ch. 26 questions
Which of the following are characteristic signs of acute arterial embolism?
Pallor, pulselessness, and pain Explanation: The presentation of acute arterial embolism is often described as that of the seven Ps: pistol shot (acute onset), pallor, polar (cold), pulselessness, pain, paresthesia, and paralysis.
Which client would the nurse recognize as needing to be assessed for orthostatic hypotension?
An 80-year-old client who has experienced two falls while attempting to ambulate to the bathroom Explanation: Dizziness, blurred vision, palpitations, and syncope (i.e., fainting) are characteristic signs and symptoms of orthostatic hypotension, and both predispose an individual to falls; this is especially the case among older adults. Headaches, edema, diabetes, and vision changes are not associated with orthostatic hypotension.
Select the response that best describes the pressure-sensitive receptors that respond to changes in the stretch of the vessel wall.
Baroreceptors Explanation: Baroreceptors are pressure-sensitive receptors located in the walls of blood vessels and the heart. The arterial chemoreceptors are cells that monitor the oxygen, carbon dioxide, and hydrogen ion content of the blood. The cardiovascular center transmits impulses to the blood vessels. Neural control of the blood pressure is related to the integration and modulation of autonomic nervous system (ANS) response.
The nurse knows that which group of antihypertensive drugs is usually the least expensive and are well tolerated?
Diuretics Explanation: Diuretics are usually the least expensive, and are usually well tolerated by most clients.
Which intervention by the client will decrease overall cardiovascular risk?
Higher levels of fitness and exercise Explanation: Research indicates that higher levels of fitness and exercise are associated with lower blood pressure and more favorable blood lipid levels. Overall cardiovascular risk is decreased with higher fitness/exercise levels. Psychological counseling and antidepressants are not an integral part of treatment for all diseases. Increased activity will assist with controlling glucose levels in persons with diabetes. Higher levels of alcohol consumption may account for as much as 10% of the population occurrence of hypertension.
A nurse is teaching a client with newly diagnosed hypertension about antihypertensive drug therapy. The nurse determines that the knowledge is understood when the client correctly describes which of the following as the mechanism of action of an angiotensin-converting enzyme (ACE) inhibitor?
Inhibits the conversion of angiotensin I to angiotensin II, decreasing angiotensin II levels and reducing its effect on vasoconstriction Explanation: The ACE inhibitors act by inhibiting the conversion of angiotensin I to angiotensin II, thus decreasing angiotensin II levels and reducing its effect on vasoconstriction.
The nurse's brother is not convinced that he should quit smoking. He asks his sister (the nurse) to demonstrate for him the more immediate effects of smoking on his health. Which of the following could be used to help convince the brother to stop smoking?
Measure his blood pressure and show him how much higher it is when he is smoking. Explanation: Although a relationship between smoking and hypertension has not been established, vasoconstriction from nicotine in cigarette smoke will raise blood pressure. Elevated blood pressure and cigarette smoking are independent risk factors for heart disease.
A client has been diagnosed with a dissecting aortic aneurysm. It is most important for the nurse to assess the client for:
Tearing or ripping-type pain in the chest or back Explanation: A major symptom of a dissecting aneurysm is the abrupt presence of excruciating pain, described as tearing or ripping. Pain associated with dissection of the ascending aorta frequently is located in the anterior chest, and pain associated with dissection of the descending aorta often is located in the back. In the early stages, blood pressure typically is moderately or markedly elevated.
A nurse is participating in a health fair and is addressing many of the varied factors that can contribute to hypertension. The nurse should be cognizant of the higher incidence and prevalence of hypertension in which groups?
Black and South Asian people Explanation: A 2006 Canadian study showed that the ethnic groups consisting of South Asians (30%) and blacks (31%) in Canada are more likely to have hypertension in comparison to the primarily white population (21%). East Asians are the least likely to have hypertension (19%).
A critical care nurse is carefully monitoring a client's mean arterial pressure. Which combination of factors is responsible for mean arterial blood pressure?
Cardiac output multiplied by systemic vascular resistance Explanation: Mean arterial blood pressure is determined by cardiac output multiplied by systemic vascular resistance. Heart rate multiplied by stroke volume yields cardiac output, but not mean arterial pressure. Multiplying stroke volume by cardiac output or multiplying systemic vascular resistance by heart rate will not provide the client's mean arterial blood pressure.
A client has just been diagnosed with hypercholesterolemia and is asking what treatment will be needed. About which topics should the nurse educate the client? Select all that apply.
