Acute & Chronic Exam 2 Quizzes

When planning care for a client at risk for PE, the nurse prioritizes A. Maintaining the client on bed rest B. Using sequential compression devices (SCDs) C. Encouraging the client to cough and deep breathe D. Teaching the client to use incentive spirometry

B

The nurse is examining a patient and notes that he has pinpoint red and reddish brown spots on his back, abdomen, and arms. These would be recorded in the nurses notes as 1) Petechiae 2) Hematomas 3) Hemorrhages 4) Ecchymotic areas.

1

The nurse analyzes the laboratory results of a child with hemophilia. Which of the following is most likely to be abnormal in this child? 1) Activated partial thromboplastin time (APTT). 2) Bleeding time. 3) Platelet count. 4) Prothrombin time (PT).

1 APTT measure clotting activity in the intrinsic pathway which includes activation of several clotting factors, among them factor VIII. In hemophilia, the intrinsic clotting factor VIII is deficient, resulting in prolonged APTT. The other values measure other components of the clotting mechanism.

A 5-year-old with previously diagnosed hemophilia A is being admitted with hemarthrosis. The nurse should include which of the following interventions for this child? Choose all that apply. 1) Ice packs to the affected joints. 2) Application of splints with elevation of affected extremity. 3) Administration of aspirin, indocin, butazolodin. 4) Administration of corticosteroids. 5) Passive range of motion exercises.

1,2 & 4

Which statement best describes aplastic anemia? 1) The bone marrow does not produce the normal cellular components of blood. 2) Intrinsic factor in the stomach is not produced in enough quantity to allow absorption of B12 from food. 3) Decreased red blood cells occur because they have fragile cell walls and are damaged in circulation. 4) Red blood cells are lost because abnormalities in the clotting cascade.

1 Aplastic anemia causes "pancytopenia" which is to say that the bone marrow is not adequately functioning. As the bone marrow produces all three blood cell types, the patient will manifest with thrombocytopenia, neutropenia and anemia.

A nursing student asks the nurse "What is the pathophysiology of disseminated intravascular coagulation (DIC)?" How best does the nurse answer the student? 1) The underlying cause in DIC is the clotting cascade is overstimulated and clotting factors are depleted, resulting in microemboli formation and bleeding. 2) Clots form form damage endothelium and the rough edges of the lumen attract platelets and begin the clotting process. 3) Clotting factors are not produced by a diseased liver and so clotting is disrupted. 4) DIC is a hereditary disorder in which the client is lacking one or more clotting factors.

1 DIC occurs when the microthrombi are formed inside of the vasculature. The process is initiated by overstimulation of of the clotting cascade. Microthrombi cause damage to small vessels all over the body, but the more impending issue in DIC is blood loss from the lack of available clotting factors and platelets.

A nurse monitors a client's peripheral pulses after an axillary-femoral bypass to ensure adeqate perfusion. The nurse knows that this is a critical assessment to perform to evaluate for 1) successful restoration of perfusion to the affected extremity. 2) fluid volume deficiency secondary to blood lose during surgery. 3) deep vein thrombosis secondary to prolonged immobility. 4) hypertension and plaque buildup in the extremities.

1 The bypass surgery in this question is performed to restore blood flow to an extremity after an arterial occlusion. Assessment of pulses reassures the healthcare team that blood flow is restored to the affected extremity and maintained in the throughout the graft which is prone to embolism.

A nurse is planning care for a 17-year-old patient who has been diagnosed with thrombocytopenia secondary to leukemia. Which of the following interventions will be included in the plan of care? 1) The patient will be started on birth control. 2) The patient will use a soft-bristle toothbrush. 3) The patient will be started on an anticoagulant. 4) The patient will not be allowed to eat acidic foods such as citrus and tomato sauce.

1 & 2 Female patients will generally be started on birth control to prevent uncontrolled blood loss that can occur with menses. Soft-bristle toothbrushes are encouraged to decrease trauma (thereby preventing blood loss) to the mucus membranes in the mouth.

The nurse is teaching a group of parents of children with hemophilia. What needs to be included in the teaching plan? Choose all that apply. 1) Hemophilia is usually an X-linked disorder that affects the male children of a carrier mother. 2) Hemophilia is a recessive disorder carried by either the mother or father. 3) All of the daughters of the parents of a child with hemophilia will be carriers. 4) Each of the sons of these parents has a 50% chance of being affected and each of their daughters has a 50% chance of being a carrier.

