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Which intervention is appropriate for a patient who is experiencing an acute attack of Raynaud's disease?
- A. Vigorously rub both the hands in ice or snow.
- B. Place the hands in ice water to observe for pallor.
- C. Apply hot water over both the hands to rapidly warm the hands.
- D. Place mittens on the hands and encourage the patient to move fingers.
Correct Answer: D
Rationale: For an acute attack, the patient should wear layers such as mittens, and move the fingers and hands to improve circulation. Placing the hands in ice, snow or ice water would worsen the arterial constriction. Applying hot water would cause serious burns.
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The nurse assesses pitting edema that can be depressed approximately $4 \mathrm{~mm}$ and refills in 15 seconds. The nurse would document this assessment as:
- A. +1 edema.
- B. +2 edema.
- C. +3 edema.
- D. +4 edema.
Correct Answer: B
Rationale: A +2 edema can be documented if the skin can be depressed $4 \mathrm{~mm}$ and respond within 15 seconds.
The nurse reminds the patient that the American Heart Association recommends a lipid study how frequently?
- A. Every 2 years
- B. Every 2 to 3 years
- C. At least every 4 years
- D. Every 4 to 6 years
Correct Answer: D
Rationale: The American Heart Association recommends a lipid study every 4 to 6 years for all Americans over the age of 20.
The nurse identifies the 'lub' sound of the 'lub/dub' of the cardiac cycle as the sound of which event?
- A. AV valves closing.
- B. closure of the semilunar valves.
- C. contraction of the papillary muscles.
- D. contraction of the ventricles.
Correct Answer: A
Rationale: The lub is the first sound of a low pitch heard when the AV valves close.
A patient questions 'Why all the fuss about a little high blood pressure? My father had it and he lived to be 65 years old.' The nurse bases the answer, knowing that which complication can occur due to untreated blood pressure?
- A. Chronic Obstructive Pulmonary Disease (COPD)
- B. Frequent and severe infectious disease of the lungs
- C. Increased risk of myocardial infarctions (MI) and stroke
- D. Severe corneal abrasions, requiring corneal transplants
Correct Answer: C
Rationale: Hypertension is called the 'silent killer' because a patient with elevated blood pressure does not display signs and symptoms of heart disease until damage has begun to develop. This damage increases the risks of heart disease, stroke, heart failure, or cardiovascular death.
The nurse would reinforce teaching for a patient with Raynaud disease to include which teaching point?
- A. Warming hands and feet with a heating pad
- B. Using mittens in cold weather
- C. Practicing stress-reducing techniques
- D. Complete smoking cessation
- E. Using caution when cleaning the refrigerator or freezer
Correct Answer: B,C,D,E
Rationale: Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.