aa 2nd playlist. Chapter 31 Brunner&Suddarth, Med surg Brunner and Suddarth - Electrolytes, Brunner and Suddarths Textbook of Medical Surgical Nursing- Chapter 27: Management of Patients with Coronary Vascular Disorders, Brunne...

Osmolality

Concentration of fluid that affects the movement of water between compartments by osmosis. Serum osmolality used to measure sodium content, BUN, glucose. Urine osmolality is determined by urea, uric acid, and creatinine levels.

Creatinine

End product of of muscle metabolism. Better indicator of renal function. Normal range is 0.7 to 1.4 mg/dl (62-124 mmol/l). Renal dysfunction would cause an increase in creatinine levels.

Sodium-potassium pump

Energy required pump regulating sodium and potassium levels against the gradient, reason for higher sodium content in ECF, and high potassium content of ICF.

Sodium

Higher quantity in ECF, important in regulating volume of body fluid.

Potassium

Higher quantity in ICF, ECF can only tolerate small changes in potassium levels, trauma which causes release of intracellular potassium can be quite dangerous, at extreme causing cessation of the heart.

Body compartments - fluid

Intracellular (inside cell) and extracellular (outside cell); extracellular sub divided into intravascular (inside blood vessels), interstitial (matrix outside cell), transcellular (space just outside the cell membrane); loss of fluid can disrupt equilibrium between compartments (fluid shift). Neurologic and circulatory symptoms, physical examination, and lab test can differentiate what compartment is experiencing fluid loss.

Systematic points of fluid gains and losses

Kidneys (urine volume 1 to 2L, or 1 ml/kg/h), skin (avg. 500ml/day of sweat containing potassium, sodium, and chloride), lungs (insensible loss of 300ml), GI (100 to 200 ml/day, circulates and 8L in a day).

Third space fluid shift

Loss of ECF into spaces that do not contribute to ICF ECF equilibrium; signs of shift include: decrease urine output, increased heart rate, decreased BP, edema, increased weight, I&O imbalance. Shift takes place with hypocalcemia, decreased iron, liver disease, alcoholism, hypothyroidism, malabsorption, immobility, burns, and cancer.

Hematocrit

Measure of volume percentage of RBCs in whole blood. Normal range is 42%-52% in men and 35%-47% for females. Values increase with dehydration and polycythemia. Percentages decrease with overhydration and anemia.

Hydrostatic pressure vs. osmotic pressure

Movement of fluid between capillary bed and tissue is regulate by opposing forces of hydrostatic and osmotic pressure. Changes in either will cause fluid to shift from one space to the other in altered proportions.

Filtration

Movement of fluid under hydrostatic pressure along capillary into interstitial. Filtration also takes place at the kidneys (180L a day)

Electrolytes

Positively charged (cations) and negatively charged (anion) chemicals. Major cations are sodium, potassium, calcium, magnesium, and hydrogen; major anions are chloride, bicarbonate, phosphate, sulfate, ad proteinate ions. Make of electrolytes differ between ICF and ECF

Diffusion

Transfer of particles moving from higher concentration to lower concentration - passive movement of electrolytes

BUN

Urea which is a by-product of metabolism of protein by the liver. Normal BUN values is 10 to 20 mg/dl (3.6-7.2 mmol/L). Factors affecting BUN level is renal function (dysfunction, BUN goes up), GI bleeding, dehydration, increased protein intake, fever, and sepsis. BUN decreases with end stage liver disease, starvation, low protein based diet, and fluid expansion (as seen in pregnancy).

Urine sodium levels

Value changes with sodium intake and fluid status (void of endocrine dysfunction). Normal urine sodium is 75 to 200 mEq/24h (75 to 200 mmol/24 hour), or random specimen will have about >40 mEq/l. Used in diagnosing hyponatremia and acute renal failure.

Hypovolemia causes

Vomiting, diarrhea, GI suctioning, sweating, decreased intake, or third-space fluid shift. Diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, and coma are also causes.

