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The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?
- A. Assess the client's mental and emotional status
- B. Assess the skin of the client
- C. Assess the characteristics of chest pain
- D. Assess for any kind of drug abuse
Correct Answer: C
Rationale: The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.
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A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regimen?
- A. Improve arterial flow
- B. Strengthen venous valves
- C. Increase venous congestion
- D. Improve venous return
Correct Answer: D
Rationale: The major goal in management of venous insufficiency is to promote venous circulation. Arterial flow improvement is not the goal of treatment for this disorder. Venous valves that are incompetent cannot be strengthened. Venous congestion is a complication of venous insufficiency.
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.
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?
- A. Pallor
- B. Cyanosis
- C. Gangrene
- D. Ulceration
Correct Answer: A
Rationale: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?
- A. Acute Pain
- B. Coping Impairment
- C. ADL Deficit
- D. Activity Intolerance
Correct Answer: A
Rationale: The hallmark symptom of Raynaud syndrome is acute pain related to the arterial insufficiency. ADL Deficit, Coping Impairment, and Activity Intolerance can occur but are less significant than Acute Pain.
The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?
- A. Arteriosclerosis
- B. Coronary thrombosis
- C. Atherosclerosis
- D. Raynaud's disease
Correct Answer: C
Rationale: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.