Hypertension Past Paper PDF

Hypertention 1. A 55-year-old male patient is admitted with a blood pressure of 180/100 mmHg. Which nursing assessment should be prioritized first? A. Checking family history B. Evaluating dietary habits C. Assessing neurological status D. Measuring BMI E. Recording fluid intake 2. A hypertensive p...

Hypertention 1. A 55-year-old male patient is admitted with a blood pressure of 180/100 mmHg. Which nursing assessment should be prioritized first? A. Checking family history B. Evaluating dietary habits C. Assessing neurological status D. Measuring BMI E. Recording fluid intake 2. A hypertensive patient reports taking garlic supplements to lower blood pressure. What is the appropriate nursing response? A. Encourage continuing the supplement B. Immediately advise stopping the supplement C. Document and inform the physician D. Ignore the information as irrelevant E. Recommend doubling the dose 3. During assessment, a hypertensive patient reports frequent nosebleeds. What is the most likely cause? A. Blood thinning medications B. Elevated blood pressure C. Vitamin K deficiency D. Allergic reaction E. Sinus infection 4. A patient with hypertension is prescribed Lisinopril. What should the nurse monitor most closely? A. Potassium levels B. Sodium levels C. Calcium levels D. Magnesium levels E. Phosphate levels 5. When developing a care plan for a newly diagnosed hypertensive patient, which intervention should be prioritized? A. Stress management techniques B. Weight loss program C. Blood pressure monitoring D. Exercise routine E. Dietary modifications 6. A hypertensive patient's blood pressure drops significantly upon standing. What is the appropriate nursing diagnosis? A. Risk for falls related to orthostatic hypotension B. Activity intolerance C. Fluid volume excess D. Anxiety E. Sleep pattern disturbance 7. Which assessment finding would indicate a hypertensive emergency requiring immediate intervention? A. Blood pressure 160/95 mmHg B. Mild headache C. Blurred vision with BP 220/120 mmHg D. Occasional dizziness E. Fatigue 8. In developing a teaching plan for a hypertensive patient, which dietary recommendation should be emphasized first? A. Increasing fiber intake B. Reducing sodium intake C. Adding potassium-rich foods D. Limiting caffeine E. Increasing protein intake 9. A patient with hypertension reports taking their medication only when they "feel bad." What nursing diagnosis is most appropriate? A. Knowledge deficit B. Noncompliance C. Ineffective health maintenance D. Risk-prone health behavior E. Deficient fluid volume 10. Which nursing intervention is most appropriate for a hypertensive patient experiencing stress? A. Prescribe anti-anxiety medication B. Teach deep breathing exercises C. Recommend immediate exercise D. Increase medication dosage E. Suggest bed rest 11. A hypertensive patient's care plan includes lifestyle modifications. Which outcome indicates successful intervention? A. Complete elimination of sodium from diet B. Weight loss of 20 pounds in one week C. Consistent blood pressure readings within target range D. Elimination of all stress factors E. Daily 2-hour exercise sessions 12. During assessment, a hypertensive patient reports morning headaches. What time should the nurse prioritize for blood pressure monitoring? A. Before breakfast B. After lunch C. Before dinner D. At bedtime E. During sleep 13. Which nursing intervention is most appropriate for a hypertensive patient with edema? A. Immediate diuretic administration B. Daily weight monitoring C. Compression stockings application D. Fluid restriction E. Salt supplementation 14. A newly diagnosed hypertensive patient asks about alcohol consumption. What is the most appropriate nursing response? A. Recommend complete abstinence B. Allow occasional drinking C. Advise limiting intake and consulting physician D. Suggest switching to red wine only E. Encourage increased water intake instead 15. When teaching about medication adherence, which strategy should the nurse emphasize first? A. Using a pill organizer B. Setting phone alarms C. Keeping a medication diary D. Taking medications with meals E. Storing medications properly 16. A patient with hypertension shows signs of decreased cardiac output. Which nursing intervention should be prioritized? A. Immediately stop all medications B. Monitor vital signs and peripheral perfusion C. Encourage increased physical activity D. Administer fluid bolus E. Call family members 17. You note "risk for ineffective renal perfusion" as a nursing diagnosis. Which assessment finding supports this? A. Peripheral edema B. Decreased urine output and elevated creatinine C. Increased thirst D. Muscle weakness E. Fatigue 18. When implementing relaxation therapy for a hypertensive patient, which intervention is most appropriate? A. Mandating 8 hours of sleep B. Teaching deep breathing exercises C. Prescribing sleeping pills D. Restricting all activities E. Eliminating all visitors 19. A nurse is teaching a patient about orthostatic hypotension. What position change should be demonstrated? A. Moving from sitting to standing quickly B. Moving from standing to sitting rapidly C. Moving from lying to sitting slowly, then to standing D. Changing positions while holding breath E. Standing up immediately from lying position 20. During medication administration, which nursing intervention is essential for patient safety? A. Give all medications at once B. Check blood pressure before antihypertensive medications C. Administer medications without water D. Skip dose if patient is sleeping E. Double the dose if BP is high 21. A hypertensive patient reports visual disturbances. Which nursing action should be taken first? A. Document the complaint only B. Assess blood pressure immediately C. Wait for doctor's rounds D. Suggest eye exercises E. Provide pain medication 22. In developing a care plan for "ineffective self-health management," which intervention should be included? A. Taking over all patient care decisions B. Teaching blood pressure self-monitoring C. Restricting all patient activities D. Eliminating family involvement E. Mandatory bed rest 23. A nurse is conducting health education about lifestyle modifications. Which topic should be addressed first? A. Advanced exercise programs B. Complex dietary changes C. Simple daily walking routine D. Complete lifestyle overhaul E. Intense weight training 24. When assessing a patient's adherence to antihypertensive treatment, which question is most appropriate? A. "Why don't you take your medications?" B. "Do you ever forget to take your medications?" C. "Don't you care about your health?" D. "Who helps you with your medications?" E. "Are you lazy about taking medications?" 