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The nurse is assessing a client with pericarditis. Which finding is most characteristic?
- A. Chest pain relieved by leaning forward
- B. Swelling in the ankles
- C. Fever above 103°F
- D. Bradycardia
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by leaning forward, reducing pressure on the inflamed pericardium.
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The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins?
- A. Wear low-heeled, comfortable shoes.
- B. Wear clean white cotton socks.
- C. Move the legs back and forth often.
- D. Wear graduated compression hose.
Correct Answer: D
Rationale: Compression hose (D) prevent venous pooling, reducing varicose vein risk. Low heels (A), socks (B), and leg movement (C) help but are less effective.
Which finding in a client with an arterial disorder indicates a worsening condition?
- A. Cool, pale skin on the affected leg
- B. Mild leg pain at rest
- C. Heart rate of 75 beats per minute
- D. Blood pressure of 125/80 mmHg
Correct Answer: A
Rationale: Cool, pale skin indicates worsening arterial insufficiency, suggesting reduced blood flow to the limb.
When assessing the client's lower leg, which findings characteristic of venous stasis ulcers is the nurse most likely to find? Select all that apply.
- A. Purulent drainage from lesions
- B. Blanched patches around open areas
- C. Dark brown, dry, and crusty skin
- D. Fluid-filled blisters
- E. Edema in the lower legs
- F. Fine red rash below the knee
Correct Answer: C,E
Rationale: Venous stasis ulcers are typically characterized by dark brown, dry, crusty skin due to hemosiderin deposition and edema in the lower legs due to venous insufficiency.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.
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).