Podcast
Questions and Answers
Which response by a patient indicates they may not be following the prescribed lifestyle changes?
Which response by a patient indicates they may not be following the prescribed lifestyle changes?
- I have no idea what to do next. (correct)
- I am feeling better already.
- What challenges are you facing with the lifestyle changes?
- I don't think I need to change anything. (correct)
What indicates successful patient education for managing hypertension?
What indicates successful patient education for managing hypertension?
- Patient memorizes medication names
- Patient can recite all information
- Family takes complete control of care
- Patient demonstrates understanding and proper technique (correct)
During the initial assessment of a patient with severe hypertension, what should the nurse prioritize?
During the initial assessment of a patient with severe hypertension, what should the nurse prioritize?
- Document family history
- Take a complete medication history
- Schedule routine diagnostic tests
- Notify the physician immediately and prepare for emergency intervention (correct)
Which findings suggest secondary hypertension in a newly diagnosed patient?
Which findings suggest secondary hypertension in a newly diagnosed patient?
Based on fundoscopic examination findings, which nursing diagnosis should be prioritized?
Based on fundoscopic examination findings, which nursing diagnosis should be prioritized?
What is the most important intervention to promote medication adherence in a patient with resistant hypertension?
What is the most important intervention to promote medication adherence in a patient with resistant hypertension?
What nursing diagnosis reflects findings of laterally displaced apical pulse and diminished peripheral pulses?
What nursing diagnosis reflects findings of laterally displaced apical pulse and diminished peripheral pulses?
For a patient with newly diagnosed hypertension and a BMI of 32 kg/m², which intervention should be prioritized?
For a patient with newly diagnosed hypertension and a BMI of 32 kg/m², which intervention should be prioritized?
Which finding would indicate successful management of heart failure?
Which finding would indicate successful management of heart failure?
What topic should be prioritized in a teaching plan for a patient with newly diagnosed heart failure?
What topic should be prioritized in a teaching plan for a patient with newly diagnosed heart failure?
In a patient prescribed spironolactone, which electrolyte should be monitored closely?
In a patient prescribed spironolactone, which electrolyte should be monitored closely?
What is the most appropriate nursing intervention for a heart failure patient with activity intolerance?
What is the most appropriate nursing intervention for a heart failure patient with activity intolerance?
Which nursing diagnosis should be prioritized for a patient with heart failure who reports anxiety about managing the condition at home?
Which nursing diagnosis should be prioritized for a patient with heart failure who reports anxiety about managing the condition at home?
What assessment finding indicates right-sided heart failure is progressing to left-sided heart failure?
What assessment finding indicates right-sided heart failure is progressing to left-sided heart failure?
What amount of weight gain requires immediate reporting to the healthcare provider for a heart failure patient monitoring daily weights?
What amount of weight gain requires immediate reporting to the healthcare provider for a heart failure patient monitoring daily weights?
Which assessment finding for a patient starting on ACE inhibitors requires immediate intervention?
Which assessment finding for a patient starting on ACE inhibitors requires immediate intervention?
Which nursing action should be prioritized when implementing 'Anxiety Reduction' for a CHD patient?
Which nursing action should be prioritized when implementing 'Anxiety Reduction' for a CHD patient?
For a patient with 'Activity Intolerance', which NIC intervention is most appropriate?
For a patient with 'Activity Intolerance', which NIC intervention is most appropriate?
Which educational topic is most important for a patient with 'Ineffective Health Management'?
Which educational topic is most important for a patient with 'Ineffective Health Management'?
Which intervention is suitable for managing chest pain according to SIKI?
Which intervention is suitable for managing chest pain according to SIKI?
Which sign supports a diagnosis of 'Decreased Cardiac Output' using SDKI?
Which sign supports a diagnosis of 'Decreased Cardiac Output' using SDKI?
When implementing 'Heart Care: Rehabilitative', which activity should be included?
When implementing 'Heart Care: Rehabilitative', which activity should be included?
Which intervention is the most important for a patient at risk for decreased cardiac tissue perfusion?
Which intervention is the most important for a patient at risk for decreased cardiac tissue perfusion?
Which outcome is appropriate for evaluating 'Cardiac Care: Acute'?
Which outcome is appropriate for evaluating 'Cardiac Care: Acute'?
Which NOC indicator shows improvement in a patient with Activity Intolerance?
Which NOC indicator shows improvement in a patient with Activity Intolerance?
What complication should a nurse suspect first in a patient presenting with acute coronary syndrome and unstable vital signs?
What complication should a nurse suspect first in a patient presenting with acute coronary syndrome and unstable vital signs?
In a post-MI patient who develops sudden severe chest pain and hypotension, which intervention should be prioritized?
In a post-MI patient who develops sudden severe chest pain and hypotension, which intervention should be prioritized?
Which patient requires immediate intervention based on their symptoms?
Which patient requires immediate intervention based on their symptoms?
What pathophysiological process best explains the sequential troponin changes observed in the patient?
What pathophysiological process best explains the sequential troponin changes observed in the patient?
Which medication interaction could explain lightheadedness and bradycardia in a patient on multiple cardiac medications?
