Module 16 - Perfusion (16.H-M)
While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."
A) "Be alert for sudden weakness or numbness."
During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke? A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?" B) "Have you noticed your baby having trouble forming words?" C) "Does your baby vomit frequently after feeding?" D) "Does your baby frequently seem to lose her balance?"
A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?"
The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "It is normal for my urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."
A) "It is normal for my urine may become darker and smaller in amount each day."
A client diagnosed with peripheral vascular disease (PVD) is obese, has a 30-year history of cigarette smoking, and works as a contractor. When discussing risk factors for PVD, which statement by the nurse is appropriate? A) "Nicotine causes vasospasms, which reduce blood flow to the legs." B) "Obesity is a factor in cardiovascular disease but not peripheral vascular disease." C) "Nicotine primarily affects coronary arteries and the lungs." D) "Your current occupation is a major risk factor."
A) "Nicotine causes vasospasms, which reduce blood flow to the legs."
The nurse instructs a client about the medication nifedipine (Procardia) for hypertension. Which client statement indicates that additional teaching is needed? A) "This medication will cause my ankles to swell, which is normal." B) "I need to drink 6 to 8 glasses of water each day." C) "I will call my doctor if I gain weight or become short of breath." D) "I need to eat foods high in fiber when taking this medication."
A) "This medication will cause my ankles to swell, which is normal."
Which client has the highest risk of developing peripheral vascular disease (PVD)? A) 83-year-old African American male B) 78-year-old African American female C) 64-year-old Hispanic male D) 75-year-old White female
A) 83-year-old African American male
Which form of peripheral vascular disease is characterized by thickening, loss of elasticity, and calcification of arterial walls? A) Arteriosclerosis B) Atherosclerosis C) Chronic venous insufficiency D) Deep venous thrombosis
A) Arteriosclerosis
The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply. A) Assessment of deep tendon reflexes B) Assessment of intake and output C) Oxygen 2 liters nasal cannula as prescribed D) Seizure precautions E) Vital sign assessment
A) Assessment of deep tendon reflexes B) Assessment of intake and output D) Seizure precautions E) Vital sign assessment
The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 mmHg B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week
A) Blood pressure of 142/92 mmHg
The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years
A) Body mass index (BMI) 35.8
A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client? A) Cardiogenic shock B) Hypovolemic shock C) Neurogenic shock D) Septic shock
A) Cardiogenic shock
The nurse is caring for a child with a fractured femur who complains of sudden chest pain and difficulty breathing. Which test would the nurse question if it was ordered by the physician? A) D-dimer test B) V/Q scans C) Computerized tomography pulmonary angiography D) Magnetic resonance pulmonary angiography
A) D-dimer test
The nurse is assessing an adult client with a cardiac dysrhythmia. Which finding would the nurse identify as possibly contributing to this client's dysrhythmia? A) Drinks caffeinated coffee in the morning and for lunch B) Does not smoke or ingest any alcohol C) Plays golf three times a week and gardens daily D) Takes antihypertensive medication as prescribed
A) Drinks caffeinated coffee in the morning and for lunch
A client reports morning headaches that extend into the neck and go away as the day wears on. Based on this initial data, which assessment finding does the nurse anticipate? A) Elevated blood pressure B) Tachycardia C) Otitis media D) Swollen lymph nodes
A) Elevated blood pressure
The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of nonaffected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly.
A) Encourage use of nonaffected arm to feed self, bathe, and dress.