1 & 4

Physical assessment of a patient yields the following data: crackles in bilateral lungs, fatigue and hacking cough. The nurse knows that these manifestations align with which of the following disorders? 1) Left-side heart failure. 2) Right-sided heart failure. 3) Peripheral vascular disease. 4) Severe hypertension.

1) Left-side heart failure Left-sided heart failure occurs when the left side of the heart does not adequately pump blood into the aorta and periphery. The blood pools in the left side and eventually collects in the lungs. Increased vascular permeability caused by increased pulmonary congestion causes crackles, coughing and shortness of breath/fatigue.

A client who is taking metoprolol (Lopressor) says, "My brother-in-law takes Inderal for his heart condition. I have high blood pressure, but I didn't think anything was wrong with my heart." Select the best nursing response. 1) "Lopressor is used for high blood pressure as well as several heart conditions." 2) "A heart condition is exactly what is causing your high blood pressure." 3) "Your brother-in-law must be confused; this drug is not used to treat heart disease." 4) "If you have questions about your medication, I would recommend that you ask your doctor."

1) Lopressor is used for high BP as well as several heart conditions Beta blockers such as metoprolol are used in HTN to decrease vasoconstriction and decrease how hard the heart must pump.

Cool temperature of the feet and pain on ambulation indicate which type of peripheral vascular disease (PVD)? 1) Arterial. 2) Venous. 3) Capillary. 4) Hypertension.

1) arterial If there is a problem with perfusion as you would see with an arterial problem, you would see cool extremities where blood supply is poor. Pain on ambulation is usually described as intermittent claudication. This pain is caused by decreased oxygenation of tissues in the extremity because the artery is partially blocked. It often occurs during exercise because of increased oxygen need and subsides with rest. These are characteristic signs of PVD.

A patient is on the DASH (Dietary Approaches to Stop Hypertension) diet and he tells the nurse what he had for lunch. Which item on his menu indicates he is non-adherent to his diet and needs further teaching? 1) Canned vegetables. 2) One cup of low-fat yogurt 3) One cup of coffee 4) Two slices of white toast with jelly

1) canned vegetables Part of the rationale for the DASH diet is to keep sodium intake to no more than 2.4 grams per day. It seems that keeping sodium at this level reduces fluid retention that can increase the workload of the heart and raise blood pressure. There are other components of the DASH diet that are important such as eating foods rich in potassium and other minerals and low in fat. Fresh fruits and vegetables are a major addition to the diet. Be sure you check out the website on Joint National Commission on Hypertension for more information on the DASH diet and other aspects of treatment for high blood pressure.

Which of the following is not a sign of right-sided heart failure? 1) Shortness of breath. 2) Distention of the jugular veins. 3) Hepatomegaly. 4) Pedal edema.

1) shortness of breath In clinical practice, it is usual to see both right- and left-sided heart failure - not just one. So patients will have signs of both. But it is important for you to understand the pathophysiology of each type separately so that you can understand rationale for treatment and teach patients about their disease process. Pulmonary congestion, dizziness, shortness of breath usually are associated with left-sided failure, while pedal edema, hepatomegaly and JVD are signs of right-sided failure.

A nurse is preparing a patient for electrical cardioversion. The nurse will include which of the following in the preparations (select all that apply)? 1) Obtain a signed consent form 2) Administer sedation, as ordered. 3) Assess the patient for any allergies. 4)Administer NSAID for pain prophylaxis.

1,2&3 Informed consent is needed in order to perform electrical cardioversion. This is considered a non-emergent intervention, so the patient can be assessed for allergies, emotional readiness, questions, etc. The procedure is generally performed under sedation; however, the nurse would not administer a non-opioid analgesic as it would have little therapeutic effect in this situation.

The nurse is assessing a patient who is newly admitted for systolic heart failure. Which of the following symptoms would the nurse expect to find (select all that apply)? 1) Shortness of breath 2) Fatigue, even at rest 3) Activity intolerance 4) Hypertension in the evening 5) High serum glucose

1,2,3 Shortness of breath, fatigue and activity intolerance are all cardinal symptoms of heart failure. HTN, which is actually a sign not a symptom, is usually not see in heart failure because the heart is not pumping adequately to produce increased blood pressure.

