Nokea
Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?
- A. High blood pressure
- B. Severe back pain
- C. Abdomen bruit
- D. Nausea and vomiting
Correct Answer: C
Rationale: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive.
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Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
- A. Inform client of diagnostic tests
- B. Remove hair from skin insertion sites
- C. Assess distal pulses
- D. Withhold anticoagulant therapy
Correct Answer: D
Rationale: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
A client is prescribed a nitroglycerin transdermal patch to treat angina. Which statement does the nurse include when reinforcing medication teaching to the client prior to discharge?
- A. You do not need the effects of this medication while you sleep
- B. The medication patch causes headaches so you should remove it daily
- C. The patch should be worn for 12 hours and then removed for 12 hours
- D. Skin irritation is common when the patch is worn for more than 12 hours
Correct Answer: C
Rationale: A transdermal nitroglycerin patch is prescribed for the prevention of angina pectoris. Nitroglycerin transdermal patches are typically applied for 12 to 14 hours, and then removed for the same amount of time. Though it is true that common adverse effects of nitroglycerin are headaches and contact dermatitis and that there is less demand on the heart when the client rests, these are not the reasons for applying and removing the patch for the same length of time in a 24-hour period.
A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?
- A. Coronary artery disease
- B. Raynaud syndrome
- C. Cardiogenic shock
- D. Venous occlusive disease
Correct Answer: A
Rationale: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud syndrome in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.
Which of the following factors would the nurse identify as a modifiable risk factor for the development of varicose veins?
- A. Mother and maternal grandmother had varicose veins
- B. Employed as an over-the-road truck driver
- C. Weight gained during past pregnancies
- D. History of thrombophlebitis in both extremities
Correct Answer: B
Rationale: Over-the-road truckers sit for long periods of time, and because prolonged sitting should be avoided, employment change could modify the risk associated with varicose vein aggravation. Varicose veins have a familial tendency, but this cannot be modified. Weight gained during previous pregnancies and history of thrombophlebitis cannot be changed.
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
- A. Moderation is the key to everything
- B. Ask your physician to prescribe the new reverse lipid drug
- C. Increase the soy in your diet
- D. Exercise, keep your blood sugar in check, and manage your stress
Correct Answer: D
Rationale: Although moderation is the key, this does not provide specific options for this client such as regular exercise and managing stress and cholesterol levels. The reverse lipid drug sounds good but is not available or approved by the FDA. Soy products have limited benefits for cholesterol control.