The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
The nurse will encourage the client to walk thirty minutes every day.
The client will monitor blood glucose and blood pressure after each meal.
The client's daily blood pressure will be less than 140/80 mm Hg this month.
The client's blood pressure readings will be less than 160/90 mm Hg.
The Correct Answer is C
Choice A reason: Encouraging the client to walk thirty minutes every day is a good practice but does not directly relate to the immediate outcome of managing chest pain.
Choice B reason: Monitoring blood glucose and blood pressure is part of ongoing management but is not a specific outcome related to exertional chest pain.
Choice C reason: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.
Choice D reason: A blood pressure reading of less than 160/90 mm Hg is less stringent than current guidelines suggest for optimal control in cardiovascular disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
Correct Answer is C
Explanation
Choice A reason: Asking for specifics about the night nurse's behavior could reinforce the client's splitting behavior, which is not therapeutic.
Choice B reason: Promising to talk to the night nurse may validate the client's negative perception without understanding the full context.
Choice C reason: Focusing on the client's progress and upcoming discharge avoids engaging in a discussion that could reinforce dichotomous thinking.This response is non-confrontational and avoids engaging in the client’s dichotomous thinking. It focuses on the positive aspect of the client’s situation, which is their improvement and discharge from the hospital. It’s important for healthcare professionals to maintain professional boundaries and not reinforce potentially harmful behavior patterns.
Choice D reason: Seeking details about the client's preference for certain staff can encourage splitting behavior and is not beneficial.
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