Cha 1 Prep U Pain, MI, CAD

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my wife look at the soles of my feet each day."

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement?

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control.

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication?

160-190 mg/dL

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for:

3 to 5 days.

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent?

50

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission?

A child quickly removing a hand when touching a hot object

Which of the following is a disadvantage of using the transdermal route of opioid administration?

A delay in effect until the dermal layer is saturated

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?

A ripping sensation in the chest

Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?

Acute pain

The nurse provides care to a menopausal client, who states, "I read a news article that says I am at risk for coronary vascular disease due to inflammation." Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?

Addressing obesity

A client is postoperative and has not taken her pain medication. The nurse is performing an assessment at the beginning of her shift and determines that sensitization has occurred. The first nursing intervention is to

Administer the prescribed intravenous opioid.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply.

An abdominal pulsatile mass A systolic bruit Low back pain Lower abdominal pain

Which aneurysm occurs as a result of infection at arterial suture or graft sites?

Anastomotic

Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

Angina pectoris

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:

Anterior surface of the foot near the ankle joint.

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect?

Aortic aneurysm

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for?

Bradypnea

Which is a diagnostic marker for inflammation of vascular endothelium?

C-reactive protein (CRP)

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

A client comes to the emergency department (ED) reporting precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?

Coronary artery disease

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

Which aneurysm results in bleeding into the layers of the arterial wall?

Dissecting

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?

Elevate the legs periodically for at least 15 to 20 minutes.

Which statement is accurate regarding Raynaud disease?

Episodes may be triggered by unusual sensitivity to cold.

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client?

Furosemide

A nurse is caring for a client after cardiac surgery. Upon assessment, the client appears restless and reports nausea and weakness. The client's ECG reveals peaked T waves. The nurse reviews the client's serum electrolytes, anticipating which abnormality?

Hyperkalemia

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?

Ineffective peripheral tissue perfusion

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion

A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking?

Intermittent claudication

Which term refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?

Intermittent claudication

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.

Intervertebral disk herniation

The nurse is caring for a client with upper extremity arterial disease. Which assessments will the nurse include in the client's plan of care? Select all that apply.

Measure blood pressure on both arms. Assess capillary refill on both arms every 2 hours. Compare radial pulses on both wrists every 2 hours.

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Moderate to severe arterial insufficiency

Aortic dissection may be mistaken for which of the following disease processes?

Myocardial infarction (MI)

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?

Numbness, cool skin temperature, and pallor

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Obesity

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?

Pallor

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in a regular walking program.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours?

Peripheral pulses every 15 minutes after surgery

A client who is watching television with a visitor reports severe pain and wants pain medication. Which action will the nurse take?

Prepare a dose of pain medication as prescribed.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

An elderly client has a fractured hip and is in Buck's traction. The client is disoriented and cannot express herself. At 0730 the client was calm. Now, at 0930, the client is restless and agitated. The nurse reviews the medication administration record. The last dose of opioid was at 0330. The nurse assesses the client's agitation may be from

Recurring pain

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system?

Respiratory

Which of the following is the most effective intervention for preventing progression of vascular disease?

Risk factor modification

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking.

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

Taking daily walks

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply a graduated compression stocking.

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details?

The client can walk about 50 feet before getting pain in the right lower leg.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery.

Which of the following is a reliable source for quantifying pain?

The client's description of the pain

Which of the following is the most common site for a dissecting aneurysm?

Thoracic area

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?

Ulceration

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

The nurse is caring for a client with kidney stones who reports severe pain. What type of pain does the nurse understand this client is experiencing?

Visceral pain

The nurse is teaching a client who has been newly diagnosed with Raynaud syndrome. Which self-care strategies should the nurse include in the teaching? Select all that apply.

Wear gloves to protect hands from injury when performing tasks. Do not smoke, or stop smoking. Reduce emotional triggers

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug?

calcium-channel blocker

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine

causes vasospasm.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography.

A client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows:

elevated troponin levels.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system.

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing?

neuropathic pain

The nurse is assessing a client with suspected post-pericardiotomy syndrome after cardiac surgery. What manifestation will alert the nurse to this syndrome?

pericardial friction rub

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes

vasospasm