Which physiological changes associated with aging increase the risk of hypertension in older adults? A) Increase in systolic blood pressure B) Increase in diastolic blood pressure C) Increase in the pulse pressure D) Decrease in the diastolic blood pressure
A) Increase in systolic blood pressure
An adult client is experiencing paroxysmal supraventricular tachycardia. Which nursing interventions are appropriate based on the data provided? Select all that apply. A) Initiate oxygen therapy B) Prepare for cardioversion C) Begin anticoagulation therapy as prescribed D) Administer intravenous adenosine as prescribed E) Administer a beta blocker as prescribed
A) Initiate oxygen therapy B) Prepare for cardioversion D) Administer intravenous adenosine as prescribed E) Administer a beta blocker as prescribed
A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply. A) Muscle spasms B) Tachycardia C) Confusion D) Gastrointestinal bleeding E) Disorientation
A) Muscle spasms B) Tachycardia C) Confusion E) Disorientation
Which is believed to be the cause of preeclampsia? A) Placental dysfunction B) Liver disease C) Anxiety D) Low sodium intake
A) Placental dysfunction
During a routine prenatal visit, a client who is 24 weeks pregnant has a blood pressure of 143/91. The client's blood pressure at her previous visit was 121/82. A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Risk for Imbalanced Fluid Volume B) Chronic Pain C) Risk for Delayed Development D) Constipation
A) Risk for Imbalanced Fluid Volume
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply. A) Slight increase in pulse B) Dry, warm skin C) Increased urine output D) Normal respirations E) Slight decrease in blood pressure
A) Slight increase in pulse D) Normal respirations E) Slight decrease in blood pressure
The medication clopidogrel (Plavix) is most commonly given during which stage of treatment for a stroke? A) Stroke prevention B) Acute care immediately after a stroke C) Recovery care after a stroke D) Rehabilitation after a stroke
A) Stroke prevention
The nurse is caring for a pregnant woman with a suspected pulmonary embolism without DVT. With regard to diagnostic tests to confirm the diagnosis what should the nurse anticipate being ordered for the client? Select all that apply. A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray D) Non-stress test
A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray
While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that: A) the client is at risk for an ischemic thrombotic stroke. B) the client will have minimal symptoms should a stroke occur. C) the client will not experience a stroke in the future. D) the client is at high risk for a hemorrhagic stroke.
A) the client is at risk for an ischemic thrombotic stroke.
The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective? A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) "My father had hypertension, did nothing, and lived to be 90 years old."
B) "I know I need to give up my cigarettes and alcohol."
The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor to avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."
B) "I need to use a soft toothbrush and an electric razor to avoid injuries."
The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective? A) "It's a protein that causes my kidneys to conserve fluid." B) "It's a protein that pulls water into my blood vessels." C) "It's a liquid that has electrolytes in it to pull water into my blood vessels." D) "It's a super-concentrated salt solution that helps me conserve body fluid."
B) "It's a protein that pulls water into my blood vessels."
Which best describes the effects of the renal system on blood pressure? A) "The release of the catecholamines epinephrine and norepinephrine cause an increase in blood pressure." B) "The release of renin causes an increase in blood pressure." C) "The release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) cause an increase in blood pressure." D) "The synthesis and release of adrenomedullin causes an increase in blood pressure."
B) "The release of renin causes an increase in blood pressure."
A client admitted with a cardiac dysrhythmia reports being easily fatigued and has difficulty performing normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue? A) Excess Fluid Volume B) Activity Intolerance C) Depression D) Situational Low Self-Esteem
B) Activity Intolerance
The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation? A) Caucasians have an increased incidence of intracerebral hemorrhage. B) African Americans have almost twice the number of first-ever strokes compared with Whites. C) Asian Americans are more likely to die following a stroke than Whites. D) The prevalence of hypertension among Hispanics is the highest in the world.
B) African Americans have almost twice the number of first-ever strokes compared with Whites.
