": Although supportive in intent, this response ignores the client’s emotional expression and can shut down open communication about their fears.
C. "Tell me what concerns you most.": This therapeutic response invites the client to express their feelings and fears openly. It helps build trust and allows the nurse to offer emotional support tailored to the client’s needs.
D. "Would you like something to calm your nerves?": Offering medication may be appropriate later, but it bypasses the opportunity to first explore the client's anxiety through conversation and emotional support.

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Correct Answer is A

Explanation

A. Left lateral: Placing the client in the left lateral decubitus position brings the heart closer to the chest wall, especially the mitral valve. This position enhances the nurse’s ability to hear low-pitched diastolic murmurs like those associated with mitral stenosis.
B. Right lateral: This position does not improve the ability to hear mitral valve sounds. It moves the heart further from the chest wall and is not used for cardiac auscultation purposes.
C. Prone: A prone position is not used for heart assessments and may interfere with effective auscultation. It compresses the chest and limits access to key valve areas.
D. Supine: While commonly used for initial heart assessments, it may not be ideal for detecting low-frequency murmurs. Certain murmurs become more audible when the client is in a specific position, such as the left lateral for mitral stenosis.

A. Maintain activity restriction to bedrest. B. Limit interaction with visitors. C. Avoid heavy meals. D. Arrange personal care supplies nearby.

Correct Answer is A

Explanation

A. Maintain activity restriction to bedrest: Bedrest reduces the heart's workload by minimizing physical exertion, thereby decreasing myocardial oxygen demand. This is crucial in cardiogenic shock, where the heart's pumping ability is severely compromised.
B. Limit interaction with visitors: While excessive stimulation can be stressful, limiting social interaction has a minimal impact on myocardial oxygen consumption compared to physical activity. Emotional support from visitors can actually benefit the client’s overall well-being.
C. Avoid heavy meals: Heavy meals may cause postprandial increases in metabolic demand, but they are not as directly impactful on cardiac workload as restricting physical activity. Meal composition should still be considered, but it's not the most immediate priority.
D. Arrange personal care supplies nearby: Placing supplies within reach helps minimize exertion during ADLs, but this is a supportive measure. Complete activity restriction is a more direct and effective intervention to reduce cardiac oxygen demand in the acute phase.

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A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?

Correct Answer is A

Explanation

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Correct Answer is A

Explanation

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