A nurse is reviewing medication orders for a client who is admitted for management of chronic heart failure. The nurse expects which of the following drug classes to be included in the orders (select all that apply)? 1) Angiotensin-converting enzyme (ACE) inhibitors 2) Beta-blockers. 3) Positive inotropes 4) Diuretics 5) Anti-platelet aggregate

1,2,3&4 Yes, these drugs reduce afterload to help treat HF. Yes, these drugs help decrease the strength and contraction as well as the heart rate which helps the failing heart. Yes, this drug class often represnted by digitalis has been used for years to treat HF. Yes, these drugs are used to decrease preload which decreases the workload of the heart.

The nurse provides instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which interventions should be included in the teaching plan. Choose all that apply. 1) Supervise the child closely 2) Pad corners of the furniture. 3) Remove household items that can easily fall over and hurt the child. 4) Pad joints with extra clothing. 5) Avoid immunizations and dental hygiene until the child is in school.

1,2,3,4 It is important to stress the importance of immunizations, dental hygeine and routine well-child care. The other interventions are important tips to help make the environment as safe as possible so that the child does not injure himself and have a bleeding episode.

The nurse is caring for a 7-year-old diagnosed with hemophila A. Which information should the nurse report immediately to the physician? 1) Platelet count of 150,000/ mm3. 2) PT of 12 seconds. 3) Headache and confusion. 4) Presence of petechiae on chest and back.

3

A patient is on bedrest after having knee surgery. Low-molecular weight heparin is given subcutaneously to prevent which complication that might be seen in this person? 1) Kidney stones. 2) Deep vein thrombosis. 3) Bleeding from the operative site. 4) Orthostatic hypotension.

2

Which of the following is the preferred intravenous solution for the administration of blood to a patient? 1) D5W 2) Normal saline 3) Lactated Ringer's solution 4) Mannitol

2 Blood products are typically infused with normal saline. It is the preferred and only acceptable solution to use in most cases.

A nurse is caring for a patient who is admitted to the hospital with suspected atrial fibrillation. The nurse knows that the plan of care for this patient will include all but what? 1) Anticoagulation therapy 2) Low sodium diet 3) Echocardiography 4) Antidysrhythmic agent

2 Anticoagulation therapy is a hallmark treatment for atrial fibrillation as it prevents a blood clot from forming in the atria. An antidysrhythmic medication such as amiodarone would be expected to treat the dysrhythmia. Echocardiography will allow for more thorough diagnosis of disorder and cause as it demonstrates heart function and anatomy. A low sodium diet would not be expected for this patient.

Which of the following interventions should be included when developing a plan to decrease preload in the patient with heart failure? 1) Administering digoxin to decrease myocardial oxygen demand. 2) Positioning the patient in a high-Fowler's position with the feet dependent in the bed 3) Administering oxygen per mask, nasal cannula, or non-invasive ventilatory support. 4) Encouraging leg exercises to improve venous return.

2 Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload.

A nurse is admitting a 57-year-old male client to the emergency department. The client states that he is having severe pain in his left upper back and shoulder. Assessment yields the following data: HR: 105bpm; BP 88/60; peripheral pulses are thready and extremities are cool to the touch. Which of the following actions should the nurse take first? 1) Assess finger stick blood sugar. 2) Obtain a type & cross for blood product. 3) Continue monitoring the patient. 4) Administer pain medication.

2 This patient is manifesting with a ruptured aortic aneurysm. As this is considered a life-threatening emergency, the priority is managing airway, breathing and circulation. Any interventions that promote IV fluids (including blood products) should be prioritized.

Which of the following statements about atria fibrillation are true (select all that apply)? 1) This rhythm is described as having a sawtooth pattern on an ECG strip. 2) The atria are not effectively contracting which causes blood to pool. 3) There is disorganized atrial activity caused by ectopic signals in the heart. 4)The ventricular rate is greater than this atrial rate in this dysrhythmia.

2&3 Atrial fibrillation is a dysrhythmia that is caused by ectopic pathways in the heart that cause extra impulses to fire. This disrupts normal atrial function and even causes the atria to lose effective contraction. If the atria is not contracting, blood will pool in the atria and eventually clot. The atria rate is much high than the ventricular rate, although the ventricular rate may be elevated above normal in this dysrhythmia.