25. A patient shows signs of hypertensive emergency. Which nursing intervention takes priority? A. Complete bed rest B. Immediate BP monitoring and physician notification C. Scheduling routine tests D. Planning discharge E. Family conference 26. In providing sexual health education to a hypertensive patient, which approach is most appropriate? A. Ignore the topic completely B. Refer all questions to the doctor C. Provide private, respectful counseling D. Discuss in front of family members E. Suggest celibacy 27. During fundoscopic examination preparation, which nursing action is essential? A. Bright room lighting B. Having patient look directly at light C. Explaining procedure and ensuring comfort D. Skipping explanation E. Conducting exam while patient is sleeping 28. A nurse is assessing a patient's dietary habits. Which finding indicates need for immediate intervention? A. Occasional fast food consumption B. Daily consumption of high-sodium processed foods C. Weekly restaurant meals D. Monthly food tracking E. Moderate salt use 29. When teaching about home blood pressure monitoring, which instruction is most important? A. Take readings at different times each day B. Measure BP immediately after exercise C. Record readings at consistent times daily D. Skip measurements if feeling well E. Share readings only if elevated 30. A patient reports stress at work affecting blood pressure. Which nursing intervention is most appropriate? A. Suggest immediate job resignation B. Teach stress management techniques C. Prescribe anti-anxiety medication D. Recommend permanent disability E. Ignore the complaint 31. Which nursing documentation best reflects accurate BP measurement technique? A. "BP 160/95, left arm, supine" B. "BP elevated" C. "BP checked" D. "Patient hypertensive" E. "BP normal for patient" 32. A nurse is planning discharge education. Which topic requires most emphasis for preventing complications? A. Maintaining perfect blood pressure B. Recognition of warning signs and symptoms C. Daily weight monitoring D. Hourly BP checks E. Complete activity restriction 33. When implementing the DASH diet, which nursing instruction is most appropriate? A. Eliminate all fats completely B. Increase fruits, vegetables, and whole grains C. Follow liquid diet only D. Fast intermittently E. Eat only organic foods 34. A patient with hypertension is starting a new exercise program. Which nursing assessment is priority? A. Maximum heart rate B. Exercise history and tolerance C. Athletic achievements D. Preferred exercise time E. Exercise equipment availability 35. During medication reconciliation, a patient reports using herbal supplements. What is the appropriate nursing action? A. Ignore the information B. Tell patient to stop immediately C. Document and inform healthcare team D. Encourage increased use E. Remove supplements without telling patient 36. A nurse identifies "Risk for ineffective cerebral tissue perfusion." Which intervention is most important? A. Monitor neurological status regularly B. Restrict all movement C. Maintain complete silence D. Prohibit visitors E. Enforce sleep 37. When teaching about antihypertensive medications, which point should the nurse emphasize? A. Stop medicines if feeling better B. Take extra doses if BP rises C. Consistency in taking medications as prescribed D. Share medicines with family members E. Double dose if one is missed 38. A patient's family asks about genetic factors in hypertension. Which response is most appropriate? A. Ignore the question B. Refer to physician only C. Explain hereditary risk factors and preventive measures D. Dismiss genetic influence E. Suggest genetic testing for everyone 39. During assessment, a patient reports nocturia. Which nursing diagnosis might this symptom support? A. Risk for falls B. Disturbed sleep pattern C. Ineffective health maintenance D. Impaired urinary elimination E. All of the above 40. A nurse is planning care for a patient with peripheral edema. Which intervention should be included? A. Keep legs dependent B. Avoid movement C. Elevate extremities D. Apply heat E. Restrict fluid completely 41. A patient asks about smoking cessation. Which nursing response is most therapeutic? A. "You must quit immediately" B. "Would you like information about quitting resources?" C. "Smoking doesn't affect blood pressure" D. "You're harming yourself" E. "Just try harder to quit" 42. Which assessment finding indicates successful hypertension management? A. BP readings within target range over time B. Complete elimination of all symptoms C. No need for medications D. Perfect diet adherence E. Daily exercise for 3 hours 43. A nurse is teaching about medication side effects. Which instruction is most important? A. Stop medication if any side effect occurs B. Report significant side effects to healthcare provider C. Ignore minor side effects D. Double dose to prevent side effects E. Take medications only when symptomatic 44. During BP monitoring, which factor should the nurse consider? A. Room temperature only B. Patient's arm position and size C. Time of day only D. Patient's mood only E. Cuff color 45. A patient reports dizziness upon standing. Which nursing intervention is priority? A. Ignore the symptom B. Teach postural changes and safety measures C. Recommend bed rest only D. Increase medication dose E. Restrict all movement 46. When documenting patient education, which statement is most appropriate? A. "Education completed" B. "Patient nodded understanding" C. "Patient demonstrates correct BP measurement technique and states warning signs" D. "Given BP handout" E. "Will educate later" 47. A nurse is preparing for discharge planning. Which aspect requires priority attention? A. Transportation arrangements B. Medication management plan C. Future appointment dates D. Patient's work schedule E. Family vacation plans 48. Which outcome indicates effective nursing intervention for anxiety management? A. Patient sleeps continuously B. Patient demonstrates stress reduction techniques C. Patient avoids all stressful situations D. Patient takes anxiety medication only E. Patient stays in bed 49. A nurse is assessing adherence to lifestyle modifications. Which question is most appropriate? A. "Why aren't you following the plan?" B. "What challenges are you facing with the lifestyle changes?" C. "Don't you want to get better?" D. "Are you lazy about exercise?" E. "Who's forcing you to change?" 50. In evaluating the effectiveness of patient education, which finding indicates success? A. Patient can recite all information B. Patient demonstrates understanding and proper technique C. Family takes complete control D. Patient has perfect BP readings E. Patient memorizes medication names 51. A 45-year-old male is admitted with BP 180/110 mmHg, severe headache, and blurred vision. During initial assessment, which nursing action takes highest priority? A. Take a complete medication history B. Notify the physician immediately and prepare for emergency intervention C. Schedule routine diagnostic tests D. Begin teaching about lifestyle modifications E. Document family history 52. The nurse is reviewing laboratory results for a newly diagnosed hypertensive patient. Which combination of findings suggests secondary hypertension? A. Elevated cholesterol and triglycerides B. Elevated serum potassium and blood glucose C. Elevated BUN, creatinine, and abnormal renal imaging D. Low sodium and normal potassium E. Normal BUN and creatinine with elevated lipids 53. During fundoscopic examination of a hypertensive patient, the physician notes arteriovenous nicking and retinal hemorrhages. Which nursing diagnosis should be prioritized based on these findings? A. Acute Pain B. Risk for ineffective cerebral tissue perfusion C. Disturbed visual sensory perception D. Risk for injury E. Anxiety 54. A patient with resistant hypertension has been prescribed multiple medications. Which nursing intervention is most important for promoting medication adherence? A. Having family manage all medications B. Teaching about medication timing and possible side effects using teach-back method C. Suggesting over-the-counter alternatives D. Recommending taking all medications at once E. Advising to skip doses if blood pressure is normal 55. Assessment of a hypertensive patient reveals laterally displaced apical pulse and diminished peripheral pulses. Which nursing diagnosis best reflects these findings? A. Activity intolerance B. Risk for decreased cardiac output C. Ineffective breathing pattern D. Acute pain E. Impaired physical mobility 56. A nurse is developing a teaching plan for a patient with newly diagnosed hypertension. Based on the patient's assessment data showing BMI of 32 kg/m², which intervention should be prioritized? A. Immediate intense exercise program B. Gradual weight reduction through diet and activity modifications C. Complete bed rest D. Fluid restriction