Chapter 27Vascular Dysfunction: Nursing Management My Nursing Test Banks

Chapter 27Vascular Dysfunction: Nursing Management

MULTIPLE CHOICE

1.Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis?

1.

Limit diet to contain less than 40% fat

2.

Restrict exercise

3.

Stop smoking

4.

Avoid prescription medications

ANS: 3

To reduce the risk for arteriosclerosis, the nurse should instruct the client to stop smoking. The diet should be limited to less than 30% of fat. Exercise should be encouraged. Prescription medications are often prescribed for clients with symptoms of arteriosclerosis.

PTS:1DIF:Apply

REF: Arteriosclerosis and Atherosclerosis: Planning and Implementation: Goals

2.The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than:

1.

3 seconds.

2.

4 seconds.

3.

5 seconds.

4.

6 seconds.

ANS: 3

Elderly patients have a greater capillary refill time due to aging. Capillary refill greater than 5 seconds is significant. Capillary refill in non-elderly clients should be 3 seconds. Capillary refill in a non-elderly client of 4 seconds would be an abnormal finding. Capillary refill of 6 seconds for all clients is an abnormal assessment finding.

PTS:1DIF:Analyze

REF: Arteriosclerosis and Atherosclerosis: Assessment with Clinical Manifestations

3.When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include?

1.

Eat more meat and eggs.

2.

Consume less meat and eggs.

3.

Incorporate more vegetables.

4.

Limit fruits.

ANS: 2

Cholesterol is located in animal sources, so decreasing meat and eggs will lower cholesterol levels. The client should not be instructed to eat more meat and eggs. Vegetables and fruits do not impact the cholesterol level.

PTS:1DIF:Apply

REF: Arteriosclerosis and Atherosclerosis: Planning and Implementation: Nutrition

4.A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client?

1.

Respiratory distress

2.

Skin breakdown

3.

Decreased urine output

4.

Bruising and bleeding

ANS: 4

A client who is prescribed blood-thinning medication is at a greater risk of bleeding and bruising. Anticoagulant therapy does not increase a clients risk for developing respiratory distress, skin breakdown, or decreased urine output.

PTS:1DIF:Apply

REF: Table 27-2 Pharmacology Facts: Pharmacology Therapy for Management of Arteriosclerosis and Atherosclerosis

5.The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?

1.

Pleural rub

2.

Hyperactive bowel sounds

3.

Crackles

4.

Bruit

ANS: 4

The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be heard when assessing the abdomen.

PTS:1DIF:Analyze

REF: Aneurysms and Aortic Dissections: Assessment with Clinical Manifestations

6.A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

1.

Hypotension

2.

Cardiac arrhythmias

3.

Aneurysm rupture

4.

Loss of bowel sounds

ANS: 3

Aneurysm rupture is a life-threatening occurrence and the highest risk for the client until it can be repaired. Hypotension, cardiac arrhythmias, and loss of bowel sounds are all significant potential complications; however, they are not life threatening.

PTS:1DIF:Analyze

REF: Aneurysms and Aortic Dissections: Assessment with Clinical Manifestations

7.A client who has experienced signs of Virchows triad has developed a deep vein thrombosis. Which of the following is not a part of this triad?

1.

Venous stasis

2.

Vessel wall injury

3.

Alteration in blood clotting

4.

Pregnancy

ANS: 4

Pregnancy is a risk factor for thrombus, but it is not part of Virchows triad.Virchows triad includes venous stasis, vessel wall injury, and alteration of blood coagulation.

PTS: 1 DIF: Analyze REF: Thrombophlebitis: Pathophysiology

8.A client is diagnosed with Buergers disease. Which of the following should the nurse instruct the client regarding this disorder?

1.

It is a common disorder.

2.

It appears in women more than in men.

3.

Smoking exacerbates the disease.

4.

It is more common in African Americans.

ANS: 3

Smoking cessation halts the disease progress, but continuation of smoking exacerbates the progression of the disease. Buergers disease is a rare disorder. It is more common in men than women. It is more common in Asians and rare among African Americans.

PTS: 1 DIF: Apply REF: Buergers Disease: Epidemiology; Etiology

9.A client is diagnosed with Raynauds disease. Which of the following will the nurse most likely assess in this client?

1.

Elevated blood pressure

2.

Pain, cyanosis, and numb, cold extremities

3.

