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The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
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The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply.
- A. Assess for paresthesia.
- B. Assess for pedal pulses.
- C. Assess for paralysis.
- D. Assess for pallor.
- E. Assess for polar (temperature).
Correct Answer: A,B
Rationale: Paresthesia (A) and pedal pulses (B) assess neurovascular status in venous insufficiency. Paralysis (C) and pallor (D) are arterial, and polar/temperature (E) is assessed but not primary.
The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client?
Correct Answer: 1180
Rationale: Total intake = IV fluids (880 mL D5W + 100 mL NS) + oral fluids (8 oz water + 4 oz milk + 6 oz broth). 1 oz = 30 mL, so oral = (8+4+6) × 30 = 540 mL. Total = 880 + 100 + 540 = 1,180 mL. Output (1,480 mL) is not included in intake.
Which complication of anticoagulant therapy should the nurse teach the client to report to the health-care provider?
- A. Gastric upset.
- B. Bleeding from any site.
- C. Constipation.
- D. Myocardial infarction.
Correct Answer: B
Rationale: Bleeding (B) is a serious anticoagulant complication, requiring HCP notification. Gastric upset (A) and constipation (C) are minor, and MI (D) is unrelated.
Which lifestyle modification should the nurse emphasize for a client newly diagnosed with hypertension?
- A. Increase dietary sodium intake.
- B. Limit exercise to once a week.
- C. Reduce alcohol consumption.
- D. Sleep 4 hours per night.
Correct Answer: C
Rationale: Reducing alcohol consumption helps lower blood pressure, as excessive alcohol can elevate it.
The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor?
- A. Blood urea nitrogen (BUN) levels.
- B. Bilirubin levels.
- C. International normalized ratio (INR).
- D. Partial thromboplastin time (PTT).
Correct Answer: C
Rationale: Warfarin toxicity is monitored via INR (C), which reflects bleeding risk. BUN (A) assesses kidneys, bilirubin (B) liver, and PTT (D) is for heparin.