E. High-protein diet 57. During assessment, a patient reports taking garlic supplements and herbal teas to "cure" hypertension. What is the most appropriate nursing response? A. Support continued use of all supplements B. Document the use, inform the healthcare team, and educate about evidence-based treatments C. Tell the patient to stop immediately without discussion D. Ignore the information as irrelevant E. Encourage increased supplement use 58. A hypertensive patient's ECG shows left ventricular hypertrophy. Which nursing intervention is most important? A. Monitor for signs of decreased cardiac output B. Restrict all physical activity C. Increase fluid intake D. Administer pain medication E. Prepare for immediate surgery 59. The nurse identifies "Ineffective self-health management" as a priority diagnosis. Which patient statement best supports this diagnosis? A. "I check my blood pressure every morning" B. "Sometimes I forget to take my medicine when I feel good" C. "I follow my low-sodium diet carefully" D. "I walk for 30 minutes most days" E. "I see my doctor regularly for check-ups" 60. A patient with hypertension reports frequent nocturia and demonstrates orthostatic hypotension. Which combination of nursing interventions is most appropriate? A. Fluid restriction and bed rest B. Slow position changes and fall precautions C. Increased fluid intake and exercise D. Salt restriction and rapid mobilization E. Caffeine increase and position changes Coronary heart disease 1. A 55-year-old male patient is admitted with chest pain. During assessment, he describes the pain as "squeezing and heavy" in the substernal area, radiating to his left arm. What type of chest pain is most likely indicated? A. Muscular pain B. Typical anginal pain C. Pleuritic pain D. Gastric pain E. Neuropathic pain 2. A patient with suspected coronary heart disease undergoes diagnostic testing. Which cardiac enzyme is most specific for myocardial damage? A. CK B. Myoglobin C. Troponin D. LDH E. AST 3. A nurse is assessing a patient's risk factors for coronary heart disease. Which risk factor cannot be modified through lifestyle changes? A. Smoking B. Obesity C. Family history D. Physical inactivity E. High cholesterol 4. A 60-year-old female presents with coronary heart disease symptoms. According to WHO data mentioned in the document, what is a significant concern about CHD globally? A. 6.7 million mortality rate B. 3.2 million mortality rate C. 5.1 million mortality rate D. 4.5 million mortality rate E. 2.8 million mortality rate 5. During assessment of a CHD patient, which physical examination finding requires immediate attention? A. Mild anxiety B. Slight fatigue C. Pulsus alternans D. Occasional cough E. Minimal edema 6. A nurse is developing a care plan for a patient with CHD. Which nursing diagnosis takes priority? A. Activity intolerance B. Decreased cardiac output C. Anxiety D. Ineffective health management E. Risk for falls 7. What is the correct normal range for Troponin levels in diagnosing CHD? A. < 0.16 Ug/L B. < 0.25 Ug/L C. < 0.35 Ug/L D. < 0.45 Ug/L E. < 0.55 Ug/L 8. A patient presents with chest pain, and the nurse needs to differentiate between stable and unstable angina. Which classification correctly groups these conditions? A. Chronic vs Acute B. Primary vs Secondary C. Stable Angina vs Acute Coronary Syndrome D. STEMI vs NSTEMI E. Minor vs Major 9. During assessment of a CHD patient, which diagnostic finding would confirm myocardial damage? A. Normal ECG B. Regular pulse C. Pathological Q wave D. Clear chest X-ray E. Normal cardiac enzymes 10. A nurse is educating a patient about CHD prevention. Which intervention should be prioritized for a patient who smokes and has high cholesterol? A. Increasing exercise only B. Smoking cessation and diet modification C. Stress management only D. Weight control only E. Blood pressure monitoring only 11. During ECG monitoring of a CHD patient, which finding indicates a STEMI? A. T wave inversion only B. ST segment depression C. ST segment elevation D. Normal QRS complex E. Regular sinus rhythm 12. A nurse assesses a patient with severe chest pain in the emergency department. Which immediate intervention should be performed first? A. Administer aspirin B. Record 12-lead ECG C. Check vital signs D. Draw blood samples E. Start oxygen therapy 13. What is the prevalence of CHD in women according to Riskesdas 2018 data? A. 1.3% B. 1.4% C. 1.5% D. 1.6% E. 1.7% 14. A patient develops complications after myocardial infarction. Which condition represents the most severe hemodynamic complication? A. Mild arrhythmia B. Cardiogenic shock C. Mild chest pain D. Slight anxiety E. Mild dyspnea 15. During health education, a patient asks about the earliest stage of atherosclerosis. What is the correct response? A. Complicated lesions B. Fatty streak C. Fibrous plaque D. Calcification E. Complete blockage 16. A nurse is teaching about modifiable risk factors. Which combination of risk factors has the strongest impact on CHD development? A. Age and gender B. Smoking and hypertension C. Family history and ethnicity D. Height and weight E. Blood type and genetics 17. A patient's laboratory results show elevated cardiac enzymes. What is the normal range for CKMB? A. < 5 U/L B. < 10 U/L C. < 15 U/L D. < 20 U/L E. < 25 U/L 18. Which assessment finding requires immediate medical intervention in a CHD patient? A. Mild fatigue B. Slight anxiety C. Cardiac tamponade D. Minor sleep disturbance E. Mild appetite changes 19. A nurse is performing cardiac assessment. Which heart sound indicates ventricular dysfunction? A. Normal S1 B. Normal S2 C. Presence of S3 D. Split S2 E. Regular rhythm 20. What is the correct sequence of atherosclerosis development? A. Fatty streak → Fibrous plaque → Complicated lesions B. Complicated lesions → Fatty streak → Fibrous plaque C. Fibrous plaque → Complicated lesions → Fatty streak D. Fatty streak → Complicated lesions → Fibrous plaque E. Fibrous plaque → Fatty streak → Complicated lesions 21. A patient with CHD exhibits diaphoresis and cold, clammy skin. Which condition should the nurse suspect? A. Mild anxiety B. Acute pain response C. Cardiogenic shock D. Normal stress response E. Medication side effect 22. During patient education about CHD prevention, which dietary modification should be emphasized? A. High salt intake B. Low cholesterol diet C. High saturated fat D. Increased sugar intake E. High processed foods 23. Which diagnostic test provides the most definitive evidence of coronary artery blockage? A. ECG B. Chest X-ray C. Cardiac enzymes D. Cardiac catheterization E. Stress test 24. A nurse is documenting integumentary assessment findings in a CHD patient. Which combination of signs indicates poor tissue perfusion? A. Warm, dry skin B. Pink, warm skin C. Pale, diaphoretic skin D. Normal skin temperature E. Regular capillary refill 25. What is the primary goal of cardiac rehabilitation in CHD patients? A. Complete bed rest B. Return to full activity immediately C. Gradual activity progression D. Avoid all exercise E. Immediate strenuous exercise 26. A patient asks about the relationship between diabetes and CHD. What is the correct explanation? A. No relationship exists B. Diabetes is a major risk factor C. Only affects blood sugar D. Temporary connection E. Minor influence only 27. During assessment of chest pain, which characteristic indicates typical angina? A. Sharp, stabbing pain B. Pain improved by movement C. Substernal pressure lasting 5-15 minutes D. Continuous pain for 24 hours E. Pain only in the arm 28. What is the correct nursing intervention for a patient experiencing acute chest pain? A. Encourage exercise B. Position flat in bed C. Provide semi-Fowler's position D. Make patient walk E. Ignore the pain 29. A nurse is preparing a teaching plan