Chapter 35 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 35

Question 1

Type: MCMA

A 65-year-old male patient arrives in the clinic complaining of numbness and tingling of the lower extremities and pain in the legs upon exercise. Which questions would the nurse ask to determine the patients possible risk factors for peripheral arterial disease (PAD)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Do you smoke?

2. Are you married?

3. Are you diabetic?

4. Where were you born?

5. Do you exercise?

Correct Answer: 1,3,5

Rationale 1: Smoking is a risk factor for peripheral arterial disease (PAD).

Rationale 2: Marital status is not a risk factor for PAD.

Rationale 3: Diabetes is a risk factor for peripheral arterial disease (PAD).

Rationale 4: Birthplace is not a risk factor for PAD.

Rationale 5: Exercise may help to delay the symptoms of PAD.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 2

Type: MCSA

A patient who has just been diagnosed with peripheral arterial disease (PAD) asks what intermittent claudication means. How should the nurse describe this condition?

1. Leg pain that occurs at rest

2. Leg pain that occurs with exercise

3. A tingling feeling in the hands

4. Pain that can occur anywhere in the body with exercise

Correct Answer: 2

Rationale 1: Intermittent claudication is typically relieved by rest.

Rationale 2: Intermittent claudication is exercise-induced leg pain that can occur in different locations throughout the leg/hip area.

Rationale 3: Intermittent claudication does not occur in the hands.

Rationale 4: The pain is unique to the lower extremities.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 3

Type: MCSA

A diabetic 68-year-old female patient arrives at the clinic with a history of smoking, hypertension, family history of cardiac disease, COPD, and infrequent exercise. The nurse identifies which of these as the most significant risk factors for peripheral arterial disease (PAD)?

1. COPD and family history of cardiac disease

2. Age and gender

3. Sedentary lifestyle and diabetes

4. Hypertension and smoking

Correct Answer: 4

Rationale 1: COPD and a family history of cardiac disease are not the patients most significant risk factors for PAD.

Rationale 2: Age over 70 and male gender are slightly more significant risk factors for PAD.

Rationale 3: A sedentary lifestyle is not one of the most significant risk factors for PAD. Diabetes is significant.

Rationale 4: Hypertension and smoking, along with diabetes, are the top risk factors for developing PAD.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 4

Type: MCSA

A patient with peripheral arterial disease has a nursing diagnosis of Ineffective Tissue Perfusion. Which nursing intervention is most appropriate for this nursing diagnosis?

1. Assist the patient in taking hot baths.

2. Do not elevate the patients legs.

3. Encourage the patient to limit activity.

4. Limit visitors.

Correct Answer: 2

Rationale 1: A patient with PAD should avoid extremes in temperature, such as hot baths and cold weather.

Rationale 2: Keeping a patients legs in the dependent position rather than elevated will help increase the arterial circulation.

Rationale 3: Activity should be encouraged, not discouraged.

Rationale 4: There is no need to limit visitors.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 5

Type: MCSA

A patient who has been diagnosed with peripheral arterial disease (PAD) has a nursing diagnosis of Risk for Impaired Skin Integrity related to reduced peripheral circulation. Which instruction is most appropriate to address this diagnosis?

1. PAD signs and symptoms

2. Pain control measures

3. Risk factors that may increase problems with PAD

4. Protecting the legs from injury

Correct Answer: 4

Rationale 1: The patient needs instruction on the signs and symptoms of PAD, but these do not relate to the Risk for Impaired Skin

Integrity.

Rationale 2: The patient will need instruction on pain control methods, but this does not relate to the Risk for Impaired Skin Integrity.

Rationale 3: The patient should be instructed regarding actions that will worsen PAD, but these do not relate to the Risk for Impaired Skin Integrity.

