What does the nurse teach the client who has had a mechanical valve placed?

Correct Answer: C

Rationale: The correct answer is C) The INR must be maintained between 2.5 and 3.5 for anticoagulant monitoring. Explanation: When a client has a mechanical valve placed, they require anticoagulation therapy to prevent blood clots. The International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy. For patients with a mechanical valve, the target INR range is higher (2.5-3.5) compared to other conditions to ensure adequate anticoagulation without increasing the risk of bleeding. Why the other options are wrong: A) The PT must remain below 1.5 times the control value - This statement does not accurately reflect the monitoring requirements for anticoagulation in patients with mechanical valves. B) The PTT must be higher than 2.5 times the control value - Partial Thromboplastin Time (PTT) is not the primary test used to monitor anticoagulation in patients with mechanical valves. D) The INR must be maintained below 2.5 for anticoagulant monitoring - This range is too low for patients with mechanical valves and may increase the risk of thrombosis. Educational context: Understanding the specific monitoring requirements for anticoagulation in patients with mechanical valves is crucial for nurses caring for these clients. Proper anticoagulation management can help prevent complications such as thromboembolism or bleeding. Nurses need to educate clients on the importance of regular INR monitoring, adherence to medication regimens, dietary considerations, and signs of potential complications.

Correct Answer: A

Rationale: In right-sided heart failure, the correct symptom observed is dependent pitting edema (Option A). This occurs due to fluid retention and increased venous pressure, leading to swelling in the lower extremities. Exertional dyspnea (Option B) is more commonly associated with left-sided heart failure, where there is a buildup of fluid in the lungs causing difficulty breathing during activity. Orthopnea (Option C) is also a symptom of left-sided heart failure, characterized by difficulty breathing when lying flat. Hemoptysis (Option D) is the coughing up of blood and is not typically associated with heart failure but can be a sign of other serious conditions such as pulmonary embolism or pneumonia. Educationally, understanding the distinct symptoms of left-sided versus right-sided heart failure is crucial for accurate assessment and management of patients with cardiovascular conditions. Recognizing these symptoms helps healthcare professionals provide appropriate interventions and improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) One or more arteries that supply blood to his heart are blocked, thereby preventing an adequate amount of blood from getting to his cardiac muscles. This response is the most appropriate because it directly addresses the patient's condition of myocardial infarction (heart attack). It provides a clear and accurate explanation in simple terms, helping the patient understand the cause of his symptoms. Option A is incorrect because leaving the patient uninformed can increase anxiety and hinder patient-provider communication. It is important to provide basic information to the patient to alleviate fear and facilitate understanding. Option B is incorrect as it refers to a congenital heart condition related to the aortic valve, which is not relevant to the patient's current situation of myocardial infarction. Option C is incorrect and promotes a harmful stereotype that overweight individuals are destined to have a heart attack. This statement lacks medical accuracy and can contribute to patient stigma. Educational context: In healthcare, effective communication with patients is essential for building trust, ensuring informed decision-making, and promoting patient satisfaction. Providing clear and accurate information empowers patients to participate in their care and promotes better health outcomes. Educating patients about their condition in simple language helps them understand the importance of treatment and lifestyle modifications.

Correct Answer: D

Rationale: In the scenario of administering thrombolytic therapy to a patient with an acute myocardial infarction (MI), the primary consideration should be the time since the onset of symptoms, making option D the correct answer. Time is crucial in this situation as thrombolytic therapy is most effective when given promptly after the onset of symptoms to dissolve the blood clot causing the MI and restore blood flow to the heart muscle. Option A, history of heart disease, while important for assessing the patient's overall cardiac health, is not the primary consideration in the acute management of an MI. Option B, sensitivity to aspirin, is relevant for other aspects of treatment but not the primary consideration for thrombolytic therapy administration. Option C, size and location of the MI, is also significant for prognosis and further management but does not take precedence over the urgency of timely thrombolytic therapy. Educationally, understanding the critical importance of timely intervention in acute myocardial infarction highlights the need for healthcare providers to rapidly assess and initiate appropriate treatments to minimize cardiac damage and improve patient outcomes. This knowledge underscores the significance of quick decision-making and action in emergency cardiac care.

Correct Answer: D

Rationale: In the context of a patient with chronic venous insufficiency, the most appropriate nursing diagnosis is "D) Skin Integrity, impaired." This is because chronic venous insufficiency often leads to poor circulation in the lower extremities, which can result in skin breakdown and ulcer formation due to decreased oxygen and nutrient delivery to the tissues. Option A) Activity Intolerance may be a common symptom of chronic venous insufficiency, but it does not address the direct impact on skin integrity that is characteristic of this condition. Option B) Body Image, disturbed may be relevant if the patient is experiencing emotional distress related to changes in physical appearance due to chronic venous insufficiency, but it is not the primary concern from a nursing diagnosis perspective. Option C) Fluid Volume, deficient is not typically associated with chronic venous insufficiency, as this condition is more focused on issues related to venous circulation and skin integrity rather than fluid volume imbalance. Educationally, understanding the rationale behind selecting the correct nursing diagnosis is crucial for providing effective care to patients with chronic venous insufficiency. By focusing on skin integrity, nurses can implement interventions to prevent skin breakdown, promote wound healing, and improve overall patient outcomes in this population. This reinforces the importance of thorough assessment and individualized care planning based on the specific needs of the patient.