Nokea
The nurse is caring for a client who is status postoperative from a vein stripping. What would the nurse monitor for in the client?
- A. Swelling in the inoperative leg
- B. Blood on the dressing on the inoperative leg
- C. Warm, pink toes in the inoperative leg
- D. Swelling in the operative leg
Correct Answer: D
Rationale: When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
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After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?
- A. Troponin I
- B. Myoglobin
- C. WBC (white blood cell) count
- D. C-reactive protein
Correct Answer: B
Rationale: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels do not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of CAD?
- A. To dilate coronary arteries
- B. To decrease workload of the heart
- C. To decrease homocysteine levels
- D. To prevent angiotensin II conversion
Correct Answer: B
Rationale: Beta-adrenergic blockers are used in the treatment of CAD to decrease the consumption of myocardial oxygen by reducing heart rate and workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and B vitamins) are used to decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.
The client asks the nurse to explain the difference between arteriosclerosis and atherosclerosis. Which is the best explanation the nurse can give to the client?
- A. Both terms refer to the same disorder and can be used interchangeably
- B. Both are disorders in which the lining of the vessels become narrowed due to plaque
- C. Arteriosclerosis is when the vessels become dilated and weakened, whereas atherosclerosis is the deposit of fatty substances in the vessel lining
- D. Arteriosclerosis is a loss of elasticity of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the arteries fill with plaque
Correct Answer: D
Rationale: Arteriosclerosis refers to the loss of elasticity or hardening of the arteries that accompanies the aging process, whereas atherosclerosis is a condition in which the lumen of arteries fills with fatty deposits called plaque. The two terms do not refer to the same disorder, nor can they be used interchangeably. The other responses provide the client with inaccurate information.
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
- A. Examine the client's mental and emotional status
- B. Examine the legs for color, capillary refill time, and tissue integrity
- C. Examine for pain around the shoulder and neck region
- D. Examine the extremities for skin lesions
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.
The nurse provides care to a menopausal client who states, 'I read a news article that says I am at risk for coronary vascular disease due to inflammation.' Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?
- A. Addressing obesity
- B. Avoiding the use of caffeine
- C. Taking a daily multivitamin
- D. Drinking at least 2 liters of water a day
Correct Answer: A
Rationale: The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.