Rationale 4: The patient with a Risk for Impaired Skin Integrity related to reduced peripheral circulation will need instruction on protecting the legs from injury. Any wound the patient acquires is likely to heal slowly.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 6

Type: MCSA

A patient with peripheral arterial disease (PAD) is a smoker. The nurse has established a nursing diagnosis of Deficient Knowledge of Self-Care Needs and Treatment Plan related to tobacco use. Which intervention should the nurse choose to implement?

1. Encourage the patient to use medications to stop smoking.

2. Discuss with the patient a smoking cessation plan.

3. Instruct the patient in increasing exercise.

4. Discuss the patients use of herbal therapies for smoking cessation.

Correct Answer: 2

Rationale 1: The nurse should provide an overall plan for smoking cessation, not just information about medications.

Rationale 2: It is critical for patients who smoke to stop smoking to improve their outcomes. A smoking cessation plan should be implemented and follow-up instituted after the patient quits smoking.

Rationale 3: Exercise may be part of an overall smoking cessation plan but will not be sufficient alone.

Rationale 4: The use of herbal therapies may help the patient stop smoking but should be discussed in the context of an overall plan.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 7

Type: MCSA

A patient with Raynauds disease presents with pallor of the fingers. The patient states that the hands turn white, then blue, then red. How should the nurse explain these symptoms to the patient?

1. Bleeding is occurring in the interior portion of your hands.

2. You have inflammation of the small vessels of your hands and feet that will eventually form small clots.

3. These symptoms are caused by spasm of the small arteries and arterioles in your hands.

4. Your symptoms are associated with atherosclerosis caused by too many circulating lipids.

Correct Answer: 3

Rationale 1: Raynauds disease is not caused by bleeding.

Rationale 2: The pathophysiology of Raynauds disease does not include inflammation of small vessels in the hands and feet.

Rationale 3: The symptoms of Raynauds disease are caused by vasospasm of the small arteries and arterioles in the hands.

Rationale 4: Atherosclerosis does not cause Raynauds disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 8

Type: MCSA

The nurse notes that a patient with Raynauds disease is more anxious than usual and states, I dont understand why my hands keep turning colors. It seems to happen when I get upset. What is the nurses most appropriate action?

1. Discuss how stress can cause the vasospasms in Raynauds disease and develop a plan to manage stress.

2. Discuss using hot water to warm up the patients hands and keep them warm.

3. Discuss how Raynauds can impact the patients health.

4. Implement a no-visitor policy to keep the patient calmer.

Correct Answer: 1

Rationale 1: Stress is related to Raynauds symptoms, and the patient should be taught how to manage stress.

Rationale 2: Patients with Raynauds may also experience paresthesia of the affected parts, so use of hot water could be dangerous. Using warm water and avoiding exposure to cold are safer.

Rationale 3: The patient is likely aware of the effects of Raynauds on health. Education time would be better spent on prevention or management.

Rationale 4: There is no indication that a no-visitor policy will keep the patient calmer or that it is a good idea.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 9

Type: MCSA

The nurse is providing preoperative instructions to a patient scheduled for endovascular repair to reduce peripheral vascular disease. The patient asks where the incision will be located. How should the nurse reply?

1. There will be a small incision in the groin area because the procedure is done via the femoral artery.

2. There will be no incisions because the repair is done via IV access.

3. There will be an incision in the mid-chest because the surgeon will need to perform bypass surgery.

4. There will be an incision in the abdomen so the surgeon can visualize the affected area.

Correct Answer: 1

Rationale 1: The endovascular repair is completed via the femoral artery, so a small incision in the groin may be necessary.

Rationale 2: This procedure is performed on the venous side, not the arterial side, and does not use an IV access.

Rationale 3: Bypass of a vessel in the chest is not associated with PAD.

Rationale 4: PAD is not associated with pain in the abdomen, so abdominal access is not required.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-4

Question 10

Type: MCSA

A patient on whom an endovascular repair of the aorta has just been performed is now complaining of numbness and tingling in the toes. The nurse inspects the patients legs and discovers weak pulses bilaterally, cool lower extremities, and capillary refill greater than 3 seconds. What immediate nursing action is indicated?

