Nokea
The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching?
- A. Severe pain
- B. Paresthesia
- C. Warm and red incisions
- D. Inability to move the foot
Correct Answer: C
Rationale: Redness and warmth along the incision line are associated with inflammation or infection, not graft occlusion. Severe pain, paresthesia, and inability to move the foot are symptoms of acute arterial occlusion, indicating the client needs further teaching about incision symptoms.
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The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply.
- A. Increase isometric arm exercises to build endurance.
- B. Wear a facemask when outdoors in cold weather.
- C. Take nitroglycerin before a stressful event even if pain free.
- D. Perform most exertional activities in the morning.
- E. Take a daily laxative to avoid straining with bowel movements.
- F. Discontinue use of all tobacco products if you use these.
Correct Answer: B;C;F
Rationale: The nurse should instruct: B) Wearing a facemask in cold weather to prevent vasoconstriction; C) Taking nitroglycerin prophylactically to improve coronary blood flow; F) Discontinuing tobacco to reduce vasoconstriction. Isometric exercises, morning exertion, and daily laxatives are not recommended as they may increase cardiac workload or cause other issues.
The client is discovered to have a popliteal aneurysm. Because of the aneurysm, the nurse should closely monitor the client for which associated problem?
- A. Thoracic outlet syndrome
- B. Ischemia in the lower limb
- C. Pulmonary embolism
- D. Raynaud’s phenomenon
Correct Answer: B
Rationale: A popliteal aneurysm (located in the space behind the knee) may cause ischemia in the leg distal to the aneurysm due to thrombus forming inside the aneurysm and potential emboli. Other options are unrelated to popliteal aneurysms.
The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homo-cysteine levels includes eating foods rich in which nutrient?
- A. Monosaturated fats
- B. B complex Vitamins
- C. Vitamin C
- D. Calcium
Correct Answer: B
Rationale: Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, Vitamin C, and Calcium do not have a direct effect on homocysteine levels.
The nurse plans teaching for a 20-year-old newly diagnosed with hypertrophic cardiomyopathy. The client is on the college soccer team. Which information should be the nurse’s priority when teaching the client?
- A. Provide pamphlets on genetic testing to avoid passing on an inherited disease.
- B. Reinforce the need to continue exercise with soccer to strengthen the heart.
- C. Provide information about CPR to persons living with the client.
- D. Counsel on foods for consuming on a low-fat, low-cholesterol diet.
Correct Answer: C
Rationale: Because sudden cardiac death is a large risk factor for those under 30 years of age, the nurse should provide information about having others living with the client trained in CPR as a preventative measure. Genetic testing, continued strenuous exercise, and diet are less immediate priorities.
The nurse is assessing the client with an 8-centimeter AAA. Which finding should the nurse expect?
- A. Report of persistent nagging pain in the upper anterior chest
- B. Systolic bruit palpated over the upper abdomen
- C. Edema of the face and neck with distended neck veins
- D. A pulsating mass in the mid to upper abdomen
Correct Answer: D
Rationale: Throbbing or pulsating in the abdomen is the sign most indicative of an AAA. Chest pain, edema, and neck vein distention are associated with thoracic aneurysms, and a bruit is auscultated, not palpated.