Extracellular fluid

1/3 of the body, high in sodium, calcium, chloride, bicarbonate, and organic acids, 6L of plasma and blood cells (RBC, WBC), 12L of interstitial (includes lymph), 1L of trancellular fluids (cerebrospinal, pericardial, synovial, intraoccular).

Intracellular fluid

2/3 of body fluid, mostly found in skeletal muscle, high in potassium, magnesium, phosphate and sulfate, and proteinate (small protein molecules which carry charges)

Body composition

60% of adult weight is fluid; age, gender, and body fat effect fluid %; skeleton least amount of fluid, muscle and skin the most.

Hypovolemia

Also known as fluid volume deficit (FVD) entails ECF loss greater than intake of fluid. Electrolytes and water are losses in the same proportion, ratios are unchanged. Hypovolemia is not dehydration (loss of water with increased sodium concentration).

When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography

Ans: A Feedback: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A) Ensure that the patient's heels are protected and supported. B) Closely monitor the patient's serum albumin and prealbumin levels. C) Perform gentle massage of the patient's lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

Ans: A Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema

Ans: A Feedback: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patient's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patient's physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

Ans: A Feedback: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patient's extremities when at rest

Ans: A Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."

Ans: A Feedback: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patient's symptoms.

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.

Ans: A Feedback: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.

Ans: A Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.

The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

Ans: A, B, E Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patient's legs E) Identification of mobility limitations

Ans: A, C, D, E Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease

Ans: B Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynaud's disease; none of these health problems produce this cluster of signs and symptoms.

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.

Ans: B Feedback: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.

Ans: B Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynaud's disease

Ans: B Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

Ans: B Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

Ans: B Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

Ans: B Feedback: Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.

Ans: B Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.

Ans: B Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patient's wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed

Ans: B Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

Ans: B, C, D Feedback: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynaud's phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

Ans: C Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.

The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE

Ans: C Feedback: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.

Ans: C Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator

Ans: C Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD

Ans: C Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.

How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.

Ans: C Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further compromise venous return.

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis

Ans: C Feedback: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%

Ans: C Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

Ans: C Feedback: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for VTE.

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

Ans: C Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

Ans: D Feedback: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

Ans: D Feedback: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD

Ans: D Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.

A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis

Ans: D Feedback: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

Ans: D Feedback: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patient's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

Ans: D Feedback: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.

A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

Ans: D Feedback: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C) "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D) "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

Ans: D Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MI—there are no "new arteries."

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

Ans: D Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

2. A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? A) Retinal blood vessel damage B) Glaucoma C) Cranial nerve damage D) Hypertensive emergency

Ans: A Feedback: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.

20. The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include? A) Patient will reduce Na+ intake to no more than 2.4 g daily. B) Patient will have a stable BUN and serum creatinine levels. C) Patient will abstain from fat intake and reduce calorie intake. D) Patient will maintain a normal body weight.

Ans: A Feedback: Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal. None of the other listed goals is quantifiable and measurable.

14. A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A) Obesity and high intake of sodium and saturated fat B) Diabetes and use of oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta

Ans: A Feedback: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal disease, and coarctation of the aorta are causes of secondary hypertension.

10. A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize? A) Rising slowly from a lying or sitting position B) Increasing fluids to maintain BP C) Stopping medication if dizziness persists D) Taking medication first thing in the morning

Ans: A Feedback: Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.

18. A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the patient has done which of the following? A) Tried to rest quietly for 5 minutes before the reading is taken B) Refrained from smoking for at least 8 hours C) Drunk adequate fluids during the day prior D) Avoided drinking coffee for 12 hours before the visit

Ans: A Feedback: Prior to the nurse assessing the patient's BP, the patient should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.

16. A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following? A) Secondary hypertension has a specific cause. B) Secondary hypertension has a more gradual onset than primary hypertension. C) Secondary hypertension does not cause target organ damage. D) Secondary hypertension does not normally respond to antihypertensive drug therapy.