about medication adherence. Which aspect should be prioritized? A. Cost of medications B. Importance of regular timing C. Color of pills D. Brand names only E. Random timing acceptable 30. Which diagnostic finding on ECG indicates myocardial ischemia? A. Normal sinus rhythm B. Regular P waves C. ST segment changes D. Normal T waves E. Regular rhythm only 31. A patient presents with acute coronary syndrome. Which set of symptoms requires immediate intervention? A. Mild fatigue only B. Slight cough C. Chest pain with dyspnea and diaphoresis D. Occasional dizziness E. Minor weakness 32. What is the correct method for assessing chest pain in CHD patients? A. PQRST assessment method B. Random questions C. Ignore patient description D. Visual assessment only E. No assessment needed 33. Which nursing intervention is appropriate for a patient with activity intolerance due to CHD? A. Force immediate activity B. Plan gradual activity progression C. Complete bed rest only D. No activity restrictions E. Maximum exercise immediately 34. A nurse is teaching about stress management in CHD. Which strategy should be recommended? A. Ignore stress B. Regular relaxation techniques C. Increase work hours D. Avoid all activities E. Suppress emotions 35. What is the correct sequence of the nursing process in managing a CHD patient? A. Intervention → Assessment → Planning B. Assessment → Diagnosis → Planning → Intervention → Evaluation C. Planning → Assessment → Intervention D. Evaluation → Intervention → Assessment E. Diagnosis → Intervention → Assessment 36. A patient with CHD has the nursing diagnosis "Decreased Cardiac Output" (00029). Which assessment finding best supports this diagnosis? A. Fatigue only B. Pulsus alternans and dyspnea C. Mild anxiety D. Normal heart sounds E. Regular pulse 37. For the nursing diagnosis "Acute Pain" (00132) in a CHD patient, which NOC outcome is most appropriate? A. Pain Control (1605) B. Sleep Enhancement C. Activity Tolerance D. Nutritional Status E. Fluid Balance 38. A nurse implements "Cardiac Care: Acute" (4044) for a CHD patient. Which intervention is most appropriate? A. Ignore vital signs B. Monitor cardiac rhythm and rate C. Encourage strenuous activity D. Withhold medications E. Avoid assessment 39. When implementing "Anxiety Reduction" (5820) for a CHD patient, which nursing action takes priority? A. Ignore patient concerns B. Create a calm environment C. Increase environmental stimuli D. Avoid communication E. Rush interventions 40. A CHD patient has "Activity Intolerance" (00092). Which NIC intervention should be prioritized? A. Energy Management (0180) B. Forced mobilization C. Continuous activity D. No rest periods E. Maximum exercise 41. For a patient with "Ineffective Health Management" (00078), which educational topic is most important? A. Unrelated diseases B. Risk factor modification C. General topics only D. Avoid medication teaching E. Ignore lifestyle changes 42. A nurse documents using SIKI (Standar Intervensi Keperawatan Indonesia). Which intervention is appropriate for chest pain management? A. Observasi tanda-tanda vital B. Abaikan keluhan nyeri C. Dorong aktivitas berat D. Hindari pengkajian E. Tolak pemberian obat 43. Using SDKI (Standar Diagnosis Keperawatan Indonesia), which sign supports "Penurunan Curah Jantung"? A. Nadi teratur B. Pulsus alternans C. Suhu normal D. Tidak ada edema E. Napas normal 44. When implementing "Heart Care: Rehabilitative" (4046), which activity is appropriate? A. Skip medication teaching B. Progress activity gradually C. Avoid exercise D. Ignore diet teaching E. Maximum exertion 45. A patient has the nursing diagnosis "Risk for decreased Cardiac Tissue Perfusion" (00200). Which intervention is most important? A. Monitor vital signs B. Ignore chest pain C. Avoid assessment D. Skip medication E. Force activity 46. Which nursing outcome (NOC) is appropriate for evaluating "Cardiac Care: Acute" (4044)? A. Fluid Balance B. Cardiac Pump Effectiveness C. Sleep Pattern D. Weight Management E. Social Interaction 47. Using SLKI (Standar Luaran Keperawatan Indonesia), which outcome indicates improvement in "Nyeri Akut"? A. Tekanan darah meningkat B. Anxiety memburuk C. Intensitas nyeri menurun D. Napas semakin cepat E. Nadi tidak teratur 48. A nurse is planning care for "Risk for Ineffective Peripheral Tissue Perfusion" (00228). Which assessment takes priority? A. Peripheral pulses B. Patient's mood C. Social history D. Food preferences E. Sleep pattern 49. For a patient with "Anxiety" (00146), which NIC intervention should be implemented first? A. Ignore concerns B. Anxiety Reduction (5820) C. Force socialization D. Avoid explanation E. Rush procedures 50. When evaluating "Activity Intolerance" (00092), which NOC indicator shows improvement? A. Worsening fatigue B. Increased chest pain C. Improved exercise tolerance D. Declining vital signs E. Increased anxiety 51. A 68-year-old male with acute coronary syndrome presents with the following symptoms: - Chest pain score 8/10 - BP 90/60 mmHg - Heart rate 110 bpm - SpO2 89% - Cold, clammy skin - ST-elevation on ECG Which complication should the nurse suspect FIRST? A. Stable angina B. Cardiac tamponade C. Cardiogenic shock D. Pericardial effusion E. Heart failure 52. During morning assessment, a post-MI patient suddenly develops: - New onset severe chest pain - ST depression on monitor - Hypotension - Muffled heart sounds The nurse should prioritize which intervention? A. Administer scheduled medications B. Prepare for pericardiocentesis C. Record 12-lead ECG D. Start deep breathing exercises E. Perform cardiac rehabilitation 53. A nurse is caring for multiple cardiac patients. Which patient requires IMMEDIATE intervention? Patient 1: Stable angina, pain score 3/10 Patient 2: NSTEMI with new ST changes and diaphoresis Patient 3: Post-MI day 3, stable vital signs Patient 4: Chronic CHD with well-controlled symptoms Patient 5: Awaiting cardiac catheterization, stable A. Patient 1 B. Patient 2 C. Patient 3 D. Patient 4 E. Patient 5 54. A coronary care nurse observes these sequential changes in a patient: Hour 1: Troponin 0.05 ng/mL Hour 3: Troponin 0.89 ng/mL Hour 6: Troponin 2.56 ng/mL ECG shows ST elevation in leads V1-V4 Which pathophysiological process best explains these findings? A. Gradual atherosclerosis development B. Stable plaque formation C. Ongoing myocardial necrosis D. Normal cardiac enzyme variation E. Reversible ischemia 55. A CHD patient is receiving multiple medications: - Metoprolol - Aspirin - Clopidogrel - Atorvastatin - Nitroglycerin The patient develops lightheadedness and bradycardia. Which medication interaction should the nurse suspect? A. Aspirin and clopidogrel B. Metoprolol and nitroglycerin C. Atorvastatin and aspirin D. Clopidogrel and atorvastatin E. Nitroglycerin and aspirin 56. A nurse is analyzing these lab results in a CHD patient: - Troponin I: 2.8 ng/mL (↑) - CK-MB: 45 U/L (↑) - BNP: 890 pg/mL (↑) - D-dimer: 850 ng/mL (↑) - WBC: 12,000/μL (↑) Which pathological process explains ALL these findings? A. Stable angina B. Acute pulmonary embolism C. Acute myocardial infarction with heart failure D. Chronic stable CHD E. Unstable angina 57. A post-cardiac catheterization patient exhibits: - Right arm numbness - Decreased radial pulse - Cool extremity - Color changes The catheterization was performed via: A. Radial approach The nurse should FIRST: A. Elevate the arm B. Apply warm compress C. Notify physician immediately D. Continue monitoring E. Remove compression device 58. During discharge teaching for a STEMI patient, which combination of medications requires the MOST careful instruction due to potential serious interactions? A. ACE inhibitor + Beta blocker B. Aspirin + Warfarin + Clopidogrel C. Statin + Beta blocker D. Nitroglycerin + ACE inhibitor E. Calcium channel