Nokea
Which nursing assessment finding(s) suggests increased risk for coronary artery disease? Select all that apply.
- A. Arcus senilis
- B. Pear-shaped body
- C. Plump ear lobes
- D. Xanthelasma
- E. Sensory loss
- F. Motor changes
Correct Answer: A,D
Rationale: Arcus senilis is the opaque ring seen around the cornea that results from deposit of fat granules, and xanthelasma is raised yellow plaque on the eyelids. Both of these findings are suggestive of lipid accumulation that can increase the risk of CAD. An apple-shaped body carries a higher risk. Diagonal creases in the earlobe have been suggestive of CAD. Sensory and motor changes are more associated with CVA than CAD.
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The nurse is caring for a client who is post-varicose vein surgery. The nurse would include which teaching measure(s)? Select all that apply.
- A. Exercise
- B. Cool compresses
- C. Elastic stockings
- D. Lower the extremities
- E. Stand rather than sit
- F. Take warm showers in the morning
Correct Answer: A,C
Rationale: Movement/exercise and use of elastic stocking aid in venous return. Cool compresses can cause vasoconstriction, which can diminish arterial blood flow. Elevation of legs can be helpful in aiding venous return. Standing or sitting for prolonged periods of time should be avoided. Showers in the morning can dilate blood vessels and contribute to venous congestion and edema.
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 scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?
- A. Everything will be fine. Your family is here for you
- B. Don't cry; you have the best team of doctors
- C. Would you like something to calm your nerves?
- D. Tell me what concerns you most
Correct Answer: D
Rationale: Allowing the client to share feelings tends to relieve or reduce emotional distress. Telling a client that everything is fine negates the feelings they are expressing. Telling a client not to cry can be viewed as insensitive to the feelings being expressed. Providing a prescribed sedative may be helpful but does not address the fears and concerns of the client.
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
- A. Examine the client's mental and emotional status
- B. Examine the legs for color, capillary refill time, and tissue integrity
- C. Examine for pain around the shoulder and neck region
- D. Examine the extremities for skin lesions
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.
The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?
- A. Arteriosclerosis
- B. Coronary thrombosis
- C. Atherosclerosis
- D. Raynaud's disease
Correct Answer: C
Rationale: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.