Nokea
A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
- A. Could you walk further than that a few months ago?
- B. Do you walk mostly uphill, downhill, or on flat surfaces?
- C. Have you ever considered swimming instead of walking?
- D. How much pain medication do you take each day?
Correct Answer: A
Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain-free indicates the client's disease is worsening. The other questions are useful but not as critical.
You may also like to solve these questions
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client's weight has decreased significantly since the last visit. What action by the nurse is best?
- A. Ask if the weight loss was intentional
- B. Encourage a high-protein, high-fiber diet
- C. Measure for new compression stockings
- D. Review a 3-day food recall diary
Correct Answer: C
Rationale: Compression stockings must fit correctly to be effective. After significant weight loss, the client should be re-measured for new stockings. The other options are appropriate but less critical.
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
- A. Administer pain medication
- B. Assess distal pulses every 10 minutes
- C. Have the client sign a surgical consent
- D. Notify the Rapid Response Team
- E. Take vital signs every 10 minutes
Correct Answer: B,D,E
Rationale: This client may have a rupturing aneurysm. The nurse should notify the Rapid Response Team and perform frequent assessments of pulses and vital signs. Pain medication could lower blood pressure further, and consent should be handled after the physician explains the procedure.
A student nurse asks what essential hypertension is. What response by the registered nurse is best?
- A. It is caused by another disease
- B. It means it must be treated immediately
- C. It has no specific cause
- D. It refers to severe and life-threatening hypertension
Correct Answer: C
Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension caused by another disease is secondary hypertension. Severe, life-threatening hypertension is malignant hypertension.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.