1. Contact the patients family to come to the hospital.

2. Instruct the patient to take deep breaths to increase oxygenation.

3. Contact the ECG technician to get an ECG because the patient is likely having a heart attack.

4. Contact the health care provider because the patient has likely developed interruption of arterial flow.

Correct Answer: 4

Rationale 1: The family should be contacted if the patient wishes, but this is not the priority.

Rationale 2: Taking deep breaths will increase oxygenation but will not affect blood flow to the lower extremities.

Rationale 3: The patient is not having a heart attack; therefore, completing an ECG is not a priority.

Rationale 4: Numbness, tingling, weak pulses, and signs of poor perfusion all indicate interruption of arterial flow. Interruption may be caused by thrombus and is an emergent situation requiring intervention by the health care provider.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 35-4

Question 11

Type: MCSA

A patient with a deep venous thrombosis (DVT) is going home on warfarin (Coumadin). The nurse instructs the patient that lab work will need to be performed frequently until the levels stabilize. For which international normalized ratio (INR) result will the patients warfarin need to be adjusted?

1. 2.8

2. 3.0

3. 2.1

4. 1.3

Correct Answer: 4

Rationale 1: This INR is within the common therapeutic range of 2.0 to 3.0.

Rationale 2: This INR is within the common therapeutic range of 2.0 to 3.0 but is nearly out of range. This patient should be monitored.

Rationale 3: This INR is within the common therapeutic range of 2.0 to 3.0 but is nearly out of range. This patient should be monitored.

Rationale 4: The ideal INR range for a patient on warfarin is 2.0 to 3.0. An INR of 1.3 will require that warfarin be increased.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 35-5

Question 12

Type: MCSA

A number of patients on the unit are at risk for deep venous thrombosis (DVT). The nurse would consider which patient at highest risk?

1. The patient who had oral surgery

2. The patient who has pneumonia

3. The patient with diabetes

4. The patient who had a hip replacement

Correct Answer: 4

Rationale 1: Oral surgery does not place a patient at high risk for DVT.

Rationale 2: Pneumonia does not put a patient at risk for DVT unless the patient experiences complications such as respiratory failure or sepsis.

Rationale 3: Diabetes does not place a patient at high risk for DVT.

Rationale 4: Major orthopedic surgeries such as total hip or total knee replacement put a patient at high risk for DVT.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 35-3

Question 13

Type: MCSA

A 38-year-old, 150-pound male has been diagnosed with deep venous thrombosis (DVT). The patients history includes recent cardiac bypass surgery, working in a pesticide plant, and hypertension. The family asks what might have put the patient at risk for DVT. How should the nurse respond?

1. Hypertension is a major contributor to the development of DVTs.

2. The cause of DVTs is unknown, but his weight may be a factor.

3. His prior employment in the pesticide plant may have contributed to the DVT.

4. His recent surgery and prolonged immobilization are risk factors.

Correct Answer: 4

Rationale 1: Hypertension does not play a direct role in DVTs.

Rationale 2: Obesity can contribute to developing DVTs, but this patient is not overweight.

Rationale 3: Working in a pesticide plant has no known correlation to the development of DVTs.

Rationale 4: Recent heart surgery and prolonged immobilization have contributed to the patients DVT.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 14

Type: MCSA

A patient on clopidogrel (Plavix) is receiving discharge instructions. What information should the nurse provide?

1. Be aware of food interactions with the medication.

2. Take the medication with an NSAID pain reliever if it gives you a headache.

3. Take vitamin C, vitamin E, and vitamin A supplements daily.

4. Take the medication with food.

Correct Answer: 4

Rationale 1: Clopidogrel does not have the same fooddrug interactions as some of the other antiplatelet medications.

Rationale 2: NSAID pain relievers should be avoided, as bleeding may occur.

Rationale 3: Clopidogrel interacts with vitamin A.