Absent peripheral pulses

4.

Increase in varicose veins

ANS: 2

Clinical manifestations of Raynauds disease include venospasms; pain; cyanosis; redness; numb, cold extremities; and swelling. Elevated blood pressure, absent peripheral pulses, and varicose veins are not associated with this disorder.

PTS:1DIF:Apply

REF:Raynauds Phenomenon: Assessment with Clinical Manifestations

10.A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?

1.

Administer oxygen.

2.

Assist with ambulation.

3.

Administer heparin as prescribed.

4.

Restrict fluids.

ANS: 3

In the treatment of acute peripheral arterial occlusion, intravenous heparin therapy is usually the first intervention. Oxygen is not the first intervention for this client. The client will most likely be on bed rest and will not ambulate. Restricting fluids would not be indicated for acute peripheral arterial occlusion.

PTS:1DIF:Apply

REF: Peripheral Arterial Occlusive Disease: Pharmacology

11.A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client?

1.

Aspirin

2.

Vitamin K

3.

Protamine sulfate

4.

Narcan

ANS: 3

Protamine sulfate is the heparin antagonist used for excessive bleeding. Vitamin K is the antagonist for warfarin. Aspirin and narcan are not used for bleeding associated with a heparin infusion.

PTS: 1 DIF: Apply REF: Thrombophlebitis: Pharmacology

12.A clients blood pressure measurements have a 20 mmHg difference between the upper extremity readings. Which of the following does this assessment finding suggest to the nurse?

1.

Arteriosclerosis

2.

Aortic aneurysm

3.

Deep vein thrombosis

4.

Subclavian steal syndrome

ANS: 4

A difference of greater than 20 mmHg when assessing bilateral blood pressure measurements is considered a significant finding in the diagnosis of subclavian steal syndrome. This blood pressure discrepancy is not a finding with arteriosclerosis, aortic aneurysm, or deep vein thrombosis.

PTS:1DIF:Analyze

REF: Subclavian Steal Syndrome: Assessment with Clinical Manifestations

13.The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this clients risk?

1.

Normal weight

2.

Prolonged standing

3.

Engages in golf three times a week

4.

Eats several servings of fruits and vegetables each day

ANS: 2

Risk factors for the development of varicose veins include thrombophlebitis, obesity, prolonged standing, pregnancy, and liver or pancreas dysfunction. Normal weight, activity, and balanced diet are not risk factors for the development of varicose veins.

PTS: 1 DIF: Analyze REF: Varicose Veins: Etiology

MULTIPLE RESPONSE

1.A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this clients medical diagnosis? (Select all that apply.)

1.

Serum cholesterol 300 mg/dL

2.

LDL 125 mg/dL

3.

Blood glucose 90 mg/dL

4.

HDL 45 mg/dL

5.

Triglycerides 400 mg/dL

6.

Serum potassium 4.0 mEq/L

ANS: 1, 2, 4, 5

Diagnostic tests used to support the medical diagnosis of arteriosclerosis include cholesterol, LDL, HDL, and triglycerides. A serum cholesterol of 300 mg/dL, LDL of 125 mg/dL, HDL of 45 mg/dL, and triglycerides of 400 mg/dL all support the diagnosis of arteriosclerosis. Blood glucose and potassium levels are not used to diagnose arteriosclerosis.

PTS:1DIF:Analyze

REF: Table 27-1 Laboratory Tests: Recommended Cholesterol Screening Levels for Patients with Arteriosclerosis and Atherosclerosis

2.The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply.)

1.

Pulselessness

2.

Pain

3.

Pallor

4.

Paresthesia

5.

Paralysis

6.

Petechiae

ANS: 1, 2, 3, 4, 5

The nurse would assess a client diagnosed with peripheral arterial disease for the six Ps: pulseless, pain, pallor, paresthesia, paralysis, and poikilocythemia. Petechiae is not a part of the six Ps assessment.

PTS:1DIF:Apply

REF: Peripheral Arterial Occlusive Disease: Assessment with Clinical Manifestations

3.The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.)

1.

Do not lift anything heavier than 15 to 20 lbs.

2.

Limit activity for up to 8 weeks after the surgery.

3.

Use a pillow to splint when coughing.

4.

Driving is permitted 1 week after surgery.

5.

Notify the physician for pain, redness, or swelling around the incision.

6.

