A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

"I will take four nitroglycerin sublingual tablets if I have chest pain."

"I will have hot, dry, and flushed skin if I am having a heart attack."

"I will wait 30 minutes before taking action if I have heartburn."

"I will notify emergency response if I have sudden jaw pain."

Answer and Explanation

The Correct Answer is D

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

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Correct Answer is C

Explanation

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter C. Tenderness at the injection site D. Palpable area of induration, greater than 10 mm (0.4 in) in diameter

Correct Answer is D

Explanation

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

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A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

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