Nokea
The nurse assesses pitting edema that can be depressed approximately $4 \mathrm{~mm}$ and refills in 15 seconds. The nurse would document this assessment as:
- A. +1 edema.
- B. +2 edema.
- C. +3 edema.
- D. +4 edema.
Correct Answer: B
Rationale: A +2 edema can be documented if the skin can be depressed $4 \mathrm{~mm}$ and respond within 15 seconds.
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The nurse is aware that which layer is the muscle layer of the heart, which is responsible for the heart's contraction?
- A. endocardium.
- B. pericardium.
- C. mediastinum.
- D. myocardium.
Correct Answer: D
Rationale: The myocardium is the specialized muscle layer that allows the heart to contract.
A patient questions 'Why all the fuss about a little high blood pressure? My father had it and he lived to be 65 years old.' The nurse bases the answer, knowing that which complication can occur due to untreated blood pressure?
- A. Chronic Obstructive Pulmonary Disease (COPD)
- B. Frequent and severe infectious disease of the lungs
- C. Increased risk of myocardial infarctions (MI) and stroke
- D. Severe corneal abrasions, requiring corneal transplants
Correct Answer: C
Rationale: Hypertension is called the 'silent killer' because a patient with elevated blood pressure does not display signs and symptoms of heart disease until damage has begun to develop. This damage increases the risks of heart disease, stroke, heart failure, or cardiovascular death.
The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called
Correct Answer: automaticity
Rationale: Automaticity is the special ability of the myocardium to contract in a rhythmic pattern.
The nurse reinforcing a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for which change?
- A. reduction of alcohol intake.
- B. avoiding cold remedies.
- C. cessation of smoking.
- D. weight reduction.
Correct Answer: C
Rationale: The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.
The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause which disorder?
- A. hypotension.
- B. thrombophlebitis.
- C. pulmonary emboli.
- D. heart failure.
Correct Answer: D
Rationale: Heart failure can result from rapid infusion of intravenous fluids in older adults.