Nokea
A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
- A. The client will not disturb the intravenous infusion.
- B. The client will comply with dietary restrictions.
- C. The client will not experience bleeding.
- D. The client will keep the right leg elevated on two pillows.
Correct Answer: C
Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.
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The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?
- A. Cardiomyopathy
- B. Paroxysmal nocturnal dyspnea
- C. High-output failure
- D. Multisystem heart failure
Correct Answer: B
Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.
The nurse is determining the type of arthritis a patient is experiencing. Which assessment finding would be present if the patient has rheumatoid arthritis?
- A. Stiffness is relieved by activity
- B. Health history includes weight loss and fever
- C. Abnormal joint findings are limited to the hands
- D. Heberden’s nodes are located on the finger joints
Correct Answer: B
Rationale: In rheumatoid arthritis, the health history often includes systemic symptoms such as weight loss and fever. Rheumatoid arthritis is a chronic inflammatory autoimmune disease that affects multiple joints symmetrically. Unlike osteoarthritis where joint stiffness is often relieved by activity, stiffness in rheumatoid arthritis is typically worse in the morning and after inactivity. In rheumatoid arthritis, joint deformities can occur in various joints, not just limited to the hands. Heberden's nodes are characteristic of osteoarthritis, not rheumatoid arthritis.
What causes brown pigmentation of the lower extremities in clients with venous stasis?
- A. The necrosis of subcutaneous fat due to tissue hypoxia
- B. Breakdown of red blood cells in the congested tissues
- C. Reduced inflammatory and immune response from congested circulation
- D. Skin atrophy caused by lack of circulation
Correct Answer: B
Rationale: The brown pigmentation of the lower extremities in clients with venous stasis is primarily caused by the breakdown of red blood cells in the congested tissues. When there is venous stasis, the blood circulation is impaired, leading to a backup of blood in the lower extremities. This stagnant blood contains hemosiderin, a byproduct of red blood cell breakdown. Over time, the hemosiderin deposits in the tissues, causing the characteristic brown discoloration seen in conditions such as chronic venous insufficiency. This process is known as hemosiderin deposition and is a common consequence of venous stasis.
A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. What is the mechanism of action of this drug?
- A. Prevents conversion of angiotensin I to angiotensin II
- B. Prevents beta-receptor stimulation in the heart
- C. Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells
- D. Blocks alpha-receptors in the vascular smooth muscle
Correct Answer: D
Rationale: Terazosin is an alpha-1 adrenergic receptor blocker. By blocking alpha-1 receptors in the vascular smooth muscle, terazosin causes dilation of both arteries and veins, leading to reduced peripheral vascular resistance and decreased blood pressure. This dilation effect is achieved by preventing the binding of norepinephrine to alpha-1 receptors, thereby inhibiting vasoconstriction. Terazosin is commonly used in the treatment of hypertension to help lower blood pressure by reducing the workload on the heart and improving blood flow to organs and tissues.
The nurse hears a grating sound while assessing the range of motion of a patient’s hip. How should the nurse document this finding?
- A. Crackles
- B. Arthritis
- C. Synovitis
- D. Crepitation
Correct Answer: D
Rationale: Crepitation refers to a grating sound or sensation that occurs when there is rubbing together of the roughened articular surfaces of bones within a joint. It is commonly associated with conditions such as osteoarthritis or joint injury. Therefore, if the nurse hears a grating sound while assessing the range of motion of a patient's hip, the appropriate documentation of this finding would be crepitation.