blocker + Statin 59. A nurse is monitoring a patient after thrombolytic therapy. Which assessment finding indicates the MOST serious complication? A. Small bruise at injection site B. Mild headache C. Decreasing blood pressure D. Neurological changes and severe headache E. Slight nausea 60. The cardiac monitor shows new onset rapid atrial fibrillation in a post-MI patient. The patient is experiencing: - Chest pain - BP 85/50 mmHg - Anxiety - Cool extremities Which sequence of interventions should the nurse prioritize? A. ECG → Oxygen → Notify MD → Prepare for cardioversion B. Prepare for cardioversion → ECG → Oxygen → Notify MD C. Notify MD → ECG → Prepare for cardioversion → Oxygen D. Oxygen → Notify MD → ECG → Prepare for cardioversion E. ECG → Notify MD → Oxygen → Prepare for cardioversion Heart Failure 1. A 65-year-old patient is admitted with heart failure NYHA Class III. During assessment, the nurse notes crackles in both lung bases, +3 peripheral edema, and dyspnea. What is the priority nursing diagnosis? A. Activity intolerance B. Decreased cardiac output C. Anxiety D. Impaired gas exchange E. Risk for falls 2. The nurse is assessing a patient with newly diagnosed heart failure. Which finding would indicate right-sided heart failure? A. Pulmonary edema B. Jugular vein distention C. Left ventricular heave D. Paroxysmal nocturnal dyspnea E. Pink frothy sputum 3. A patient with heart failure has a nursing diagnosis of decreased cardiac output. Which nursing intervention should be prioritized? A. Administering prescribed diuretics B. Encouraging rest between activities C. Monitoring vital signs and hemodynamics D. Teaching about sodium restriction E. Performing passive range of motion exercises 4. A heart failure patient is receiving furosemide (Lasix). Which assessment finding requires immediate notification of the physician? A. Blood pressure 100/60 mmHg B. Potassium level 3.0 mEq/L C. Respiratory rate 20/minute D. Urine output 50 mL/hour E. Heart rate 88 beats/minute 5. The nurse is teaching a patient with Stage C heart failure about fluid restrictions. What is the recommended daily fluid intake? A. 1000 mL/day B. 1500 mL/day C. 2000 mL/day D. 2500 mL/day E. 3000 mL/day 6. A patient with heart failure reports orthopnea. Which nursing intervention would be most appropriate? A. Placing the patient in Trendelenburg position B. Elevating the head of bed 30-45 degrees C. Having the patient lie flat for examination D. Encouraging deep breathing exercises E. Administering supplemental oxygen 7. Which assessment finding indicates the effectiveness of prescribed ACE inhibitors in a heart failure patient? A. Decreased peripheral edema B. Improved exercise tolerance C. Reduced blood pressure D. Increased urine output E. Normal heart sounds 8. A nurse is developing a care plan for a patient with heart failure. Which nursing outcome (NOC) would be most appropriate for the diagnosis of activity intolerance? A. Vital Sign Status B. Activity Tolerance C. Energy Conservation D. Cardiac Pump Effectiveness E. Self-Care: Activities of Daily Living 9. When teaching a heart failure patient about daily weight monitoring, which instruction is most important? A. Weigh after breakfast B. Use different scales for accuracy C. Weigh at the same time daily D. Record weight weekly E. Weigh after exercise 10. A patient with heart failure has a B-type natriuretic peptide (BNP) level of 900 pg/mL. What does this indicate? A. Normal heart function B. Mild heart failure C. Moderate heart failure D. Severe heart failure E. False positive result 11. Which nursing intervention is most appropriate for a heart failure patient with a nursing diagnosis of fatigue? A. Encouraging continuous activity B. Scheduling activities during peak energy C. Limiting all physical activity D. Performing all care for the patient E. Recommending caffeine intake 12. A nurse is assessing a patient with heart failure. Which finding suggests fluid overload? A. Weight loss of 2 kg in 24 hours B. Clear breath sounds C. Decreased jugular venous pressure D. +2 pitting edema in ankles E. Normal heart sounds 13. What is the primary goal of cardiac resynchronization therapy (CRT) in heart failure patients? A. Reduce blood pressure B. Improve ventricular contractility C. Prevent arrhythmias D. Decrease heart rate E. Increase cardiac output 14. A patient with heart failure is prescribed digoxin. Which lab value should the nurse monitor most closely? A. Sodium B. Potassium C. Calcium D. Magnesium E. Chloride 15. Which nursing intervention is most appropriate for a heart failure patient with impaired gas exchange? A. Encouraging deep breathing exercises B. Placing in supine position C. Restricting fluid intake D. Administering pain medication E. Performing passive ROM exercises 16. A patient with heart failure reports being unable to sleep flat and needs 3 pillows at night. What term best describes this condition? A. Dyspnea B. Orthopnea C. Tachypnea D. Apnea E. Paroxysmal nocturnal dyspnea 17. The nurse is assessing a heart failure patient's jugular venous pressure (JVP). At what degree should the head of bed be elevated for accurate measurement? A. 15 degrees B. 30 degrees C. 45 degrees D. 60 degrees E. 90 degrees 18. A patient with heart failure has the nursing diagnosis "excess fluid volume." Which nursing outcome (NOC) is most appropriate? A. Nutritional Status B. Fluid Balance C. Cardiac Pump Effectiveness D. Vital Sign Status E. Activity Tolerance 19. A heart failure patient's family asks about dietary restrictions. What is the maximum recommended daily sodium intake? A. 1000 mg/day B. 2000 mg/day C. 3000 mg/day D. 4000 mg/day E. 5000 mg/day 20. Which assessment finding indicates deterioration in a patient with heart failure? A. Increased exercise tolerance B. Weight loss of 2 kg in 24 hours C. Decreased jugular venous distention D. Resolution of peripheral edema E. Improved breath sounds 21. The nurse is teaching a patient about beta-blocker therapy. Which statement indicates the patient understands the teaching? A. "I should stop the medication if I feel better" B. "I need to monitor my pulse daily" C. "I can double the dose if symptoms worsen" D. "The medication will increase my heart rate" E. "I should take the medication only when needed" 22. A patient with heart failure has an ejection fraction of 25%. Which NYHA classification would this most likely correspond to? A. Class I B. Class II C. Class III D. Class IV E. Cannot be determined by ejection fraction alone 23. Which nursing intervention is most important for preventing digitalis toxicity? A. Monitoring serum potassium levels B. Checking blood pressure daily C. Assessing respiratory rate D. Measuring daily weight E. Recording fluid intake 24. A heart failure patient develops acute pulmonary edema. What is the priority nursing intervention? A. Administering prescribed diuretics B. Positioning patient upright C. Providing emotional support D. Measuring vital signs E. Recording intake and output 25. Which finding would indicate successful management of heart failure? A. Increased use of accessory muscles B. Decreased peripheral edema C. Elevated jugular venous pressure D. Presence of S3 heart sound E. Decreased urine output 26. A nurse is developing a teaching plan for a patient with newly diagnosed heart failure. Which topic should be addressed first? A. Long-term prognosis B. Medication schedule C. Recognition of worsening symptoms D. Exercise recommendations E. Dietary modifications 27. A patient with heart failure is prescribed spironolactone. Which electrolyte should be monitored most closely? A. Sodium B. Potassium C. Calcium D. Magnesium E. Chloride 28. What is the most appropriate nursing intervention for a heart failure patient with activity intolerance? A. Encouraging complete bed rest B. Planning