A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
Encourage active range of motion exercises.
Assist with ambulation in the hallway.
Provide a bedside commode for toileting.
Teach to sleep in a side lying position.
The Correct Answer is C
A. Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B. Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.
C. Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D. Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While bowel function can be affected by medication, it's not a primary indicator of thyroid hormone replacement effectiveness.
B. These are the most important assessments to determine the effectiveness of thyroid replacement therapy. Thyroid hormones influence metabolic rate, which directly affects heart rate and body weight. Changes in these parameters can indicate under- or over-replacement of thyroid hormones.
C. While medication adherence is important, it doesn't directly assess the medication's effectiveness.
D. Dietary intake is important for overall health but is not directly related to thyroid hormone replacement therapy effectiveness.
Correct Answer is D
Explanation
A. Monitoring intake and output can be important for overall fluid management, it is not the most urgent intervention for a client presenting with symptoms suggestive of a stroke or other acute neurological event. The immediate concern should be to evaluate and manage the neurological symptoms rather than focusing on urinary output at this stage.
B. Bilateral intermittent sequential pneumatic compression devices are used to prevent deep vein thrombosis (DVT) in immobile patients. This is not directly relevant to the acute neurological symptoms described and does not address the immediate need for evaluating the cause of the sudden headache and facial droop.
C. While aspirin may be used in some cases to prevent further clot formation in patients with certain types of strokes, administering it without a clear diagnosis and without ruling out contraindications could be harmful. The client needs immediate diagnostic evaluation to determine if a stroke or another condition is present before starting any medication like aspirin.
D. Obtaining a focused history is crucial in the context of sudden onset neurological symptoms. This includes assessing for recent bleeding, trauma, or the use of anticoagulants, which can help in diagnosing and managing conditions like stroke. Understanding the client's medication history and any recent bleeding events is important for guiding appropriate treatment and ensuring safe management.
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