166) A client with a history of angina pectoris tells Athe nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. What type of angina should the nurse determine that the client is experiencing?
Correct Answer:1，Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.
167） The client with a chronic kidney disease has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. Which action should the nurse shouldimmediately take?
1.Change the dressing.
2.Reinforce the dressing.
3.Flush the peritoneal dialysis catheter.
4.Scrub the catheter with povidone-iodine.
Correct Answer:1，Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
168） The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?
Correct Answer:2，Cranial nerve II (the optic nerve) is responsible for visual acuity. This may be tested by using a Snellen chart to assess distant vision. Another item that may be used to evaluate the optic nerve function is a Rosenbaum card to evaluate near vision. This card is a hand-held card used to test visual acuity. The nurse records the smallest line seen as well as the distance that the card is held from the client. A flashlight is used to test the pupillary reaction. A reflex hammer is used to test reflexes. An ophthalmoscope is used to examine the retina.