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Which assessment data would support that the client has a venous stasis ulcer?
- A. A superficial pink open area on the medial part of the ankle.
- B. A deep pale open area over the top side of the foot.
- C. A reddened blistered area on the heel of the foot.
- D. A necrotic gangrenous area on the dorsal side of the foot.
Correct Answer: A
Rationale: Venous stasis ulcers are superficial, pink, and medial (A) due to venous pooling. Deep/pale (B) or necrotic (D) ulcers suggest arterial insufficiency, and blisters (C) are unrelated.
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The client with coronary artery disease asks why they need a stress test. What is the best response?
- A. It checks for blood clots in your heart.
- B. It evaluates how your heart works under stress.
- C. It measures your cholesterol levels.
- D. It monitors your blood pressure.
Correct Answer: B
Rationale: A stress test assesses heart function during physical stress to detect ischemia or blockages.
Which risk factor revealed in the client's health history is most closely related to the development of varicose veins?
- A. The client's mother also has varicose veins.
- B. The client was a track athlete in high school.
- C. The client is a 50-year-old corporate executive.
- D. The client smokes one pack of cigarettes daily.
Correct Answer: A
Rationale: Varicose veins have a strong genetic component, so a family history, such as the client's mother having varicose veins, is a significant risk factor.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
The client diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.
Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome?
- A. The physical therapist.
- B. The thoracic surgeon.
- C. The occupational therapist.
- D. The social worker.
Correct Answer: A
Rationale: Physical therapy (A) helps relieve thoracic outlet syndrome symptoms through exercises and posture correction. Surgery (B) is rare, OT (C) is less specific, and social work (D) is unrelated.