Rationale 4: Clopidogrel should be taken with food.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-5

Question 15

Type: MCSA

A patient receiving enoxaparin (Lovenox) is scheduled for surgery. Why should the nurse discuss this medication with the anesthesia care provider?

1. Correct body alignment during surgery will be critical.

2. Aspirin may need to be substituted for the enoxaparin.

3. The patient should not receive medications that interact with enoxaparin.

4. The patient should not receive an epidural.

Correct Answer: 4

Rationale 1: Correct body alignment is critical for all patients. Being on enoxaparin does not increase this concern.

Rationale 2: Aspirin and enoxaparin act by two different mechanisms.

Rationale 3: Medication interaction is not common with enoxaparin.

Rationale 4: An epidural is contraindicated in patients receiving enoxaparin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-5

Question 16

Type: MCSA

A patient who is pondering surgical repair of varicose veins asks the nurse how long the hospital stay would be. How should the nurse respond?

1. The procedure is an inpatient procedure that requires an overnight stay.

2. The procedure is completed over several days, so you will return to the hospital every day until the process is complete.

3. Surgical repair of varicose veins is an outpatient procedure. There is no inpatient stay.

4. The procedure is complicated and will require at least 2 days in the hospital.

Correct Answer: 3

Rationale 1: The typical varicose vein repair does not require inpatient stay.

Rationale 2: Surgical repair of varicose veins is usually a one-time outpatient procedure.

Rationale 3: Surgical repair of varicose veins is usually a one-time outpatient procedure and does not require inpatient care.

Rationale 4: No inpatient care is anticipated with varicose vein surgery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-4

Question 17

Type: MCMA

A patient who has had a dissecting aneurysm repaired is being prepared for discharge. The patient has a history of hypertension. The nurse is careful to emphasize the importance of which precaution?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Do not run out of your prescribed medications.

2. Take your pulse twice daily.

3. Do not drink too much fluid.

4. Watch the incision for signs of infection.

5. Keep your blood pressure well managed.

Correct Answer: 1,4,5

Rationale 1: Compliance with the prescribed medication regime is essential.

Rationale 2: There should be no reason to take the pulse twice daily at home.

Rationale 3: A fluid restriction would be unlikely for this patient.

Rationale 4: All patients who have had invasive surgeries should be taught to monitor the incision for infection.

Rationale 5: Keeping the blood pressure at desired levels is critical to a good outcome from surgery to repair an aneurysm.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-4

Question 18

Type: MCSA

A patient presents to the emergency department with complaints of feeling like something is ripping in my chest and sudden onset of mid-back pain. The patient has a history of hypertension. What is the top priority in the care of this patient?

1. Contact the patients family.

2. Facilitate an immediate CT scan.

3. Obtain a surgical history.

4. Provide pain medication.

Correct Answer: 2

Rationale 1: Contacting the family is not a top priority but should be done at the patients request.

Rationale 2: Rapid diagnosis for this patient is imperative and may mean the difference between life and death. Facilitating an immediate CT or other diagnostic study will help with a diagnosis.

Rationale 3: A surgical history will be necessary for this patient but is not the initial priority.

Rationale 4: Pain medication will be required, but another intervention has top priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 19

Type: MCSA

A patients visit to the health care clinic reveals a blood pressure of 130/82. The patients blood pressure has been 138/88 at each of the last three clinic visits. How does the nurse evaluate this information?

1. The patients blood pressure meets the criteria for stage 1 hypertension.

2. The patient should be educated on lifestyle modifications to reduce the risk of developing stage 1 hypertension.

3. The patients risk of developing hypertension is no higher than anyone elses.

4. The patient has stage 2 hypertension and requires medication.

Correct Answer: 2

Rationale 1: Stage 1 hypertension is a blood pressure of 140 to 159 mmHg systolic or 90 to 99 mmHg diastolic measured over multiple office visits.

Rationale 2: This patients blood pressure meets the criteria for prehypertension (systolic 120139 or diastolic 8089). Prehypertension increases the risk of developing stage 1 or stage 2 hypertension.