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care? A) Monitor serum sodium levels B) Assess postural blood pressures C) Monitor serum creatinine levels D) Monitor blood pressure every 2 h
B) Assess postural blood pressures
The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client? A) Auscultate breath sounds for inspiratory stridor B) Auscultate breath sounds for crackles C) Auscultate breath sounds for hyperresonance D) Auscultate for an absence of breath sounds in the lower lobes
B) Auscultate breath sounds for crackles
The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS) guidelines? A) Begin ventilations B) Begin chest compressions C) Obtain a defibrillator D) Establish vascular access
B) Begin chest compressions
What causes brown pigmentation of the lower extremities in clients with venous stasis? A) The necrosis of subcutaneous fat due to tissue hypoxia B) Breakdown of red blood cells in the congested tissues C) Reduced inflammatory and immune response from congested circulation D) Skin atrophy caused by lack of circulation
B) Breakdown of red blood cells in the congested tissues
A client is admitted to the hospital for a surgical intervention due to peripheral vascular disease (PVD). The nurse should be prepared to answer questions about which procedure? A) Stent placement B) Endarterectomy C) Percutaneous transluminal angioplasty D) Atherectomy
B) Endarterectomy
A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain
B) Excessive protein in the urine
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP? A) Decreased liver enzymes B) Hemolysis C) Elevated lipid panel D) Increased platelet count
B) Hemolysis
A client with hemophilia is at increased risk for what type of shock? A) Cardiogenic shock B) Hemorrhagic shock C) Anaphylactic shock D) Distributive shock
B) Hemorrhagic shock
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data? A) Normal B) Hypertension stage I C) Prehypertension D) Hypertension stage II
B) Hypertension stage I
After a stroke, sensory-perceptual changes increase the client's risk for what? A) Aspiration B) Injury C) Bleeding D) Infection
B) Injury
The nurse is caring for a client with hypertension. Which diagnostic tests should the nurse anticipate being ordered to rule out secondary causes? Select all that apply. A) Cerebral angiogram B) Intravenous pyelogram C) Renal ultrasonography D) Cardiac catheterization E) Myelogram
B) Intravenous pyelogram C) Renal ultrasonography
A client with peripheral vascular disease (PVD) is experiencing pain. Which nursing intervention addresses the client's pain? A) Elevate legs in bed B) Keep the extremities warm C) Encourage to ambulate several times each day D) Apply cool compresses to the extremities
B) Keep the extremities warm
The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care? A) Restrict fluids B) Keep the skin clean and dry, and moisturize areas of dryness C) Encourage bedrest with legs elevated on pillows D) Consult a dietitian for low-protein diet
B) Keep the skin clean and dry, and moisturize areas of dryness
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use? A) Indifference B) Nonjudgmental C) Demanding D) Confrontational
B) Nonjudgmental
Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.
B) Place the client in left lateral position when the client feels the urge to push.
A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury? A) Elevate the client's legs B) Place the client on the left side and protect the airway C) Place the client in the supine position D) Elevate the head of the bed
B) Place the client on the left side and protect the airway
A client with sepsis has a temperature of 40°C. Which dysrhythmia is most likely to occur in this client? A) Bradydysrhythmia B) Tachydysrhythmia C) Wolff-Parkinson-White dysrhythmia D) Long QT dysrhythmia
B) Tachydysrhythmia
The nurse is providing care to several clients on a medical-surgical unit. Which client is at highest risk for a nonthrombotic pulmonary embolism (PE)? A) The client who is receiving intravenous pain medication B) The client who is postoperative from a femur fracture repair C) The client with a primary abdominal tumor D) The client who uses intravenous illicit drugs
B) The client who is postoperative from a femur fracture repair
A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia. Which is an appropriate client outcome related to adhering to the provided medication instruction? A) The client will monitor the pulse and not take the medication if the pulse is less than 60. B) The client will take the medication as directed, even when feeling well. C) The client will take the medication on an empty stomach. D) The client will take the medication with food.
B) The client will take the medication as directed, even when feeling well.
What is the purpose of using warm IV fluids to help resuscitate clients in shock? A) To increase vasodilation B) To prevent hypothermia C) To prevent hyperthermia D) To increase vasoconstriction
B) To prevent hypothermia
The nurse is providing discharge instructions to an older adult client who is going home after having a total knee replacement. Which should the nurse include in the discharge teaching to decrease the client's risk for developing a thrombosis or pulmonary embolism (PE)? Select all that apply. A) Place pillows under the knees when in bed. B) Use compression stockings. C) Limit ambulation. D) Limit fluids. E) Continue with leg exercises.
B) Use compression stockings. E) Continue with leg exercises.