Smoking cessation Weight reduction if overweight Dietary measures to reduce LDL levels Explanation: The management of hypercholesterolemia focuses on dietary and therapeutic lifestyle changes; when these are unsuccessful, pharmacologic treatment may be necessary. Therapeutic lifestyle changes include an increased emphasis on physical activity, dietary measures to reduce LDL levels, smoking cessation, and weight reduction for people who are overweight. Increased intake of fats and sodium would cause weight gain and hypertension and result in a negative consequence.
A nurse has worked for 25 years and has recently noticed the development of varicose veins. Which part of the nurse's job is likely most responsible for the development of the varicose veins?
Standing upright for long periods Explanation: Prolonged standing and increased intra-abdominal pressure are important contributing factors in the development of primary varicose veins. Prolonged standing increases venous pressure and causes dilation and stretching of the vessel wall. Stress and sleep patterns have no effect on venous circulation. Lifting can also cause varicose veins, but standing upright is known to be a more significant risk factor.
Which blood vessel layer is composed primarily of smooth muscle cells?
Tunica media Explanation: The tunica media consists primarily of circumferentially arranged layers of smooth muscle cells. The tunica externa is composed of loose connective tissue and the tunica intima of endothelial cells. The endothelium is the lining of the vascular system and is composed of endothelial cells.
Which type of blood vessel cells in the tunica media layer produce vasoconstriction and/or dilation of blood vessels?
Vascular smooth muscle cells (SMCs) Explanation: Vascular SMCs, which form the predominant cellular layer in the tunica media, produce vasoconstriction and/or dilation of blood vessels.
While working triage in the emergency department, which client report should alert the nurse to imminent danger and, thus, that client should be seen first?
A client holding the abdomen and reporting a tearing and ripping feeling inside. Explanation: A major symptom of a dissecting aneurysm is the abrupt presence of excruciating pain, described as tearing or ripping. The location of the pain may point to the site of dissection. Because aortic dissection is a life-threatening emergency, a client with a probable diagnosis is stabilized medically even before the diagnosis is confirmed. Painful urination with fever is usually associated with a urinary tract infection and is not an imminent threat. A dislocated kneecap is extremely painful, but again not an imminent threat. The respiratory client with productive cough with green sputum likely has an infection like pneumonia and needs treatment but is not the priority when the priority client may be experiencing a dissecting aortic aneurysm.
The nurse is reviewing laboratory results for a client who is experiencing angina. Which finding might be expected in a client with dyslipidemia?
Elevated total cholesterol Explanation: Elevated total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride levels are associated with dyslipidemia. All the other answers are normal findings.
A client is immobilized following a hip injury. The client has developed lower leg discoloration with edema, pain, and tenderness in the midcalf area. How should the nurse document these clinical findings?
Deep vein thrombosis Explanation: Venous insufficiency with deep vein thrombus formation is characterized by pain, swelling [edema], and deep muscle tenderness. Fever, general malaise, and elevated white blood cell count and erythrocyte sedimentation rate are accompanying indications of inflammation. Swelling may vary from minimal to maximal. Immobility raises the risk for thrombus formation. The skin is intact, so venous stasis ulcerations are not present. Distended torturous veins (varicosity manifestations) are not present with deep vein thrombosis.
An older adult client's blood pressure (BP) is 120/80 mm Hg when in a lying position. When the nurse retakes the client's BP in a sitting position, the BP is 92/60 mm Hg. Which intervention is appropriate for the nurse to implement?
Encouraging the client to maintain hydration throughout the day Explanation: Significant drops in systolic blood pressure on the assumption of the upright position (orthostatic hypotension) are more common in older adults due to compensatory cardiovascular mechanisms that are delayed or insufficient. Appropriate interventions by the nurse include encouraging the client to change positions slowly to decrease the risk of falls. Measures designed to help people prevent symptomatic orthostatic drops in BP include gradual ambulation to allow the circulatory system to adjust. Correcting the fluid deficit may help. Avoiding excess diuresis, diaphoresis, or loss of body fluids will help. There is no indication that the physician needs to be contacted, that the client needs to be placed in a supine position, or that oxygen needs to be administered at this time.
The nurse is counseling a client regarding a high cholesterol level. The nurse teaches the client that which lipoprotein is the main carrier of cholesterol?
LDL Explanation: LDL is the main carrier of cholesterol. HDL is 50 percent protein; VLDL carries a large amount of triglycerides. IDLs are fragments of VLDLs after the triglycerides are removed and can be recycled to form VLDLs or converted to LDLs.
The nurse is developing a plan of care for a postsurgical client. A major goal is to prevent the formation of deep vein thrombosis (DVT). Which nursing intervention should the nurse implement?
apply sequential pneumatic compression devices to lower extremities Explanation: The application of sequential pneumatic compression devices augments blood flow and reduces stasis. Early ambulation is encouraged. Ice applications would not be recommended due to venous constriction.
