The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?

Occurs during stress

Occurs without any EKG changes

Occurs with reversible EKG changes

Occurs at rest

Answer and Explanation

The Correct Answer is D

A. Occurs during stress: This describes stable angina, which is precipitated by predictable stress or exertion.

B. Occurs without any EKG changes: Unstable angina often presents with reversible ischemic EKG changes, such as ST depression or T wave inversion.

C. Occurs with reversible EKG changes: While this is true for unstable angina, it is not the primary differentiator compared to other types of angina.

D. Occurs at rest: Correct. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion, differentiating it from stable angina.

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Correct Answer is D

Explanation

A. Removing the cast correctly at the end of the treatment period. The nurse would not instruct the patient to remove the cast. This should be done by a healthcare provider at the appropriate time.

B. Using crutches efficiently. While crutch use is important, it is secondary to monitoring for impaired circulation, which can have immediate, serious consequences.

C. Exercising joints above and below the cast, as prescribed. This may be part of rehabilitation but does not have the same urgency as monitoring circulation for complications.

D. Reporting signs of impaired circulation. The nurse should emphasize the importance of monitoring for signs of impaired circulation, such as increased pain, numbness, or color changes, which could indicate complications like compartment syndrome or poor blood flow.

A. The client's blood pressure has decreased since the last visit B. The client's liver is enlarged and the abdomen is edematous C. The client has jugular vein distention and 3+ pedal edema D. The client complains of shortness of breath when walking

Correct Answer is D

Explanation

A. The client's blood pressure has decreased since the last visit. Decreased blood pressure is not a typical early sign of mitral valve stenosis.

B. The client's liver is enlarged and the abdomen is edematous. These are signs of more advanced heart failure, which can result from mitral valve stenosis but are not early indicators.

C. The client has jugular vein distention and 3+ pedal edema. Jugular vein distention and pedal edema are later signs of heart failure caused by mitral valve stenosis, not early signs.

D. The client complains of shortness of breath when walking. Shortness of breath on exertion is an early sign of mitral valve stenosis as the left atrium is unable to effectively pump blood into the left ventricle, leading to pulmonary congestion and difficulty breathing.

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The nurse is assessing a client with unstable angina. Which finding would the nurse expect the client to report that differentiates this from other types of anginas?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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