Which dysrhythmia is most commonly associated with sudden cardiac death (SCD)? A) Atrial flutter B) Ventricular fibrillation C) Paroxysmal supraventricular tachycardia D) Junctional escape rhythm
B) Ventricular fibrillation
The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD). Which client observation indicates teaching has been effective? A) Sitting in a chair with a pillow behind knees B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C) Sitting in a chair with left leg crossed over the right D) Smoking a pipe instead of cigarettes
B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer
The nurse is planning care for an older adult client with chronic venous insufficiency. Which will the nurse include in the client's teaching plan? A) Keep the legs dependent as much as possible and elevate only when asleep. B) Wear elastic hose as prescribed. C) Standing will prevent the progression of the disease. D) Cross legs only at the knees.
B) Wear elastic hose as prescribed.
A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply. A) Pulses absent in the extremity with the wound B) Wound that is pink with skin warm C) Ulceration that is pale in color D) Skin surrounding ulcer that is cool to the touch E) Surrounding skin brown in color
B) Wound that is pink with skin warm E) Surrounding skin brown in color
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."
C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood."
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as: A) Class I B) Class II C) Class III D) Class IV
C) Class III
What increases after an embolus has become trapped in the pulmonary microvasculature? A) Perfusion B) Ventilation C) Dead space D) Alveolar surfactant
C) Dead space
Which strategy to prevent hypertension is correct? A) Increase salt intake B) Reduce physical activity C) Decrease stress D) Take hot baths
C) Decrease stress
The nurse caring is caring for a client who is recovering from a hysterectomy. Which clinical manifestation supports that the client is experiencing a pulmonary embolism (PE)? A) Nausea B) Decreased urine output C) Dyspnea and chest pain D) Activity intolerance
C) Dyspnea and chest pain
During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse? A) Suggest the client stop exercising B) Reassure these are normal changes associated with aging C) Ensure the client is evaluated by his/her medical provider D) Check laboratory values for hypothyroidism
C) Ensure the client is evaluated by his/her medical provider
The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.
C) Heparin and warfarin (Coumadin) are usually initiated at the same time.
The nurse is caring for a 13-year-old female with a BMI of 30.4. When taking the child's vital signs, the nurse documents a blood pressure of 121/83. How would this blood pressure be categorized for this client? A) Normal blood pressure B) Prehypertension C) Hypertension D) Hypotension
C) Hypertension
A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility
C) Impaired Gas Exchange
A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication? A) It causes pain that occurs during periods of inactivity. B) It causes pain that increases when the legs are elevated and decreases when the legs are dependent. C) It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. D) It is often described as a burning sensation in the lower legs.
C) It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity.
A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. What does the nurse understand about the physiology of progressive shock? A) It involves a sustained decrease of 10 mmHg of the client's mean arterial pressure (MAP). B) It involves a blood loss of 25%. C) It involves a change from aerobic to anaerobic metabolism. D) It involves a decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
C) It involves a change from aerobic to anaerobic metabolism.
A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain? A) Anterior cerebral artery B) Vertebral artery C) Left hemisphere of the brain D) Right hemisphere of the brain
C) Left hemisphere of the brain
The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output? A) Provide oxygen B) Keep protamine sulfate at the bedside C) Monitor pulmonary arterial pressures D) Assess for bleeding
C) Monitor pulmonary arterial pressures
The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client? A) Restrict fluids B) Encourage bedrest C) Monitor serum electrolyte levels D) Instruct in a low-fat diet
C) Monitor serum electrolyte levels
The nurse is preparing to discharge a client recovering from a pulmonary embolism (PE). Which topics should the nurse to include in the teaching session? Select all that apply. A) Limit the use of over-the-counter medications B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level
C) Symptoms of recurrence D) Anticoagulant administration schedule
The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 159/100 mmHg B) Urinary output 40 mL/hour C) Urine protein 2+ D) Lungs clear to auscultation
C) Urine protein 2+
The nurse is caring for a 6-year-old child when the child goes into cardiac arrest. When performing compressions for CPR, what should the nurse do? A) Place thumbs side by side and perform compressions below the nipple line B) Use two fingers in the upright position to perform compressions C) Use two fingers plus the heel of the other hand to perform compressions D) Use both hands on the lower half of the breastbone to perform compressions
C) Use two fingers plus the heel of the other hand to perform compressions
A client with peripheral vascular disease (PVD) asks the nurse what types of exercise would improve the client's condition and overall health. Which type of exercise will the nurse include in the response to the client? A) Passive ROM B) Weight lifting C) Yoga D) Team sports
C) Yoga
A home care nurse is explaining the application of an Unna boot to a client with a stasis ulcer. Which statement about this dressing is accurate? A) "A nurse will change this dressing every 2 days." B) "It is important that you maintain strict bedrest." C) "The dressing will be applied to the entire length of your leg." D) "The dressing I am applying is semi-rigid."