activities with rest periods C. Performing all activities for the patient D. Promoting continuous activity E. Restricting all physical activity 29. A patient with heart failure reports anxiety about managing the condition at home. Which nursing diagnosis should be prioritized? A. Ineffective coping B. Knowledge deficit C. Fear D. Powerlessness E. Social isolation 30. Which assessment finding indicates right-sided heart failure is progressing to left-sided heart failure? A. Decreased peripheral edema B. Improved jugular venous pressure C. Development of crackles D. Resolution of ascites E. Decreased liver size 31. The nurse is teaching a patient about monitoring daily weights. What amount of weight gain requires immediate reporting to the healthcare provider? A. 1 pound in 1 day B. 2 pounds in 1 day C. 3 pounds in 1 week D. 4 pounds in 1 month E. 5 pounds in 2 months 32. A patient with heart failure has developed hepatomegaly. This finding is most likely related to: A. Left ventricular failure B. Right ventricular failure C. Pulmonary edema D. Renal dysfunction E. Respiratory failure 33. Which intervention is most appropriate for a heart failure patient with the nursing diagnosis "decreased cardiac output"? A. Administering prescribed oxygen B. Monitoring hemodynamic parameters C. Encouraging deep breathing exercises D. Providing frequent rest periods E. Restricting fluid intake 34. A patient with heart failure is started on ACE inhibitors. Which assessment finding requires immediate intervention? A. Heart rate of 82 beats/minute B. Respiratory rate of 18/minute C. Blood pressure of 90/60 mmHg D. Temperature of 37.2°C E. Oxygen saturation of 95% 35. What is the most appropriate nursing intervention for a heart failure patient with fatigue? A. Clustering care activities B. Encouraging continuous activity C. Promoting complete bed rest D. Performing all care activities E. Limiting family visits 36. A heart failure patient has been prescribed carvedilol. Which statement by the patient indicates understanding of the medication? A. "I should stop the medication if I feel dizzy" B. "The medication will immediately improve my symptoms" C. "I need to take this medication exactly as prescribed" D. "I can skip doses when I feel better" E. "This medication will increase my heart rate" 37. Which nursing intervention is most appropriate for a heart failure patient with impaired gas exchange? A. Maintaining supine position B. Encouraging deep breathing C. Restricting fluid intake D. Promoting continuous activity E. Administering pain medication 38. A patient with heart failure reports difficulty sleeping at night due to breathing problems. Which position should the nurse recommend? A. Flat on back B. Right side-lying C. Left side-lying D. Semi-Fowler's position E. Trendelenburg position 39. Which finding would indicate successful management of fluid volume excess in a heart failure patient? A. Increased peripheral edema B. Decreased urine output C. Weight gain D. Decreased jugular venous distention E. Increased crackles 40. A nurse is planning discharge teaching for a heart failure patient. Which topic should be prioritized? A. Long-term prognosis B. Warning signs of worsening condition C. Exercise recommendations D. Dietary preferences E. Sleep habits 41. Which nursing intervention is most appropriate for a heart failure patient with the nursing diagnosis "ineffective breathing pattern"? A. Encouraging deep breathing exercises B. Maintaining flat position C. Promoting continuous activity D. Restricting fluid intake E. Administering pain medication 42. A patient with heart failure is prescribed digoxin. Which finding requires immediate notification of the physician? A. Heart rate 58 beats/minute B. Blood pressure 120/80 mmHg C. Respiratory rate 18/minute D. Temperature 37°C E. Oxygen saturation 96% 43. Which assessment finding indicates worsening left-sided heart failure? A. Peripheral edema B. Jugular vein distention C. Paroxysmal nocturnal dyspnea D. Hepatomegaly E. Ascites 44. A nurse is developing an exercise plan for a heart failure patient. Which statement is most appropriate? A. "Exercise as much as possible without resting" B. "Stop activity if you experience chest pain" C. "Continue exercising even if you feel short of breath" D. "Exercise only in the evening" E. "Avoid all physical activity" 45. Which nursing intervention is most appropriate for a heart failure patient with anxiety? A. Administering sedatives immediately B. Restricting family visits C. Providing information about condition D. Encouraging continuous activity E. Promoting complete bed rest 46. A patient with heart failure is prescribed a low-sodium diet. Which food choice indicates understanding of dietary restrictions? A. Canned soup B. Fresh fruits C. Processed meats D. Frozen dinners E. Pickled vegetables 47. Which assessment finding indicates the need for immediate intervention in a heart failure patient? A. Oxygen saturation 95% B. Heart rate 82 beats/minute C. Respiratory rate 28/minute D. Temperature 37.2°C E. Blood pressure 118/78 mmHg 48. A nurse is teaching a heart failure patient about fluid restrictions. Which statement by the patient indicates understanding? A. "I should drink whenever I feel thirsty" B. "I need to measure and record my fluid intake" C. "I can drink as much as I want if I take my diuretics" D. "Fluid restrictions only apply to water" E. "I should avoid all fluids" 49. Which nursing intervention is most appropriate for a heart failure patient with the nursing diagnosis "knowledge deficit"? A. Providing written materials only B. Teaching during acute symptoms C. Using complex medical terminology D. Assessing learning needs first E. Delegating teaching to family members 50. A patient with heart failure is being discharged. Which instruction should be prioritized? A. Follow up appointment schedule B. Medication side effects C. Signs and symptoms requiring emergency care D. Exercise recommendations E. Dietary restrictions TBC 1. A 45-year-old patient is diagnosed with pulmonary TB. During the assessment, the nurse found a productive cough with blood-tinged sputum. What is the priority nursing diagnosis for this patient? A. Risk for infection transmission B. Ineffective breathing pattern C. Ineffective airway clearance D. Activity intolerance E. Acute pain 2. During the initial assessment of a TB patient, which finding should prompt immediate isolation? A. Night sweats B. Weight loss C. Hemoptysis D. Fatigue E. Low-grade fever 3. A patient with TB is prescribed Isoniazid (INH). What key nursing intervention is most important? A. Monitor liver function tests B. Check blood pressure daily C. Monitor blood glucose D. Check kidney function E. Monitor platelet count 4. Which nursing intervention is most appropriate for a TB patient with ineffective breathing pattern? A. Administer bronchodilators as needed B. Position patient in high Fowler's position C. Encourage deep breathing exercises D. Apply oxygen therapy immediately E. Perform chest physiotherapy 5. A TB patient reports difficulty sleeping due to night sweats. What is the appropriate nursing intervention?  A. Administer sleep medication B. Provide fresh linens and gowns as needed C. Increase room temperature D. Reduce fluid intake at night E. Apply cooling blanket 6. What is the most important health teaching topic for a newly diagnosed TB patient? A. Importance of medication adherence B. Proper hand washing technique C. Dietary modifications D. Exercise restrictions E. Sleep positioning 7. A patient with TB shows signs of peripheral neuropathy. Which medication is likely causing this side effect? