NSG 330: Med-Surge II Exam #1
Question 1:
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
Selected Answer: d. Disorientation and confusion Response Feedback:
In older adults, disorientation or confusio...
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which
clinical manifestation should the nurse expect?
Selected Answer: d. Disorientation and confusion
Response Feedback:
In older adults, disorientation or confusion may be the major manifestation of
myocardial infarction caused by poor cardiac output. Pain manifestations and numbness
and tingling of the arm could also be related to the myocardial infarction. However, the
nurse should be more concerned about the new onset of disorientation or confusion
caused by decreased perfusion.
Question 2:
Ms. Richards, a 39-year-old female, is seen in the Emergency Department for dizziness,
dyspnea, and heart palpitations. Vital Signs: BP 92/58, HR 225/min, RR 24/min; SPO2 90% on
Room Air. Ms. Richards' rhythm on the telemetry monitor and subsequent 12-lead ECG show
Supraventricular Tachycardia (SVT). Which of these is an intervention a nurse may implement
to decrease Ms. Richards’ heart rate?
Selected Answer: My Answer Carotid Massage (Right Answer Valsalva)
Question 3:
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the
possibility of a serious complication from this condition?
Selected Answer: Speech Alterations
Question 4:
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks,
“Why will I need to take anticoagulants for the rest of my life?” How should the nurse respond?
Selected Answer: “Blood clots form more easily in artificial replacement valves.”
Response Feedback:
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can
aggregate easily and initiate the formation of blood clots. The other responses are
inaccurate.
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