Avoid pain medication.

ANS: 1, 2, 3, 5

Instructions appropriate after surgery to repair an arterial aneurysm include limit lifting to 15 to 20 lbs; limit activity for up to 8 weeks after the surgery; use a pillow to splint when coughing; and notify the physician for pain, redness, or swelling around the incision. Driving may be restricted for several weeks. Pain medication will be prescribed and encouraged to be used.

PTS:1DIF:Apply

REF:Aneurysms and Aortic Dissections: Patient and Family Teaching

4.The nurse is utilizing the Wells Scale to assess a client for deep vein thrombosis. Which of the following is assessed when using this scale? (Select all that apply.)

1.

Treatment for cancer

2.

Recent immobility for greater than 3 days

3.

Recovery from surgery with general anesthesia within 12 weeks

4.

Entire leg edematous

5.

Pitting edema of the symptomatic leg

6.

Blood pressure 130/86 mmHg

ANS: 1, 2, 3, 4, 5

The Wells Scale is a tool used to assess a client for the presence of a deep vein thrombosis. Areas assessed include treatment or diagnosis of cancer, recent immobility for greater than 3 days, recovery from surgery during which the client received general or regional anesthesia within 12 weeks, entire leg swollen, and pitting edema confined to the symptomatic leg. Blood pressure is not a criteria used on this scale.

PTS: 1 DIF: Apply REF: Table 27-4 Modified Wells Clinical Score

5.A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this clients plan of care? (Select all that apply.)

1.

Administer oral antibiotics if infection is present.

2.

Keep the foot open to the air.

3.

Cover the foot with a hydrocolloidal dressing.

4.

Provide pain medication with debridement.

5.

Restrict fluids.

6.

Instruct the client to ambulate without shoes.

ANS: 1, 3, 4

Nursing care of a client diagnosed with a venous stasis ulcer includes provide with oral antibiotics if infection is present, cover the wound with hydrocolloidal dressing if indicated to promote the formation of granulation tissue, provide pain medication with debridement. The wound should not be kept open to the air. The client does not need a fluid restriction. The client should be instructed to never ambulate without appropriate foot protection.

PTS: 1 DIF: Apply REF: Venous Stasis Ulcer: Planning and Implementation

MULTIPLE CHOICE

1.Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis?

1.

Limit diet to contain less than 40% fat

2.

Restrict exercise

3.

Stop smoking

4.

Avoid prescription medications

ANS: 3

To reduce the risk for arteriosclerosis, the nurse should instruct the client to stop smoking. The diet should be limited to less than 30% of fat. Exercise should be encouraged. Prescription medications are often prescribed for clients with symptoms of arteriosclerosis.

PTS:1DIF:Apply

REF: Arteriosclerosis and Atherosclerosis: Planning and Implementation: Goals

2.The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than:

1.

3 seconds.

2.

4 seconds.

3.

5 seconds.

4.

6 seconds.

ANS: 3

Elderly patients have a greater capillary refill time due to aging. Capillary refill greater than 5 seconds is significant. Capillary refill in non-elderly clients should be 3 seconds. Capillary refill in a non-elderly client of 4 seconds would be an abnormal finding. Capillary refill of 6 seconds for all clients is an abnormal assessment finding.

PTS:1DIF:Analyze

REF: Arteriosclerosis and Atherosclerosis: Assessment with Clinical Manifestations

3.When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include?

1.

Eat more meat and eggs.

2.

Consume less meat and eggs.

3.

Incorporate more vegetables.

4.

Limit fruits.

ANS: 2

Cholesterol is located in animal sources, so decreasing meat and eggs will lower cholesterol levels. The client should not be instructed to eat more meat and eggs. Vegetables and fruits do not impact the cholesterol level.

PTS:1DIF:Apply

REF: Arteriosclerosis and Atherosclerosis: Planning and Implementation: Nutrition

4.A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client?

1.

Respiratory distress

2.

Skin breakdown

3.

Decreased urine output

4.

Bruising and bleeding

ANS: 4

A client who is prescribed blood-thinning medication is at a greater risk of bleeding and bruising. Anticoagulant therapy does not increase a clients risk for developing respiratory distress, skin breakdown, or decreased urine output.

PTS:1DIF:Apply

REF: Table 27-2 Pharmacology Facts: Pharmacology Therapy for Management of Arteriosclerosis and Atherosclerosis

5.The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?