A patient who is being seen at a clinic complains of pain in the right leg that occurs when walking. The patient states, "I could walk from here to the door and be in pain. When I sit down to rest, it goes away." The nurse knows that this symptom is consistent with 1) hypertension. 2) arterial disease. 3) venous disease. 4) heart failure.

2) arterial disease Regardless of which arteries are involved in occlusion, it seems that plaque formation within vessels or arterosclerosis is responsible in most cases for the narrowing of the vessel lumen that results in arterial vascular disease. Because there is narrowing due to buildup of plaque along the walls of the vessels, blood supply through the vessel is decreased. The occlusion can progress even to the point in which supply is very decreased. Clinical manifestations occur when the occlusion is 60%-75%. This patient is manifesting signs of acute arterial occlusion that resolves with rest which is called intermittent claudication- a sign of arterial disease.

Which is the most common manifestion of thalassemia? 1) Polycythemia 2) Cranial bossing. 3) Excess absoprtion of iron. 4) Increased secretions in lungs.

3 Although patients with thalessemia major may manifest cranial bossing secondary to bone marrow expansion, this is not a typical manifestation of thalessemia minor. All patients with thalessemia will require frequent blood transfusion to treat chronic anemia and a secondary complication of this treatment is iron overloading. Chelation therapy is used to rid the body of excess iron.

A patient is leaving the hospital after being diagnosed with pernicious anemia. Which of the following statements to the patient by the nurse is correct about this disease? 1) "You will take sub Q injections of B12 for the rest of your life." 2) "Heat treatments with a heating pad will decrease swollen joints." 3) "The incidence of gastric cancer is increased with your disease and you should continue follow-up care." 4) "Your unsteady balance will completely reverse once folic acid and B12 are started."

3 B12 injections are given IM; PO administration of B12 will render ineffective due to the lack of intristic factor available to bind to the B12 in the stomach, which is why IM injections are necessary. Swollen joints are not a symptom that occurs with pernicious anemia. Gastric cancer is at greater incidence in patients with pernicious anemia is it is caused by an underlying disorder of the stomach lining. The patient should be referred for follow-up care to determine the cause of the pernicious anemia and rule out cancerous cells.

The nurse is developing a discharge plan for parents of a child with sickle cell disease (SCD). What is the most important intervention to be included in this plan? 1) Be sure that meals are on a regular schedule. 2) Provide a low salt diet to the child. 3) Stress the importance of routine immunizations. 4) Watch for frequent nosebleeds.

3 Because acute sickling is likely to occur during periods of stress, illness and dehydration, it is critically important that the nurse teach the parents of this patient to immunize the child to prevent communicable disease. Additionally, the nurse should also teach the parents how to avoid other triggers.

Which of the following provides the most accurate description of a thrombocyte? 1) Works within the intristic pathway of the clotting cascade to promote a fibrin clot. 2) Establishes a fibrin clot by promoting clotting factor accumulation along the extrinsic pathway. 3) Thrombocytes work to stop bleeding by accumulating to form a platelet plug. 4) Thrombocytes facilitate gas exchange by binding to oxygen and carbon dioxide.

3 Consider the clotting process. Platelets (or thrombocytes) are the basis of what forms the initial platelet plug. Clotting factors in the intrinsic and extrinsic pathway are responsible for forming a fibrin clot that is longer lasting and is later dissolved by the body's intrinsic heparin.

The nurse instructs a patient with iron-deficiency anemia about foods to include in her diet. Which of the following should be included in the diet for this patient? 1) Fruit and milk 2) Cheeses and processed lunch meat. 3) Dark green vegetables and muscle meats 4) Fruit juices and cornmeal breads

3 Muscle meats and organ meats are high in iron as are dark green leafy vegies. Eggs yolks, dried fruits, beans, whole-grains and enriched bread and cereal and even potatoes are other good sources of iron. The other sources, even processed lunch meat are not particularly high in iron which this person needs to make more RBCs.

Which of the following items should the nurse instruct the client with iron deficiency anemia to avoid? 1) Citrus fruits 2) Poultry 3) Tea 4) Leafy green vegetables

3 Tannates (in tea and coffee), carbonates, the chelating agent EDTA, and the medicinal antacid trisilicate all hinder iron absorption from the gut. Green leafy vegetables (remember Popeye and spinach) are good sources of iron. Citrus fruits with Vitamin C help improve Fe absorption and while poultry is not a great source of iron, it does not have to be avoided in this case.

