Nokea
Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
- A. Cool dry lower limb
- B. Darker, thick and toughened skin on medial surface of the leg
- C. Lack of hair and shiny appearance of the lower leg
- D. Lack of a pedal pulse
Correct Answer: B
Rationale: Signs of a venous disorder include darker, thick and toughened skin. Venous disorders can lead to a stasis ulcer. Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.
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The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
- A. I can ambulate in the hallway with this gadget on.'
- B. I always take off the telemetry device when I shower.'
- C. My EKG is being watched by one of the nurses in CCU on the home unit.'
- D. I am able to sleep just fine with this device on.'
Correct Answer: B
Rationale: Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.
What is the major cause of cardiac valve disease in past years?
- A. Rheumatic fever
- B. Long history of malnutrition
- C. Drug abuse
- D. Obesity
Correct Answer: A
Rationale: Rheumatic fever, a streptococcal infection, was the major cause of cardiac valve disease in past years.
A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?
- A. CK-MB
- B. Elevated white count
- C. Elevated sedimentation rate
- D. Low level of sodium
Correct Answer: A
Rationale: The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific.
The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is
Correct Answer: intermittent claudication
Rationale: Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest.
The nurse is aware that which layer is the muscle layer of the heart, which is responsible for the heart's contraction?
- A. endocardium.
- B. pericardium.
- C. mediastinum.
- D. myocardium.
Correct Answer: D
Rationale: The myocardium is the specialized muscle layer that allows the heart to contract.