1.

Pleural rub

2.

Hyperactive bowel sounds

3.

Crackles

4.

Bruit

ANS: 4

The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be heard when assessing the abdomen.

PTS:1DIF:Analyze

REF: Aneurysms and Aortic Dissections: Assessment with Clinical Manifestations

6.A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

1.

Hypotension

2.

Cardiac arrhythmias

3.

Aneurysm rupture

4.

Loss of bowel sounds

ANS: 3

Aneurysm rupture is a life-threatening occurrence and the highest risk for the client until it can be repaired. Hypotension, cardiac arrhythmias, and loss of bowel sounds are all significant potential complications; however, they are not life threatening.

PTS:1DIF:Analyze

REF: Aneurysms and Aortic Dissections: Assessment with Clinical Manifestations

7.A client who has experienced signs of Virchows triad has developed a deep vein thrombosis. Which of the following is not a part of this triad?

1.

Venous stasis

2.

Vessel wall injury

3.

Alteration in blood clotting

4.

Pregnancy

ANS: 4

Pregnancy is a risk factor for thrombus, but it is not part of Virchows triad.Virchows triad includes venous stasis, vessel wall injury, and alteration of blood coagulation.

PTS: 1 DIF: Analyze REF: Thrombophlebitis: Pathophysiology

8.A client is diagnosed with Buergers disease. Which of the following should the nurse instruct the client regarding this disorder?

1.

It is a common disorder.

2.

It appears in women more than in men.

3.

Smoking exacerbates the disease.

4.

It is more common in African Americans.

ANS: 3

Smoking cessation halts the disease progress, but continuation of smoking exacerbates the progression of the disease. Buergers disease is a rare disorder. It is more common in men than women. It is more common in Asians and rare among African Americans.

PTS: 1 DIF: Apply REF: Buergers Disease: Epidemiology; Etiology

9.A client is diagnosed with Raynauds disease. Which of the following will the nurse most likely assess in this client?

1.

Elevated blood pressure

2.

Pain, cyanosis, and numb, cold extremities

3.

Absent peripheral pulses

4.

Increase in varicose veins

ANS: 2

Clinical manifestations of Raynauds disease include venospasms; pain; cyanosis; redness; numb, cold extremities; and swelling. Elevated blood pressure, absent peripheral pulses, and varicose veins are not associated with this disorder.

PTS:1DIF:Apply

REF:Raynauds Phenomenon: Assessment with Clinical Manifestations

10.A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?

1.

Administer oxygen.

2.

Assist with ambulation.

3.

Administer heparin as prescribed.

4.

Restrict fluids.

ANS: 3

In the treatment of acute peripheral arterial occlusion, intravenous heparin therapy is usually the first intervention. Oxygen is not the first intervention for this client. The client will most likely be on bed rest and will not ambulate. Restricting fluids would not be indicated for acute peripheral arterial occlusion.

PTS:1DIF:Apply

REF: Peripheral Arterial Occlusive Disease: Pharmacology

11.A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client?

1.

Aspirin

2.

Vitamin K

3.

Protamine sulfate

4.

Narcan

ANS: 3

Protamine sulfate is the heparin antagonist used for excessive bleeding. Vitamin K is the antagonist for warfarin. Aspirin and narcan are not used for bleeding associated with a heparin infusion.

PTS: 1 DIF: Apply REF: Thrombophlebitis: Pharmacology

12.A clients blood pressure measurements have a 20 mmHg difference between the upper extremity readings. Which of the following does this assessment finding suggest to the nurse?

1.

Arteriosclerosis

2.

Aortic aneurysm

3.

Deep vein thrombosis

4.

Subclavian steal syndrome

ANS: 4

A difference of greater than 20 mmHg when assessing bilateral blood pressure measurements is considered a significant finding in the diagnosis of subclavian steal syndrome. This blood pressure discrepancy is not a finding with arteriosclerosis, aortic aneurysm, or deep vein thrombosis.

PTS:1DIF:Analyze

REF: Subclavian Steal Syndrome: Assessment with Clinical Manifestations

13.The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this clients risk?

1.

Normal weight

2.

Prolonged standing

3.

Engages in golf three times a week

4.