Rationale 3: Prehypertension increases the patients risk of developing hypertension.

Rationale 4: This is not stage 2 hypertension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-1

Question 20

Type: MCSA

A patients visit to the health care clinic reveals a blood pressure of 142/90. What is the nurses next step?

1. Notify the physician or primary health care provider immediately.

2. Identify medications the patient has been taking.

3. Discuss the diagnosis of hypertension with the patient.

4. Check the patients record for the past several blood pressure readings.

Correct Answer: 4

Rationale 1: There is no need to notify the health care provider immediately.

Rationale 2: The nurse will review medications, but this is not the next step.

Rationale 3: The nurse should not assume this is hypertension.

Rationale 4: The nurse should review the last few blood pressure readings to assess for possible trends.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-1

Question 21

Type: MCMA

A patient has been diagnosed with stage 2 hypertension. What should the nurse teach this patient about managing the disease?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Take the prescribed medication as directed.

2. Stop taking medication when blood pressure returns to normal limits.

3. Exercise when the weather permits.

4. Two or three glasses of wine with dinner will help to control blood pressure.

5. Eat three balanced meals every day.

Correct Answer: 1,5

Rationale 1: The priority teaching includes ensuring the patient understands that the medication must be taken as directed even when the patient is feeling well.

Rationale 2: The patient may not realize that blood pressure has likely returned to normal because of the medication regimen. Medication should not be stopped without consulting the health care provider.

Rationale 3: Daily exercise is necessary for blood pressure control.

Rationale 4: Alcohol use should be moderate, meaning one drink per day.

Rationale 5: Eating a balanced diet is essential for blood pressure control.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-2

Question 22

Type: MCMA

Which statements by the patient would the nurse evaluate as indicating a need for additional teaching about hypertension?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hypertension affects my blood vessels only if I have other underlying health problems.

2. Hypertension causes my blood vessels to become inflamed and reduces the blood supply to my organs if left untreated.

3. Hypertension damages my blood vessels even if I dont have any symptoms.

4. I will be more prone to heart disease and eye problems if I discontinue my blood pressure medications.

5. As long as I take my medications, I am cured of hypertension.

Correct Answer: 1,5

Rationale 1: Hypertension affects blood vessels whether or not the patient has comorbid conditions.

Rationale 2: Hypertension does cause inflammation and reduced blood supply to organs if left untreated.

Rationale 3: Underlying organ damage may develop even in the absence of symptoms of high blood pressure.

Rationale 4: Other health problems, such as heart disease and eye problems, can result from untreated hypertension.

Rationale 5: Medications cannot cure hypertension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 35-2

Question 23

Type: MCSA

A patient has been prescribed propranolol (Inderal) 80 mg twice daily. To maximize the patients safety, what should the nurse teach the patient about this drug?

1. Stop the medication immediately if you experience nausea or a cough, and then contact the health care provider.

2. Do not stop the medication abruptly without consulting the physician.

3. Contact the health care provider immediately if you experience fatigue.

4. If you have a headache, take an extra tablet at the next dose time.

Correct Answer: 2

Rationale 1: Abrupt withdrawal of the medication could cause life-threatening dysrhythmias.

Rationale 2: This medication should not be stopped abruptly.

Rationale 3: The nurse should advise the patient that as blood pressure returns to normal, the patient may experience fatigue. It is not necessary to contract the health care provider immediately.

Rationale 4: Taking extra medication is never advised unless the health care provider is consulted.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-2

Question 24

Type: MCSA

The medical-surgical nurse is providing a hypertensive patient and the family with discharge instructions. The family is concerned about complications from hypertension. What information should the nurse provide?

1. The complications are relatively minor.

2. The physician will discuss the complications with you at a later date.

3. There are potential complications, but the risks can be minimized if the hypertension is well controlled.

4. People die if they dont manage their hypertension well.

Correct Answer: 3

Rationale 1: Complications can be life-threatening.