The dysrhythmia, bradycardia, in an adult means what? 1) Irregular heartbeat. 2) Heart rate of 90. 3) Heart rate below 60. 4) Bounding heart rate.

3 A heart rate below 60 beats/minute is usually considered bradycardia in an adult. In some individuals who have large muscular hearts, the heart rate might be abnormally low and still not interfere with CV function or cardiac output. This is especially true of adolescents and athletes. Children have higher rates normally than do most adults. A HR below 100 beats per minute is usually considered bradycardia in an infant.

Question 12 1 / 1 point An elderly patient with a 1 pack per day (ppd) history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath. There is a need to rule out pneumonia versus heart failure. Which is the best diagnostic test to help a nurse and health care team in determining whether the patient has heart failure? 1) 12-lead electrocardiogram (ECG) 2) Arterial blood gases (ABGs) 3) B-type natriuretic peptide (BNP) 4) Troponin and creatine kinase (CK)

3 BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and electrolytes may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

Which of the following provides the best description of the concept of stroke volume? 1) Stroke volume is the amount of blood expelled by the heart each minute. 2) Stroke volume is the number of times the ventricles contract each minute. 3) Stroke volume is the amount of blood pumped with each ventricular contraction. 4) Stroke volume is the force with which the ventricles contract with each beat.

3 Stroke volume is the amount of blood pumped out of the heart with each beat. If you time this amount by the heart rate (the number of times the heart beats in one minute), it would yield the cardiac output. Contractility is the force with which the ventricles beat.

What is the effect on the heart when the vagus nerve is stimulated? 1) Increased force of contraction. 2) Increased excitability of the heart. 3) Decreased rate of firing of the SA node. 4) Prolonged PR interval.

3 When the vagus nerve (or the parasympathetic nervous system) is stimulated, the heart rate slows down. This is accomplished through a decreased rate of firing of the SA node. There is also a decreased force of contraction. Stimulation of the sympathetic nervous system (flight or fight) increases the heart rate and strength of contraction of the heart.

The nurse is reviewing a presentation on sickle cell anemia (SCA) that a peer is presenting to parents. Which part of the presentation needs to be questioned by the reviewing nurse? 1) Under certain circumstances HgbS changes its normal round shape to a long slender shape. 2) If a person with sickle cell anemia marries a person with normal hemoglobin A, all of their offspring will carry the trait. 3) The first symptoms are noticed in the first 2-3 months of life 4) The usual hemoglobin level of the child may be as low as 6g/dL

3 So you are looking for the false choice here - different type of question than usual in which you are looking for the one true answer. In this one there are 3 true choices and 1 false (the answer). Be sure you read and understand the stem of the question before you choose. This is true and ok to include in the presentation. The person who has SCA has only affected genes to pass on to the offspring. All offspring will carry the trait. The disease will not be manifested though, because of the normal partner. Do the Punnett sqare to visulaize this if needed. Remember from bilogy?

A nurse is teaching a patient who is newly diagnosed with Buerger's Disease. The nurse should include which of the following statements in this teaching (select all that apply)? 1) "You will experience edema in your hands." 2) "It's typical to have shortness of breath with this disease." 3) "The only way to prevent advancement of the disease is to stop smoking." 4) "You should avoid caffeinated beverages." 5) "You will be placed on a fluid restriction."

3 & 4 Buerger's Disease is commonly caused by smoking and using tobacco products. The patient should be counseled to stop smoking and also avoid anything that may cause vasoconstriction including caffeine. Edema and shortness of breath are not symptoms that occur with this disease and fluid restriction is not included in the plan of care.

The nurse is reviewing orders for a patient who is admitted for possible heart failure. The provider has requested frequent assessment of urine output. The nurse knows that this is because 1) urine output often increases during physiologic stress 2) an increase in urine output is expected because of peripheral vasodilatation and bedrest 3) adequate heart function is needed for kidneys to function properly and produce urine. 4) an increase in urine output indicates impending heart failure.

