A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?
"I will call the provider after taking one dose of nitroglycerin."
"I will hold my breath and bear down."
"I will stop what I am doing and lie down."
"I will take two 325 milligram aspirin tablets at the same time.”
The Correct Answer is C
Choice A: While nitroglycerin is a common medication for angina, calling the provider after just one dose is not the recommended action. Nitroglycerin helps relax coronary arteries and improve blood supply to the heart. However, if chest pain persists, the client should follow additional steps..
Choice B: This describes the Valsalva maneuver, which involves holding the breath and bearing down as though straining to initiate a bowel movement. While this technique can regulate heart rhythms and help the ears to pop, it is not the recommended response to chest pain from angina.
Choice C: Correct: This statement demonstrates an understanding of appropriate action. When experiencing angina, the client should stop any physical activity, sit down, or lie down. Resting helps reduce the heart’s workload and allows blood flow to stabilize.
Choice D: Aspirin can be beneficial during angina episodes. However, the recommended dose is usually 162 to 325 milligrams (one tablet). Taking two tablets at once may not be necessary unless specifically advised by a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.
The other options are not appropriate based on the information provided:
- "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
- "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
- "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
- "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.
Correct Answer is D
Explanation
Hair loss is a common side effect of chemotherapy, and it can have a significant impact on the client's self-esteem and body image. The nurse should respond with empathy and provide supportive information and resources to help the client cope with hair loss.
Offering head-covering options such as wigs, scarves, or hats can help the client feel more comfortable and confident during the hair loss process.
The other responses are less appropriate:
- "I can't imagine how difficult it would be to lose my hair." While expressing empathy is important, it is crucial to focus on the client's needs and experiences rather than the nurse's own feelings. This response may unintentionally minimize the client's concerns.
- "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing or minimizing the client's concerns about hair loss can be invalidating and may not address the emotional impact it can have on the client. It is important to provide information and support regarding hair loss management as part of comprehensive care.
- "Let's discuss this when we have more time." This response delays addressing the client's concerns and may leave the client feeling unheard or dismissed. The nurse should make an effort to provide support and information in a timely manner to address the client's needs.
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