Rationale 2: The patient is asking about complications now, and the nurse should be prepared to discuss this topic.

Rationale 3: The potential complications from hypertension can be minimized if hypertension is kept under control.

Rationale 4: The patient should be aware of the seriousness of hypertension early in the treatment plan without being unduly alarmed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-2

Question 25

Type: MCSA

A patient admitted with hypertension reports peripheral edema, difficulty breathing, and a cough following ambulation. The nurse chooses which priority nursing diagnosis?

1. Impaired Tissue Perfusion

2. Risk of Noncompliance

3. Imbalanced Nutrition

4. Fatigue

Correct Answer: 1

Rationale 1: The patient who has a cough and difficulty breathing following exercise, as well as ongoing peripheral edema, has impaired tissue perfusion related to resistance to blood flow.

Rationale 2: There is no evidence that this patient is at risk of noncompliance.

Rationale 3: There is not enough information to choose this nursing diagnosis.

Rationale 4: The patient may experience fatigue, but this is not the priority nursing diagnosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 35-2

Question 26

Type: MCMA

The nurse is instructing a patient with hypertension about lifestyle modifications. Which instructions would be appropriate to include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Review the DASH diet.

2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.

3. Plan a weight-lifting regimen.

4. Eliminate dairy products from the diet.

5. Restrict fluid intake.

Correct Answer: 1,2

Rationale 1: Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intake, and reducing total and saturated fat intake. The DASH diet has proven to be beneficial in lowering blood pressure.

Rationale 2: Regular exercise reduces blood pressure and contributes to weight loss, stress reduction, and feelings of overall well-being. Previously sedentary patients are encouraged to engage in aerobic exercise for 30 to 45 minutes per day most days of the week.

Rationale 3: Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood pressure.

Rationale 4: Dietary approaches to managing hypertension do not focus on eliminating dairy products.

Rationale 5: Fluid restriction is not indicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-2

Question 27

Type: MCMA

A patients blood pressure continues to be elevated even though the patient was prescribed an ACE inhibitor for several weeks. What are appropriate nursing interventions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask if the patient is taking the prescribed medication.

2. Suggest to the physician that a different medication be prescribed.

3. Schedule another blood pressure check in a week.

4. Realize that the patients anxiety over the diagnosis is affecting treatment.

5. Ask if the patient is experiencing side effects from the medication.

Correct Answer: 1,5

Rationale 1: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for patients with chronic diseases.

Rationale 2: Further assessment is indicated prior to this intervention.

Rationale 3: The nurse should complete further assessment today.

Rationale 4: There is no evidence that the patient is anxious.

Rationale 5: The patient may stop taking the medication or reduce the dose because of adverse effects.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-2

Question 28

Type: MCMA

During the abdominal assessment of an elderly patient, the nurse palpates a mass in the mid-abdomen. What actions should the nurse take?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Percuss the mass.

2. Ask the patient to cough forcefully and reassess.

3. Notify the physician immediately.

4. Auscultate the mass.

5. Ask the patient about any recent pain in the abdomen.

Correct Answer: 4,5

Rationale 1: If an aneurysm is suspected, percussing the mass could increase the pressure on the weakened site and cause leakage or rupture.

Rationale 2: If this mass is an aneurysm, coughing may increase pressure on the weakened site enough to cause leakage or rupture.

Rationale 3: The nurse should conduct further assessment prior to contacting the physician.

Rationale 4: Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam.

Rationale 5: Abdominal aneurysms are generally asymptomatic, but the nurse should ask about pain as part of the assessment of this mass.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 29

Type: MCMA

The nurse suspects that a patient who is recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. Which findings are indications of this event?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Urine output 45 mL/hr

2. Complaint of groin pain

3. Abdominal dressing dry and intact

4. Respiratory rate 16 and regular

5. Complaint of back discomfort

Correct Answer: 2,5

Rationale 1: The nurse would not be concerned about urine output unless it was less than 30mL/hour.