3) adequate heart function is needed for kidneys to function properly and produce urine The client in heart failure or one who does not have adequate cardiac output does not have an adequate blood supply to perfuse the major organs, especially the kidneys. A fall in urine output is an early sign that the kidneys are not being perfused. The kidneys must have a good blood supply in order to produce urine. This is an important concept to grasp since it is used in several different disease processes besides heart failure, including shock, myocardial infarction, sepsis, many others. The cause of decreased cardiac output might be different, but decreased perfusion of kidneys and resultant decreased urine output are a sign of trouble that should be investigated.

oung, immature erythrocytes that normally account for less than 2% of the circulating red blood cells (RBCs) are: 1) eosinophils. 2) moncytes. 3) hematocrit. 4) reticulocytes.

4

A 42-year-old woman was diagnosed with ruptured appendix. She was hospitalized for surgery, peritonitis, and sepsis and is being cared for by the nurse in the ICU. She is complaining of generalized weakness and headache. She has a large echymotic area on her right upper arm, fine pinpoint, flat red rash on her abdomen and back, and oozing of blood from one of her old IV sites. Her urine is darker than it was yesterday. Her vital signs are as follows: T 100.4 degrees F, P 95, RR 26, BP, 100/50. The nurse knows that signs and symptoms with this history most like indicate what disorder? 1) Hemorrhagic shock. 2) Septic shock due to infection. 3) Undiagnosed hemophilia A. 4) Disseminated intravascular coagulation (DIC).

4 Bleeding in a person with no history or obvious cause should be questioned because it may be one of the first manifestations of acute DIC. Bleeding manifestations may include skin (petechiae, oozing blood, venipuncture site bleeding, and occult hemorrhages), hematuria, tachypnea, orthopnea, bone and joint pain, GI bleeding.

A nursing student is called into a room by the mother of a patient. The student finds the patient non-responsive and the ECG tracing on the monitor is "flat-lined". Which of the following actions should the student take first? 1) Call time of death and notify the patient's nurse. 2) Assess the patient's finger stick blood sugar. 3) Ensure that the ECG leads are connected appropriately. 4) Initiate basic life support and call for help.

4 Basic life support is initiated when the student assesses breathing and pulse. The student would allow that assessment data to guide further actions, as needed (chest compressions and rescue breaths). If the patient is breathing and a pulse is present, the student's next action is to ensure that the leads are attached and trouble shoot ECG tracing issues. Assessing FSBS is not the highest priority intervention; however, low blood sugar may be the cause of the patient's non-responsive state.

What is the most significant, immediate consequence that occurs as a result of ventricular tachycardia (VT)? 1) The heart will cease to beat altogether. 2) Blood clots form in the ventricle because of pooling of blood. 3) A heart attack is often caused by VT. 4) There is severe decrease in cardiac output.

4 Because the heart is not pumping in an organized fashion in VT, there is significant decrease in the ability of the heart to pump effectively. Cardiac output can decrease significantly resulting in decreased perfusion of tissues. Usually blood clots are not a major problem as they are in atrial fibrillation. VT is often a result of a heart attack (myocardial infarction) not a cause.

A nurse has received change-of-shift report about the following clients on the telemetry unit. Which client should the nurse see first? 1) A client with atrial fibrillation, heart rate 88, who has a new warfarin order 2) A client with type 1 second-degree AV block, heart rate 60, who is dizzy during ambulation. 3) A client who is in a sinus rhythm, heart rate 98, after having electrical cardioversion 2 hours ago 4) A client with an implantable cardiac defibrillator (ICD) that fired three times today and who is scheduled for a dose of amiodarone.

4 The frequent firing of the ICD indicates that the client's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

A patient comes to the ER complaining of severe upper back pain that started suddenly this morning. Upon assessment of the patient, the nurse also finds a midline abdominal pulsation, thready pulses in all four extremities and decreased urine output. Given this information, the nurse suspects 1) deep vein thrombus. 2) right sided heart failure. 3) chronic arterial obstruction. 4) aortic aneurysm.

4 The midline abdominal pulsation coupled with the pain experienced by this patient indicates abdominal aneurysm. The decreased urine output and thready peripheral pulses occur secondary to decreased blood flow to the periphery. The nurse would act quickly to facilitate diagnosis and treatment for this patient.

