Concept 15: Perfusion My Nursing Test Banks

Concept 15: Perfusion

Test Bank

MULTIPLE CHOICE

1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student states, Central perfusion

a.

is monitored only by the physician.

b.

involves the entire body.

c.

is decreased with hypertension.

d.

is toxic to the cardiac system.

ANS: B

Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the bodys ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.

REF: 149 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

2. A patient was diagnosed with hypertension. The patient asks the nurse how this disease could have happened to them. The nurses best response is Hypertension

a.

happens to everyone sooner or later. Dont be concerned about it.

b.

can happen from eating a poor diet, so change what you are eating.

c.

can happen from arterial changes that impede the blood flow.

d.

happens when people do not exercise, so you should walk every day.

ANS: C

Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patients diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.

REF: 153 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best response would be, The sinoatrial node

a.

provides the heart with the stimulation to beat in a normal rhythm.

b.

protects the heart from atherosclerotic changes.

c.

provides the heart with oxygenated blood.

d.

protects the heart from infection.

ANS: A

The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.

REF: 149

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

4. The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. The nurses primary concern is to monitor for

a.

mental alertness.

b.

perfusion.

c.

pain.

d.

reaction to medications.

ANS: B

Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.

REF: 153

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A patients serum electrolytes are being monitored. The nurse notices that the potassium level

is low. The nurse knows that the patient should be observed for

a.

tissue ischemia.

b.

brain malformations.

c.

intestinal blockage.

d.

cardiac dysthymia.

ANS: D

Cardiac dysthymia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.

REF: 152

OBJ: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student states, Perfusion

a.

is a normal function of the body, and I dont have to be concerned about it.

b.

is monitored by the physician, and I just follow orders.

c.

is monitored by vital signs and capillary refill.

d.

varies as a person ages, so I would expect changes in the body.

ANS: C

The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.

REF: 154 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

7. The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment?

a.

Blood pressure above the normal range

b.

Bounding pedal pulses

c.

Night blindness

d.

Reflux disease

ANS: A

Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

REF: 151

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

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