Rationale 2: The nurse should monitor for and report any manifestations of graft leakage, including groin pain.

Rationale 3: This is a normal finding.

Rationale 4: This is a normal finding.

Rationale 5: The nurse should monitor for and report any manifestations of graft leakage, including back pain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 30

Type: MCMA

A patient is demonstrating signs of thrombophlebitis. The nurse understands that which mechanisms occur with this disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Bleeding into surrounding tissues

2. Blood hypercoagulation

3. Sluggish blood flow

4. Elevated systemic blood pressure

5. Vessel damage

Correct Answer: 2,3,5

Rationale 1: Bleeding into surrounding tissues is not associated with thrombophlebitis.

Rationale 2: Blood hypercoagulation is one part of Virchows triad, the three pathologic factors associated with thrombophlebitis.

Rationale 3: Stasis of blood is one of three pathologic factors, called Virchows triad, associated with thrombophlebitis.

Rationale 4: Systemic blood pressure elevation is not a mechanism of this problem.

Rationale 5: Vessel damage is one of three pathologic factors, called Virchows triad, associated with thrombophlebitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 31

Type: FIB

The patients brachial artery systolic pressure is 144 mmHg, and the right ankle systolic pressure is 120 mmHg. The nurse calculates the patients anklebrachial index to be ______.

Standard Text:

Correct Answer: 1.2

Rationale : The anklebrachial index is calculated by dividing the average brachial systolic pressure by the average ankle systolic pressure: 144/120 = 1.2.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 32

Type: FIB

The nurse would conduct additional assessment for peripheral arterial disease if the patients anklebrachial index is lower than_______.

Standard Text:

Correct Answer: 0.4

Rationale : A patient whose anklebrachial index is lower than 0.4 is likely to have severe peripheral arterial disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 35-3

Question 33

Type: FIB

A patient has the nursing diagnosis Impaired Physical Mobility related to decreased blood flow to the lower extremities. To address this nursing diagnosis, the nurse should instruct the patient to walk for at least 30 minutes at least _______ times a week.

Standard Text:

Correct Answer: 3

Rationale : Walking for 30 minutes at least three times a week will promote collateral development and enhance existing circulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-3

Question 34

Type: MCMA

A patient is transferred to the postanesthesia unit after surgery to repair an abdominal aortic aneurysm. The patients temperature is 34.6C. What actions should be taken by the nurse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Plan to keep the patients temperature low until he is completely awake from anesthesia.

2. Wrap the patients head in warmed blankets.

3. Rewarm the patient as quickly as possible.

4. Administer warmed IV fluids.

5. Ask respiratory therapy to warm inspired ventilator air.

Correct Answer: 2,4,5

Rationale 1: Low temperature increases systemic vascular resistance, so the patient should be rewarmed.

Rationale 2: Heat is rapidly lost from the head. Wrapping the head in warm blankets helps to rewarm the patient.

Rationale 3: The patient should be rewarmed slowly, no more than 1 degree per hour.

Rationale 4: Warm IV fluids are used to rewarm the patient.

Rationale 5: Settings on the ventilator can warm inspired air and help to rewarm the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 35-4

Question 35

Type: MCMA

The nurse has provided medication instruction for a patient who will be discharged on warfarin therapy. The nurse evaluates the patient has understood dietary restrictions when the patient lists which foods to avoid?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Green tea

2. Soybeans

3. Caffeinated beverages

4. Avocado

5. Cauliflower

Correct Answer: 1,2,4,5

Rationale 1: Green tea is brewed from green leaves and can increase vitamin K in the body if taken in large quantities.

Rationale 2: Soybeans can change the amount of vitamin K in the body.

Rationale 3: There is no indication that caffeinated beverages alter the amount of vitamin K in the body.

Rationale 4: Avocado can change the amount of vitamin K in the body.

Rationale 5: Cauliflower can change the amount of vitamin K in the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 35-5

 

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