Eats several servings of fruits and vegetables each day

ANS: 2

Risk factors for the development of varicose veins include thrombophlebitis, obesity, prolonged standing, pregnancy, and liver or pancreas dysfunction. Normal weight, activity, and balanced diet are not risk factors for the development of varicose veins.

PTS: 1 DIF: Analyze REF: Varicose Veins: Etiology

MULTIPLE RESPONSE

1.A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which of the following laboratory values would support this clients medical diagnosis? (Select all that apply.)

1.

Serum cholesterol 300 mg/dL

2.

LDL 125 mg/dL

3.

Blood glucose 90 mg/dL

4.

HDL 45 mg/dL

5.

Triglycerides 400 mg/dL

6.

Serum potassium 4.0 mEq/L

ANS: 1, 2, 4, 5

Diagnostic tests used to support the medical diagnosis of arteriosclerosis include cholesterol, LDL, HDL, and triglycerides. A serum cholesterol of 300 mg/dL, LDL of 125 mg/dL, HDL of 45 mg/dL, and triglycerides of 400 mg/dL all support the diagnosis of arteriosclerosis. Blood glucose and potassium levels are not used to diagnose arteriosclerosis.

PTS:1DIF:Analyze

REF: Table 27-1 Laboratory Tests: Recommended Cholesterol Screening Levels for Patients with Arteriosclerosis and Atherosclerosis

2.The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply.)

1.

Pulselessness

2.

Pain

3.

Pallor

4.

Paresthesia

5.

Paralysis

6.

Petechiae

ANS: 1, 2, 3, 4, 5

The nurse would assess a client diagnosed with peripheral arterial disease for the six Ps: pulseless, pain, pallor, paresthesia, paralysis, and poikilocythemia. Petechiae is not a part of the six Ps assessment.

PTS:1DIF:Apply

REF: Peripheral Arterial Occlusive Disease: Assessment with Clinical Manifestations

3.The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.)

1.

Do not lift anything heavier than 15 to 20 lbs.

2.

Limit activity for up to 8 weeks after the surgery.

3.

Use a pillow to splint when coughing.

4.

Driving is permitted 1 week after surgery.

5.

Notify the physician for pain, redness, or swelling around the incision.

6.

Avoid pain medication.

ANS: 1, 2, 3, 5

Instructions appropriate after surgery to repair an arterial aneurysm include limit lifting to 15 to 20 lbs; limit activity for up to 8 weeks after the surgery; use a pillow to splint when coughing; and notify the physician for pain, redness, or swelling around the incision. Driving may be restricted for several weeks. Pain medication will be prescribed and encouraged to be used.

PTS:1DIF:Apply

REF:Aneurysms and Aortic Dissections: Patient and Family Teaching

4.The nurse is utilizing the Wells Scale to assess a client for deep vein thrombosis. Which of the following is assessed when using this scale? (Select all that apply.)

1.

Treatment for cancer

2.

Recent immobility for greater than 3 days

3.

Recovery from surgery with general anesthesia within 12 weeks

4.

Entire leg edematous

5.

Pitting edema of the symptomatic leg

6.

Blood pressure 130/86 mmHg

ANS: 1, 2, 3, 4, 5

The Wells Scale is a tool used to assess a client for the presence of a deep vein thrombosis. Areas assessed include treatment or diagnosis of cancer, recent immobility for greater than 3 days, recovery from surgery during which the client received general or regional anesthesia within 12 weeks, entire leg swollen, and pitting edema confined to the symptomatic leg. Blood pressure is not a criteria used on this scale.

PTS: 1 DIF: Apply REF: Table 27-4 Modified Wells Clinical Score

5.A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this clients plan of care? (Select all that apply.)

1.

Administer oral antibiotics if infection is present.

2.

Keep the foot open to the air.

3.

Cover the foot with a hydrocolloidal dressing.

4.

Provide pain medication with debridement.

5.

Restrict fluids.

6.

Instruct the client to ambulate without shoes.

ANS: 1, 3, 4

Nursing care of a client diagnosed with a venous stasis ulcer includes provide with oral antibiotics if infection is present, cover the wound with hydrocolloidal dressing if indicated to promote the formation of granulation tissue, provide pain medication with debridement. The wound should not be kept open to the air. The client does not need a fluid restriction. The client should be instructed to never ambulate without appropriate foot protection.

PTS: 1 DIF: Apply REF: Venous Stasis Ulcer: Planning and Implementation

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