Ans: A Feedback: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.

7. A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patient's care, what desired outcome should the nurse identify? A) Patient takes medication as prescribed and reports any adverse effects. B) Patient's BP remains consistently below 140/90 mm Hg. C) Patient denies signs and symptoms of hypertensive urgency. D) Patient is able to describe modifiable risk factors for hypertension.

Ans: A Feedback: The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the patient's role in his or her treatment regimen.

9. A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem? A) Renal failure B) Right ventricular hypertrophy C) Glaucoma D) Anemia

Ans: A Feedback: When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.

23. The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. A) Transient ischemic attacks B) Cerebrovascular accident C) Retinal hemorrhage D) Venous insufficiency E) Right ventricular hypertrophy

Ans: A, B, C Feedback: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.

8. The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patient's adherence to the prescribed therapeutic regimen? A) Screen the patient for visual disturbances regularly. B) Have the patient participate in monitoring his or her own BP. C) Emphasize the dire health outcomes associated with inadequate BP control. D) Encourage the patient to lose weight and exercise regularly.

Ans: B Feedback: Adherence to the therapeutic regimen increases when patients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen.

13. The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions? A) Measuring the BP after the patient has been seated quietly for more than 5 minutes B) Taking the BP at least 10 minutes after nicotine or coffee ingestion C) Using a cuff with a bladder that encircles at least 80% of the limb D) Using a bare forearm supported at heart level on a firm surface

Ans: B Feedback: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.

22. The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem? A) Deficient knowledge regarding the lifestyle modifications for management of hypertension B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C) Deficient knowledge regarding BP monitoring D) Noncompliance with treatment regimen related to medication costs

Ans: B Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their BP.

15. The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client's hypertension? A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption. B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient. D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging.

Ans: B Feedback: Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.

27. During an adult patient's last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient's BP be categorized? A) Normal B) Prehypertensive C) Stage 1 hypertensive D) Stage 2 hypertensive

Ans: B Feedback: Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.

6. A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient? A) Quitting smoking will cause the patient's hypertension to resolve. B) Tobacco use increases the patient's concurrent risk of heart disease. C) Tobacco use is associated with a sedentary lifestyle. D) Tobacco use causes ventricular hypertrophy.

Ans: B Feedback: Smoking increases the risk for heart disease, for which a patient with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse's advice; the association with heart disease is more salient.

11. The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment? A) 156/96 mm Hg or lower B) 140/90 mm Hg or lower C) Average of 2 BP readings of 150/80 mm Hg D) 120/80 mm Hg or lower

Ans: B Feedback: The goal of antihypertensive drug therapy is a BP of 140/90 mm Hg or lower. A pressure of 130/80 mm Hg is the goal for patients with diabetes or chronic kidney disease.

39. A patient's medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A) Drowsiness or lethargy B) Increased urine output C) Decreased heart rate D) Mild agitation

Ans: B Feedback: Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output. These drugs do not cause bradycardia, agitation, or drowsiness.

29. A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state? A) Avoid excessive potassium intake. B) Exercise on a regular basis. C) Eat less protein and more vegetables. D) Limit morning activity.

Ans: B Feedback: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein intake.

36. The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A) Increased venous return B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions E) Decreased blood viscosity

Ans: B, C, D Feedback: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.

17. The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? A) Progressive target organ damage B) Possibility of medication interactions C) Lack of adherence to prescribed drug therapy D) Possible heavy alcohol use or use of recreational drugs

Ans: C Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of patients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions.

1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse's health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Ans: C Feedback: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

19. The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia

Ans: C Feedback: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.

5. A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" Which of the following responses by the nursing instructor would be best? A) "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." B) "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." C) "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." D) "You have no need to worry. Your pressure is probably elevated because you are being tested."

Ans: C Feedback: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the student that there is no need to worry.

