You are working with an experienced nursing assistant and LPN/LVN in caring for a group of patients. You have developed a nursing diagnosis of Activity Intolerance related to fatigue and chest pain for a patient who had an acute myocardial infarction 3 days ago. Which of these nursing activities included in the care plan is best delegated to the LPN/LVN?

Correct Answer: B

Rationale: In caring for a patient with Activity Intolerance post-myocardial infarction, monitoring pulse, blood pressure, and oxygen saturation before and after ambulation is best delegated to the LPN/LVN. This task involves basic assessment skills within their scope of practice and allows for timely detection of any adverse responses during ambulation, which are crucial in the early identification of complications. Administering nitroglycerin (A) requires a higher level of assessment and decision-making skills typically within the registered nurse's scope. Teaching energy conservation techniques (C) and explaining rationale for rest-exercise alternation (D) involve patient education and critical thinking, making them more appropriate for the registered nurse who can provide comprehensive education and individualized care planning. Educationally, understanding delegation based on scope of practice is vital for safe and effective patient care. LPNs/LVNs play a crucial role in providing direct patient care under the supervision of an RN, and knowing which tasks can be delegated ensures efficient teamwork and optimal patient outcomes. This scenario highlights the importance of clear communication and collaboration among healthcare team members to deliver holistic care.

Correct Answer: B

Rationale: The correct answer is B) Chorea. Chorea is a movement disorder characterized by brief, irregular contractions that are not repetitive or rhythmic, resulting in involuntary, abrupt, rapid, non-stereotyped movements affecting multiple body regions. Chorea is a central nervous system manifestation often associated with conditions such as Huntington's disease. A) Congestive heart failure is primarily a result of the heart's inability to pump blood effectively, leading to fluid overload and subsequent symptoms like edema and shortness of breath. It is not directly related to central nervous system manifestations. C) Valve damage typically results from conditions like infective endocarditis or rheumatic fever, where the heart valves are structurally affected due to infections or autoimmune reactions. While these conditions may have some neurological symptoms, valve damage itself is not a central nervous system manifestation. D) Pericarditis is the inflammation of the pericardium, the sac surrounding the heart. It can be caused by infections, autoimmune diseases, or other underlying conditions. Though pericarditis can lead to chest pain and other symptoms, it is not a direct central nervous system manifestation. Educational context: Understanding the various manifestations of cardiovascular system disorders is crucial in clinical practice. Recognizing the different presentations helps healthcare professionals make accurate diagnoses and provide appropriate treatment. In this case, linking chorea to central nervous system involvement highlights the interconnectedness of different bodily systems and the importance of considering comorbidities in patient care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Mitral stenosis. A P wave notch in the ECG of a client is a classic finding in mitral stenosis. When mitral stenosis is present, left atrial enlargement occurs due to the increased pressure in the left atrium. This enlargement causes a delay in the conduction of the electrical impulse through the atria, resulting in a notch in the P wave on the ECG. Now, let's analyze why the other options are incorrect: A) Aortic stenosis: Aortic stenosis typically presents with a systolic murmur and does not directly impact the P wave on an ECG. B) Mitral regurgitation: Mitral regurgitation may cause an enlarged left atrium, but it does not lead to a P wave notch on the ECG. C) Aortic regurgitation: Aortic regurgitation primarily affects the diastolic phase of the cardiac cycle and is not associated with a P wave notch. Educational context is crucial for healthcare professionals to understand the intricate details of interpreting ECG findings accurately. By grasping these nuances, healthcare providers can make informed clinical decisions and provide optimal care for patients with cardiovascular conditions. Understanding the specific ECG patterns associated with different cardiac pathologies is essential for accurate diagnosis and management.

Correct Answer: D

Rationale: In the context of the cardiovascular system exam question regarding the most common cause of dysrhythmias in a hospitalized client, the correct answer is D) Ischemic heart disease. Ischemic heart disease, such as myocardial infarction, can lead to the development of dysrhythmias due to the damage or inadequate blood supply to the heart muscle. This can disrupt the electrical conduction system of the heart, leading to abnormal heart rhythms. Option A) Hypothermia can cause dysrhythmias by slowing down the electrical impulses in the heart, but it is not as common a cause as ischemic heart disease. Option B) Metabolic acidosis can also lead to dysrhythmias by affecting the electrolyte balance in the body, but it is not as prevalent a cause as ischemic heart disease in a hospitalized client. Option C) Drug therapy can certainly contribute to dysrhythmias as a side effect of certain medications, but again, ischemic heart disease is a more common underlying cause. Educationally, understanding the relationship between ischemic heart disease and dysrhythmias is crucial for healthcare professionals caring for patients with cardiovascular conditions. Recognizing the most common causes of dysrhythmias can aid in prompt identification, appropriate treatment, and improved patient outcomes.

Correct Answer: C

Rationale: In caring for a client with congestive heart failure and decreased cardiac output, it is crucial for nurses to prioritize interventions that support the patient's cardiovascular function. Option C, which is to assess the apical heart rate before administering digitalis, is the correct nursing intervention in this scenario. Digitalis is a medication commonly used to improve cardiac output in patients with heart failure. However, it can also slow down the heart rate and potentially cause adverse effects like bradycardia. Therefore, assessing the patient's heart rate prior to giving digitalis is essential to ensure that the medication is safe to administer at that time. Option A, encouraging activities that engage the Valsalva maneuver, is incorrect in this context. The Valsalva maneuver involves forced exhalation against a closed airway, which can lead to a sudden drop in blood pressure and potentially worsen cardiac output in a patient with heart failure. Option B, encouraging the client to perform exercises, may not be appropriate for a patient with congestive heart failure and decreased cardiac output. While exercise is generally beneficial for heart health, in this particular situation, the patient's cardiac output is already compromised, and engaging in physical activity without proper assessment and monitoring could be harmful. Option D, offering small, frequent feedings, is not directly related to addressing decreased cardiac output in a patient with congestive heart failure. While nutrition is important for overall health, it is not the priority intervention when managing a patient with a cardiac condition that impacts their cardiac output. In an educational context, understanding the rationale behind each nursing intervention is crucial for providing safe and effective care to patients with cardiovascular conditions. Nurses must be able to critically think through the implications of each option and choose the most appropriate intervention based on the patient's specific condition and needs. By knowing the effects of medications like digitalis and the potential complications of certain actions like the Valsalva maneuver, nurses can make informed decisions that promote positive outcomes for their patients.