A nurse is called to assess a neighbor's father, who has a history of heart disease. He is complaining of pain in his left leg unrelieved by position changes. Also the leg is pale, cold, and pulseless. The nurse suspects which disease process and does what about it? 1) Chronic arterial disease and suggests he make an appointment with his doctor as soon as possible. 2) Deep vein thrombosis and dorsiflexes the foot to check for Homan's sign. 3) Pulmonary embolism and calls for immediate emergency medical services. 4) Acute arterial occlusion and advises the neighbor to transport now him to the nearest hospital.

4 The symptoms correlate with acute arterial occlusion. Emergent transportation to the nearest hospital is needed to restore arterial blood flow and preserve the function and integrity of the affected extremity. The symptoms of acute arterial occlusion can be remembered by the 6 P's- Pulselessness, pallor, pain, poikilothermia (temperature is the same as the environment), paralysis and paresthesia.

A patient is seen in a clinic for evaluation of a vascular disease. The patient states that when she drinks cold beverages or goes outside on a cool day she experiences discoloration and pain in her fingers. The nurse suspects 1) peripheral vascular disease. 2) venous thrombosis. 3) Buerger's Disease 4) Raynaud's Phenomenon

4) Raynaud's Phenomenon Raynaud's is triggered by acute arterial occlusion secondary to vasospasm of the distal arteries and terminal arterioles and typically occurs in the hands and feet. Symptoms include pallor or cyanosis of the fingers when exposed to temperature changes. Pain and numbness may also be experienced during acute vasospastic episodes.

A nurse is monitoring a patient's ECG pattern and notes that the QRS complex has greater amplitude than what is expected. The nurse knows that this indicates 1) the ventricles are highly irritable. 2) the atria are contracting too often. 3) the SA node is firing too frequently. 4) the ventricles are contracting forcefully.

4) the ventricles are contracting forcefully The QRS complex on an ECG corresponds to ventricular contraction. Amplitude is the vertical plane on an ECG strip and correlates with how forcefully the muscle is contracting.

The nurse is providing discharge instructions regarding precipitating factors of sickle cell disease (SCD) to the parents of a 5-year old with this disorder. Which of the following are precipitating factors for SCD? Choose all that apply. 1) Infection. 2) Trauma. 3) Dehydration. 4) Stress 5) Hypoxia

All of them All of these are triggers for sickling episodes and should be avoided as possible.

A patient with a history of chronic heart failure is hospitalized with severe dyspnea and a dry, hacking cough. Assessment findings include pitting edema in both ankles, BP 170/100 mm Hg, pulse 92 beats/minute, and respirations 28 breaths/minute. Which explanation, if made by the nurse, is most accurate? a. "The assessment indicates that venous return to the heart is impaired, causing a decrease in cardiac output." b. "The manifestations indicate impaired emptying of both the right and left ventricles, with decreased forward blood flow." c. "The myocardium is not receiving enough blood supply through the coronary arteries to meet its oxygen demand." d. "The patient's right side of the heart is failing to pump enough blood to the lungs to provide systemic oxygenation."

B The patient is experiencing acute decompensated heart failure with symptoms of both right- and left-sided heart failure. Left-sided heart failure prevents normal, forward blood flow and causes pulmonary congestion. Right-sided heart failure causes a backup of blood and results in venous congestion.

The home care nurse visits a patient with chronic heart failure who is taking digoxin (Lanoxin) and furosemide (Lasix). The patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take? a.Perform a dipstick urine test for protein. b.Notify the health care provider immediately. c.Have the patient eat foods high in potassium. d.Ask the patient to record a weight every morning.

B Administration of furosemide increases excretion of potassium and may cause hypokalemia. The risk for digitalis toxicity increases if potassium levels are below normal and digoxin is administered. Signs and symptoms of digitalis toxicity include anorexia, nausea and vomiting, visual disturbances (such as "yellow" vision), and dysrhythmias.

A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these drugs? a. Observe skin turgor b. Auscultate lung sounds c. Measure blood pressure d. Review intake and output

B Left-sided heart failure will prevent normal blood flow and will cause blood to back up into the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium and then the alveoli, which manifests as pulmonary congestion and edema. The most important assessment to determine if the drugs are improving the patient's condition is to auscultate lung sounds. The other assessments are important, but the best indicator of improvement of left ventricular function is a reduction in adventitious lung sounds (crackles).