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol E. Streptomycin 8. Which assessment finding indicates successful TB treatment? A. Weight gain B. Decreased appetite C. Increased coughing D. Night sweats resolution E. Negative sputum culture 9. What is the priority nursing intervention for a TB patient with malnutrition? A. Provide high-calorie supplements B. Force fluid intake C. Monitor daily weight D. Administer tube feeding E. Restrict sodium intake 10. A nurse is caring for a patient with active TB. Which PPE is most essential? A. Surgical mask B. N95 respirator  C. Face shield D. Gloves E. Gown 11. What is the most appropriate NOC outcome for a TB patient with knowledge deficit? A. Knowledge: Disease Process B. Knowledge: Health Behaviors C. Knowledge: Treatment Regimen D. Knowledge: Infection Control E. Knowledge: Medication 12. A TB patient shows poor medication adherence. Which nursing intervention is most appropriate? A. Directly observed therapy B. Written medication schedule C. Family education D. Pill counting E. Medication reminders 13. Which assessment finding indicates TB treatment failure? A. Persistent positive sputum after 3 months B. Weight gain C. Improved appetite D. Decreased cough E. Resolution of night sweats 14. A patient with TB complains of orange-colored urine. Which medication is causing this side effect? A. Isoniazid B. Rifampin C. Pyrazinamide D. Ethambutol E. Streptomycin 15. What is the priority nursing intervention for a TB patient with hemoptysis? A. Position patient in high Fowler's B. Administer oxygen therapy C. Monitor vital signs  D. Notify physician immediately E. Prepare for emergency intubation 16. Which nursing diagnosis is most appropriate for a TB patient with persistent fatigue? A. Activity intolerance B. Fatigue C. Sleep pattern disturbance D. Ineffective breathing pattern E. Imbalanced nutrition 17. A TB patient reports vision changes. Which medication should be suspected? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol E. Streptomycin 18. What is the most important teaching point for TB patients regarding infection control? A. Hand washing technique B. Proper cough etiquette C. Room ventilation D. Mask wearing E. Disposal of tissues 19. Which nursing intervention is most appropriate for a TB patient with weight loss? A. High-protein diet B. Frequent small meals C. Nutritional supplements D. Force fluids E. All of the above 20. A TB patient shows signs of liver dysfunction. Which medication should be held? A. Isoniazid B. Streptomycin C. Ethambutol D. Amikacin E. Kanamycin 21. What is the most appropriate NIC intervention for a TB patient with ineffective airway clearance? A. Airway Management B. Oxygen Therapy C. Positioning D. Vital Signs Monitoring E. Medication Administration 22. Which assessment finding indicates miliary TB? A. Localized chest pain B. Productive cough C. Widespread small nodules on chest x-ray D. Pleural effusion E. Cavitary lesions 23. What is the priority nursing intervention for a TB patient with social isolation? A. Encourage family visits with proper precautions B. Provide diversional activities C. Facilitate phone calls D. Arrange for social worker consultation E. Promote rest periods 24. Which laboratory value should be monitored most closely in a patient taking Isoniazid? A. Complete blood count B. Liver function tests C. Kidney function tests D. Electrolytes E. Coagulation profile 25. A TB patient reports joint pain. Which medication is likely causing this side effect? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol E. Streptomycin 26. A 45-year-old patient is admitted with pulmonary TB diagnosis. The assessment reveals productive cough, fatigue, and night sweats. The patient is receiving Isoniazid therapy. What is the main role of Isoniazid in TB treatment? A. Bacterial cell wall synthesis inhibition B. Protein synthesis inhibition C. DNA synthesis inhibition D. RNA synthesis inhibition E. Mycolic acid synthesis inhibition 27. A 38-year-old female patient with TB reports experiencing orange-colored urine after taking medication. The nurse explains this is a normal side effect. Which nursing role has been demonstrated? A. Care provider B. Educator C. Advocate D. Coordinator E. Researcher 28. During the assessment of a TB patient, the nurse found decreased breath sounds and dullness to percussion. What is the most likely underlying pathophysiological mechanism? A. Airway inflammation B. Pleural effusion C. Bronchial obstruction D. Alveolar collapse E. Parenchymal scarring 29. A patient with pulmonary TB shows signs of peripheral neuropathy. Laboratory tests reveal decreased vitamin B6 levels. Which medication is most likely causing this side effect? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol E. Streptomycin 30. The nurse is planning care for a TB patient with ineffective airway clearance. According to SIKI, what is the primary nursing intervention? A. Administer bronchodilators B. Teach effective coughing techniques  C. Position patient in high Fowler's D. Perform chest physiotherapy E. Monitor oxygen saturation 31. A TB patient reports difficulty sleeping due to persistent cough. Based on NANDA nursing diagnosis, what is the priority problem? A. Disturbed sleep pattern B. Activity intolerance C. Ineffective breathing pattern D. Anxiety E. Acute pain 32. The nurse is assessing a patient's understanding of TB medication adherence. Which NOC outcome indicator best evaluates this? A. Knowledge: Medication B. Treatment Behavior: Illness C. Symptom Control D. Health Beliefs E. Self-Care: Medication Management 33. A 50-year-old male patient with TB presents with hemoptysis. What is the priority nursing intervention? A. Administer oxygen therapy B. Position patient laterally C. Monitor vital signs D. Position in high Fowler's E. Prepare for intubation 34. Following TB medication administration, a patient develops joint pain. Which medication is most likely responsible? A. Isoniazid B. Rifampin C. Pyrazinamide D. Ethambutol E. Streptomycin 35. A nurse is teaching a TB patient about infection prevention. According to SIKI, what is the most important point to emphasize?  A. Hand hygiene B. Proper cough etiquette C. Medication adherence D. Nutrition E. Exercise 36. During assessment, a TB patient shows signs of malnutrition. What is the pathophysiological basis for weight loss in TB? A. Increased metabolic rate B. Decreased appetite C. Medication side effects D. Psychological stress E. Nutrient malabsorption 37. The nurse is documenting care for a TB patient. Which nursing diagnosis from SDKI best describes the risk of disease transmission? A. Risk for infection spread B. Ineffective protection C. Impaired host defense D. Risk for contamination E. Compromised family coping 38. A TB patient is preparing for discharge. According to NIC, what is the priority discharge planning intervention? A. Medication schedule education B. Follow-up appointment scheduling C. Nutrition counseling D. Exercise planning E. Environmental modification 39. The nurse observes a patient having difficulty with medication adherence. What is the most appropriate intervention based on SIKI? A. Directly observed therapy B. Written medication schedule C. Family education D. Medication reminders E. Simplified regimen 40. A patient with TB reports vision changes. Which assessment finding should the nurse prioritize? A. Visual acuity B. Color vision C. Peripheral vision D. Eye movement E. Pupillary response 41. A 55-year-old patient is admitted with pulmonary TB. The nurse finds decreased appetite and weight loss of 5kg in the past month. According to NANDA, what is the priority nursing intervention to address the nutritional status? A. Monitor daily weight B. Provide high-protein supplements C. Recommend small, frequent meals D. Force fluid intake E. Administer parenteral nutrition 42. A nurse is caring for a TB patient in isolation. The family asks why they need to wear masks when visiting. What is the nurse's