12. A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the patient's age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to 120/75 mm Hg as quickly as possible.

Ans: C Feedback: Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.

24. The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following? A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D

Ans: C Feedback: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not normally indicated.

34. A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student? A) "Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up." B) "Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly." C) "Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure." D) "The neurologic system of older adults is less efficient at monitoring and regulating blood pressure."

Ans: C Feedback: Structural and functional changes in the heart and blood vessels contribute to increases in BP that occur with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes.

25. The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)

Ans: C Feedback: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patient's immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.

37. A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient? A) "Eat a banana every day because Diuril causes moderate hyperkalemia." B) "Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium." C) "Diuril can cause low blood pressure and dizziness, especially when you get up suddenly." D) "Diuril increases sodium levels in your blood, so cut down on your salt."

Ans: C Feedback: Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids, or hot weather. Diuril does not cause either moderate hyperkalemia or severe hypokalemia and it does not result in hypernatremia.

3. A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks "about a pack of beer" every day. The nurse notes what nonmodifiable risk factor for hypertension? A) Hyperlipidemia B) Excessive alcohol intake C) A family history of hypertension D) Closer adherence to medical regimen

Ans: C Feedback: Unlike cholesterol levels, alcohol intake and adherence to treatment, family history is not modifiable.

31. A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following? A) Heart rate B) Sodium levels C) Potassium levels D) Blood lipid levels

Ans: D Feedback: Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate does not correlate closely with BP. Potassium levels do not normally relate to BP.

35. A 55-year-old patient comes to the clinic for a routine check-up. The patient's BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse's best response? A) "Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs." B) "Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group." C) "Hypertension is the leading cause of death in people your age." D) "Hypertension greatly increases your risk of stroke and heart disease."

Ans: D Feedback: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.

4. The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? A) The BP is always higher in a hypertensive emergency. B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.

Ans: D Feedback: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the patient's BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies.

26. A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurse's most appropriate action? A) Add sodium to the patient's IV fluid, as ordered. B) Administer a vasoconstrictor, as ordered. C) Promptly cease antihypertensive therapy. D) Administer normal saline IV, as ordered.

Ans: D Feedback: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.

38. A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency? A) Normalizing BP within 2 hours B) Obtaining a BP of less than 110/70 mm Hg within 36 hours C) Obtaining a BP of less than 120/80 mm Hg within 36 hours D) Normalizing BP within 24 to 48 hours

Ans: D Feedback: In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to 48 hours. For patients with this health problem, a BP of 120/80 mm Hg may be unrealistic.

30. The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal? A) Less than 140/90 mm Hg B) Less than 130/90 mm Hg C) Less than 129/89 mm Hg D) Less than 120/80 mm Hg

Ans: D Feedback: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.

28. A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patient's vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patient's BP be defined if a similar reading were obtained at a subsequent office visit? A) High normal B) Normal C) Stage 1 hypertensive D) Stage 2 hypertensive

Ans: D Feedback: JNC 7 defines stage 2 hypertension as a reading 160/100 mm Hg.

40. A patient's recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following? A) The client's oxygen saturation level B) The patient's red blood cells, hematocrit, and hemoglobin C) The patient's level of consciousness D) The patient's potassium level

Ans: D Feedback: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation.

32. A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A) Pacific Islanders B) African Americans C) Asian-Americans D) Hispanics

Ans: D Feedback: The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.

33. The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) "Are you eating less salt in your diet?" B) "How is your energy level these days?" C) "Do you ever get chest pain when you exercise?" D) "Do you ever see spots in front of your eyes?"

Ans: D Feedback: To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.

21. A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurse's best response? A) "We do this so you don't suffer a stroke." B) "We do this to determine how your blood pressure changes throughout the day." C) "We do this to see how often you should change your medication dose." D) "We do this to make sure your health is stable. We'll then monitor it at routinely scheduled intervals."

Ans: D Feedback: When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient must not change his or her medication doses unilaterally.