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Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
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The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
- A. I have stomach pain every time I eat a big, heavy meal.'
- B. I don’t have any abdominal pain or any type of problems.'
- C. I have periodic episodes of constipation and then diarrhea.'
- D. I belch a lot, especially when I lie down after eating.'
Correct Answer: B
Rationale: Small AAAs are often asymptomatic (B). Postprandial pain (A), bowel changes (C), and belching (D) suggest GI issues, not AAA.
Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.
The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
Which medication would the nurse expect to administer to a client with an arterial disorder to improve blood flow?
- A. Warfarin (Coumadin)
- B. Clopidogrel (Plavix)
- C. Furosemide (Lasix)
- D. Metoprolol (Lopressor)
Correct Answer: B
Rationale: Clopidogrel is an antiplatelet medication that reduces the risk of clot formation, improving blood flow in arterial disorders.
The client is at risk for a myocardial infarction due to decreased tissue perfusion as a result of atherosclerosis. Which instructions can the nurse provide the client to reduce the risk?
- A. Teach the client to control the blood pressure to less than 140/90.
- B. Instruct the client to exercise 30 minutes a day three (3) times a week.
- C. Demonstrate how to take the blood pressure using a battery-operated cuff.
- D. Inform the client to limit fat intake and which foods have a higher fat content.
Correct Answer: A,B,D
Rationale: Controlling BP <140/90 (A), exercising 30 min 3×/week (B), and limiting fat (D) reduce MI risk. BP cuff use (C) is monitoring, not prevention.