primary role in this situation? A. Implementing safety protocols B. Providing patient education C. Managing infection control D. Coordinating care E. Advocating for patient rights 43. In assessing a TB patient's breathing pattern, what is the most important initial nursing action? A. Count respiratory rate B. Observe breathing depth C. Check oxygen saturation D. Auscultate breath sounds E. Measure peak flow rate 44. A patient receiving TB treatment reports yellowing of the skin. What immediate nursing action should be taken? A. Stop medication administration B. Monitor vital signs C. Notify the physician immediately  D. Increase fluid intake E. Check urine color 45. A nurse is teaching a TB patient about medication adherence. What is the most effective approach according to evidence-based practice? A. Written instructions B. Verbal explanation C. Demonstration method D. Return demonstration E. Visual aids 46. A patient with TB shows signs of peripheral neuropathy. Which vitamin supplement is most appropriate to prevent this complication? A. Vitamin B1 B. Vitamin B6 C. Vitamin B12 D. Vitamin C E. Vitamin D 47. The nurse assesses a TB patient's cough. Which finding indicates the most serious complication? A. Dry cough B. Productive cough C. Blood-tinged sputum D. Yellow sputum E. Morning cough 48. A 40-year-old TB patient reports fatigue and weakness. What nursing approach best addresses this problem? A. Encourage complete bed rest B. Plan graduated activity C. Provide assistive devices D. Restrict all activities E. Schedule rest periods 49. During medication administration, a TB patient complains of joint pain. Which medication is most likely causing this side effect? A. Isoniazid  B. Rifampin C. Pyrazinamide D. Ethambutol E. Streptomycin 50. A nurse is preparing discharge education for a TB patient. What is the most important topic to address? A. Diet modifications B. Activity restrictions C. Medication schedule D. Follow-up appointments E. Infection prevention 51. The family of a TB patient asks about home care management. What is the nurse's priority teaching point? A. Room ventilation B. Separate utensils C. Mask wearing D. Hand hygiene E. Sputum disposal 52. A patient on TB treatment shows signs of liver dysfunction. What is the most important laboratory value to monitor? A. ALT/AST levels B. Bilirubin C. Albumin D. Prothrombin time E. Alkaline phosphatase 53. During assessment, a TB patient demonstrates correct cough etiquette. What nursing outcome has been achieved? A. Knowledge of disease transmission B. Effective airway clearance C. Improved self-care D. Infection prevention E. Symptom management 54. A nurse is reviewing a TB patient's medication regimen. What is the most important aspect to assess? A. Time of administration B. Drug interactions C. Side effects understanding D. Storage requirements E. Cost implications 55. A patient with TB experiences anxiety about the treatment duration. What is the most appropriate nursing intervention? A. Provide emotional support B. Explain treatment rationale C. Refer to counseling D. Teach relaxation techniques E. Involve family support 56. A 42-year-old patient with TB reports difficulty completing daily activities. According to NANDA, what is the most appropriate nursing diagnosis? A. Impaired physical mobility B. Activity intolerance C. Fatigue D. Self-care deficit E. Sleep pattern disturbance 57. A nurse identifies a patient's risk factors for TB treatment non-compliance. What is the most appropriate intervention based on evidence-based practice? A. Provide written instructions B. Implement DOT (Directly Observed Therapy) C. Schedule frequent follow-ups D. Involve family members E. Simplify medication regimen 58. During assessment, a TB patient shows increased work of breathing. What is the nurse's priority action? A. Administer prescribed oxygen B. Position in high Fowler's C. Assess vital signs D. Perform chest auscultation  E. Notify physician immediately 59. A patient with TB is preparing for discharge. What is the most important aspect of the discharge plan? A. Medication schedule B. Diet modifications C. Activity restrictions D. Follow-up appointments E. Environmental modifications 60. The nurse assesses a TB patient's understanding of infection control. Which patient statement indicates effective learning? A. "I will take my medications regularly" B. "I will cover my mouth when coughing" C. "I will eat a balanced diet" D. "I will exercise daily" E. "I will get enough rest" 61. A TB patient develops hearing problems during treatment. Which medication is likely responsible? A. Isoniazid B. Rifampin C. Pyrazinamide D. Ethambutol E. Streptomycin 62. A nurse is teaching a family about preventing TB transmission at home. What is the most important environmental modification? A. Separate bedroom B. Adequate ventilation C. Regular cleaning D. UV light installation E. Air purification 63. A patient's sputum culture remains positive after 3 months of treatment. What is the most likely cause? A. Drug resistance B. Poor compliance  C. Inadequate dosing D. Immune suppression E. Incorrect diagnosis 64. A nurse observes a patient's medication administration technique. Which finding requires immediate intervention? A. Taking medication with water B. Taking all pills at once C. Taking medication after meals D. Crushing the tablets E. Spacing doses throughout day 65. During assessment, a TB patient reports chronic cough with occasional blood. What is the priority nursing diagnosis? A. Risk for infection B. Ineffective breathing pattern C. Risk for aspiration D. Anxiety E. Ineffective airway clearance 66. A nurse is planning care for a TB patient with malnutrition. What is the most appropriate collaborative intervention? A. Consult with dietitian B. Start tube feeding C. Administer supplements D. Monitor daily weight E. Increase protein intake 67. A patient receiving TB treatment develops joint pain. Which medication should the nurse suspect? A. Isoniazid B. Rifampin C. Pyrazinamide D. Ethambutol E. Streptomycin 68. The nurse is evaluating a TB patient's response to treatment. Which finding indicates improvement?  A. Decreased appetite B. Weight gain C. Increased coughing D. Night sweats E. Fatigue 69. A nurse is teaching a patient about TB medication side effects. What is the most important point to emphasize? A. Urine color changes B. Vision changes C. Gastrointestinal upset D. Joint pain E. Skin rash 70. During assessment, a TB patient shows signs of depression. What is the nurse's best initial action? A. Refer to psychiatrist B. Assess support system C. Provide emotional support D. Administer antidepressants E. Schedule counseling 71. A nurse is monitoring a TB patient's respiratory status. Which finding requires immediate intervention? A. Respiratory rate 24/minute B. Occasional coughing C. Clear breath sounds D. SpO2 88% E. Mild dyspnea 72. A patient asks why TB treatment takes so long. What is the nurse's best response? A. "It ensures complete cure" B. "The bacteria grow slowly" C. "It prevents drug resistance" D. "It's the standard protocol" E. "It reduces side effects" 73. The nurse is assessing a TB patient's nutritional status. Which finding indicates the greatest concern? A. BMI 18.5 B. Poor appetite C. Weight loss >10% in 3 months D. Decreased albumin E. Low protein intake 74. A nurse is planning discharge care for a TB patient. Which intervention has the highest priority? A. Arrange follow-up appointments B. Provide medication schedule C. Teach infection control D. Plan dietary modifications E. Discuss activity restrictions 75. During medication administration, a patient reports visual disturbances. What is the nurse's priority action? A. Stop Ethambutol immediately B. Document the complaint C. Assess visual acuity D. Notify physician E. Continue medication