D) "The dressing I am applying is semi-rigid."
A nurse is teaching a group of pregnant clients regarding seizures associated with eclampsia. Which statement associated with eclampsia are accurate? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."
D) "Seizures do not occur in preeclampsia."
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to break up existing clots and increase cerebral blood flow
D) Administered to break up existing clots and increase cerebral blood flow
A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse? A) Administer epinephrine B) Immediately defibrillate the client C) Assess the cardiac monitor electrodes D) Assess the client's pulse
D) Assess the client's pulse
A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. What is the mechanism of action of this drug? A) Prevents conversion of angiotensin I to angiotensin II B) Prevents beta-receptor stimulation in the heart C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells D) Blocks alpha-receptors in the vascular smooth muscle
D) Blocks alpha-receptors in the vascular smooth muscle
Which property of cardiac cells is mechanical in nature? A) Automaticity B) Excitability C) Conductivity D) Contractility
D) Contractility
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client? A) Deficient Fluid Volume B) Ineffective Coping C) Ineffective Airway Clearance D) Decreased Cardiac Output
D) Decreased Cardiac Output
A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis
D) Deep vein thrombosis
A client who is taking beta-adrenergic blockers for angina is experiencing hypovolemic shock. Which does the nurse anticipate being the priority collaborative intervention for this client? A) Administering analgesics for control of pain B) Assessing the cause of bleeding C) Providing replacement of volume D) Establishing invasive cardiac monitoring
D) Establishing invasive cardiac monitoring
The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify? A) Hypertension B) Dysrhythmias C) Arteriosclerosis D) Head trauma
D) Head trauma
A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client? A) Increased platelet count B) Decreased liver enzymes C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine
D) Increased serum creatinine
What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis? A) Intracerebral stroke B) Subarachnoid stroke C) Hemorrhagic stroke D) Ischemic stroke
D) Ischemic stroke
The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session? A) Improve muscle strength B) Maintain cardiopulmonary function C) Improve endurance D) Maintain joint flexibility
D) Maintain joint flexibility
The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of preeclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1-year prior C) Fibrocystic breast disease D) Obesity
D) Obesity
What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin? A) Hypovolemic shock B) Cardiogenic shock C) Neurogenic shock D) Septic shock
D) Septic shock
The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)? A) Lack of infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG
D) Tachycardia and nonspecific T-wave changes on EKG
Which risk factor for hypertension is modifiable? A) Age B) Ethnicity C) Family history D) Tobacco use
D) Tobacco use
A nurse caring for a client in the in the intensive care unit (ICU) notes that the client is experiencing a ventricular tachycardia dysrhythmia. Which rhythm is a type of ventricular tachycardia? A) Sinus tachycardia B) Atrial flutter C) Junctional escape D) Torsades de Pointes
D) Torsades de Pointes
A client is scheduled for temporary pacemaker insertion. What instruction will this client need prior to discharge? A) Dizziness is to be expected. B) There are no special precautions. C) Wear a tight-fitting shirt to help hold the pacemaker in place. D) Use battery-powered equipment.
D) Use battery-powered equipment.