Which medication interaction could explain lightheadedness and bradycardia in a patient on multiple cardiac medications?
Which pathological process explains elevated lab results, including troponin I and BNP in a CHD patient?
Which pathological process explains elevated lab results, including troponin I and BNP in a CHD patient?
Which nursing diagnosis best describes the risk of disease transmission in a TB patient?
Which nursing diagnosis best describes the risk of disease transmission in a TB patient?
What is the priority discharge planning intervention for a TB patient?
What is the priority discharge planning intervention for a TB patient?
What is the most appropriate intervention for a patient struggling with medication adherence?
What is the most appropriate intervention for a patient struggling with medication adherence?
Which assessment finding should be prioritized when a TB patient reports vision changes?
Which assessment finding should be prioritized when a TB patient reports vision changes?
What is the priority intervention to address nutritional status in a TB patient with decreased appetite and weight loss?
What is the priority intervention to address nutritional status in a TB patient with decreased appetite and weight loss?
When caring for a TB patient in isolation, what is the nurse's primary role when family members ask about mask usage?
When caring for a TB patient in isolation, what is the nurse's primary role when family members ask about mask usage?
What is the most important initial nursing action when assessing a TB patient's breathing pattern?
What is the most important initial nursing action when assessing a TB patient's breathing pattern?
What immediate nursing action should be taken for a patient receiving TB treatment who reports yellowing of the skin?
What immediate nursing action should be taken for a patient receiving TB treatment who reports yellowing of the skin?
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Study Notes
Hypertension
- Patient education success: Demonstrates understanding and proper technique
- Hypertensive crisis: High priority nursing action is to notify the physician immediately and prepare for emergency intervention
- Secondary hypertension: Look for elevated BUN, creatinine, and abnormal renal imaging
- Fundoscopic exam findings: Arteriovenous nicking and retinal hemorrhages indicate a priority nursing diagnosis of Risk for ineffective cerebral tissue perfusion
- Resistant hypertension: Most important nursing intervention for promoting medication adherence is teaching about medication timing and possible side effects using teach-back method
- Assessment findings: Laterally displaced apical pulse and diminished peripheral pulses indicate a priority nursing diagnosis of Risk for decreased cardiac output
- BMI of 32 kg/m²: Prioritize weight management interventions for a patient with newly diagnosed hypertension
Coronary Heart Disease (CHD)
- Anxiety Reduction: Create a calm environment
- Activity Intolerance: Prioritize Energy Management (0180)
- Ineffective Health Management: Most important educational topic is risk factor modification
- Chest Pain Management: Observe vital signs
- Penurunan Curah Jantung: Pulsus alternans supports this diagnosis
- Heart Care: Rehabilitative: Progress activity gradually
- Risk for decreased Cardiac Tissue Perfusion: Monitor vital signs
- Cardiac Care: Acute: Appropriate NOC (Nursing Outcome Classification) is Cardiac Pump Effectiveness
- Nyeri Akut: Intensitas nyeri menurun indicates improvement
- Risk for Ineffective Peripheral Tissue Perfusion: Assess peripheral pulses
- Anxiety: Implement Anxiety Reduction (5820) first
- Activity Intolerance: Improved exercise tolerance indicates improvement
Acute Coronary Syndrome
- Suspected complications: Nurse should suspect cardiogenic shock FIRST based on the patient's presentation
- New onset chest pain: Prioritize preparing for pericardiocentesis based on the patient's presentation
- Immediate intervention: Patient 2 requires immediate intervention because they have NSTEMI with new ST changes and diaphoresis
- Troponin levels: Ongoing myocardial necrosis best explains the rising troponin levels
- Medication interactions: Nurse should suspect a Metoprolol and nitroglycerin interaction based on the patient's presentation
- Lab results: Acute myocardial infarction with heart failure explains ALL the findings
Heart Failure
- Successful heart failure management: Decreased peripheral edema indicates successful management
- Newly diagnosed heart failure: Prioritize teaching the patient to recognize worsening symptoms
- Spironolactone: Monitor potassium levels most closely
- Activity intolerance: Plan activities with rest periods
- Anxiety: Prioritize the nursing diagnosis of Ineffective coping
- Right-sided heart failure: Development of crackles indicates progressing to left-sided heart failure
- Weight gain: Immediate reporting to the healthcare provider is required for a 2 pound weight gain in 1 day
- Hepatomegaly: Most likely related to right ventricular failure
- Decreased cardiac output: Monitor hemodynamic parameters
- ACE inhibitors: Immediate intervention is required if the patient's blood pressure is 90/60 mmHg
Tuberculosis (TB)
- SDKI TB Diagnosis: Risk for infection spread
- NIC Discharge Planning: Priority intervention is medication schedule education
- Medication adherence: Prioritize Direct Observed Therapy (DOT)
- Vision changes: Prioritize assessment of visual acuity
- Decreased appetite and weight loss: Prioritize providing high-protein supplements
- TB Isolation: Nurse's primary role is to provide patient education
- Breathing pattern: Most important initial nursing action is to count respiratory rate
- Yellowing of the skin: Notify the physician immediately
- Medication adherence: Most effective approach is return demonstration
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