Nokea
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.
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Which medical treatment would be prescribed for the client with an AAA less than 3 cm?
- A. Ultrasound every six (6) months.
- B. Intravenous pyelogram yearly.
- C. Assessment of abdominal girth monthly.
- D. Repair of abdominal aortic aneurysm.
Correct Answer: A
Rationale: Small AAAs (<3 cm) are monitored with ultrasound every 6 months (A). IV pyelogram (B) is irrelevant, girth (C) is not standard, and repair (D) is for larger AAAs (>5.5 cm).
Which finding in a client post-myocardial infarction requires immediate action?
- A. Chest pain lasting 20 minutes
- B. Heart rate of 85 beats per minute
- C. Blood pressure of 135/90 mmHg
- D. Mild anxiety
Correct Answer: A
Rationale: Prolonged chest pain post-myocardial infarction may indicate reinfarction or ischemia, requiring immediate intervention.
Which complication should the nurse monitor for in a client with pericarditis?
- A. Cardiac tamponade
- B. Pneumonia
- C. Renal failure
- D. Seizures
Correct Answer: A
Rationale: Cardiac tamponade is a serious complication of pericarditis, where fluid accumulation compresses the heart.
The client with aortic stenosis asks why they feel tired. What is the best response?
- A. Your heart is not pumping enough blood.
- B. Your lungs are retaining fluid.
- C. Your blood pressure is too high.
- D. Your heart rate is too slow.
Correct Answer: A
Rationale: Aortic stenosis restricts blood flow from the heart, reducing cardiac output and causing fatigue.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client's BP is 110/70.
- B. The client's potassium level is 3.4 mEq/L.
- C. The client has a barky cough.
- D. The client's apical pulse is 56.
Correct Answer: D
Rationale: Beta blockers slow heart rate; an apical pulse of 56 (D) may indicate bradycardia, warranting caution. BP 110/70 (A) is acceptable, K+ 3.4 (B) is low but unrelated, and cough (C) is not a contraindication.