CHAPTER 18 - DISORDERS OF BLOOD FLOW AND BLOOD PRESSURE

A client's primary care provider has added 20 mg of Lasix (furosemide) to his medication regimen to treat his primary hypertension. How does this agent achieve its therapeutic effect? A) By decreasing vascular volume by increasing sodium and water excretion B) By blocking the release of antidiuretic hormone from the posterior pituitary C) By inhibiting the conversion of angiotensin I to angiotensin II D) By inhibiting the movement of calcium into arterial smooth muscle cells

Ans: A Feedback: Diuretics lower blood pressure initially by decreasing vascular volume (by suppressing renal reabsorption of sodium and increasing sodium and water excretion) and cardiac output. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I, and calcium channels blockers inhibit the movement of calcium into arterial smooth muscle. Common antihypertensives do not act directly on the pituitary.

Which of the following is a nonmodifiable risk factor for the development of primary hypertension? A) African American race B) High salt intake C) Male gender D) Obesity

Ans: A Feedback: Hypertension not only is more prevalent in blacks than whites, but also is more severe, tends to occur earlier, and often is not treated early enough or aggressively enough. Blacks also tend to experience greater cardiovascular and renal damage at any level of pressure. High salt intake and obesity are modifiable risk factors for hypertension. Male gender is not identified as a risk factor for hypertension.

A client is receiving home care for the treatment of a wound on the inside of her lower leg that is 3 cm in diameter with a yellow wound bed and clear exudate. Assessment of the client's legs reveals edema and a darkened pigmentation over the ankles and shins of both legs. What is this client's most likely diagnosis? A) Chronic venous insufficiency B) Deep vein thrombosis C) Varicose veins D) Peripheral arterial disease

Ans: A Feedback: In contrast to the ischemia caused by arterial insufficiency, venous insufficiency leads to tissue congestion, edema, and eventual impairment of tissue nutrition (development of a venous ulcer). The edema is exacerbated by long periods of standing. Necrosis of subcutaneous fat deposits occurs, followed by skin atrophy. Brown pigmentation of the skin caused by hemosiderin deposits resulting from the breakdown of red blood cells is common. DVTs, varicose veins, and PAD do not have this symptomatology.

Which of the following would be considered a major cause of secondary hyperlipoproteinemia since it increases the production of VLDL and conversion to LDL? A) High-calorie diet B) Diabetes mellitus C) Bile-binding resin D) Cholesterol ingestion

Ans: A Feedback: Obesity with high-calorie intake increases the production of VLDL, with triglyceride elevation and high conversion of VLDL to LDL. Excessive cholesterol intake reduces formation of LDL receptors. Diabetes is associated with high triglycerides and minimal elevation of LDL. Bile salt-binding resin is one treatment used to lower cholesterol levels.

A 29-year-old woman who considers herself active and health conscious is surprised to have been diagnosed with preeclampsia-eclampsia in her second trimester. What should her care provider teach her about this change in her health status? A) "We don't really understand why some women get high blood pressure when they're pregnant." B) "This is likely a result of your nervous system getting overstimulated by pregnancy." C) "Hypertension is a common result of all the hormonal changes that happen during pregnancy." D) "Even though you're a healthy person, it could be that you have an underlying heart condition."

Ans: A Feedback: The cause of pregnancy-induced hypertension is largely unknown.

While lecturing on blood pressure, the nurse will emphasize that the body maintains its blood pressure by adjusting the cardiac output to compensate for changes in which of the following physiologic processes? A) Peripheral vascular resistance B) Electrical impulses in the heart C) Release of stress hormones D) Rigidity of the ventricular walls

Ans: A Feedback: The systolic and diastolic components of blood pressure are determined by cardiac output and total peripheral vascular resistance and can be expressed as the product of the two (blood pressure = cardiac output × total peripheral resistance). The body maintains its blood pressure by adjusting the cardiac output to compensate for changes in peripheral vascular resistance, and it changes the peripheral vascular resistance to compensate for changes in cardiac output. Electrical impulses from the SA node regulate heart rate. Release of stress hormones and rigidity of the ventricular walls do not primarily influence BP; however, they may impact this secondarily.

Which of the following clients would be at high risk for developing primary varicose veins? Select all that apply. A) A 47-year-old waitress who works 12-hour shifts three or four times/week B) A morbidly obese (>100 pounds overweight) male who works behind the counter of a convenience store 10 hours/day, 5 days/week C) A 56-year-old male who has been immobile due to back surgery and has developed a deep vein thrombosis D) A Marathon runner who has completed three marathons in the past 3 months E) A new peritoneal dialysis client who has been utilizing a home machine and performing dialysis every evening beginning at 8 PM

Ans: A, B Feedback: Prolonged standing and increased intra-abdominal pressure are important contributing factors in the development of primary varicose veins. Because there are no valves in the inferior vena cava or common iliac veins, blood in the abdominal veins must be supported by the valves located in the external iliac or femoral veins. Immobility may cause DVTs (a secondary cause of varicose veins). Peritoneal dialysis has no effect on the development of varicose veins.

Which of the following children may be considered high risk for developing hypertension? Select all that apply. A) Diagnosed with coarctation of the aorta as an infant B) Recent scan showing a pheochromocytoma C) Has a history of epilepsy with weekly seizures D) Takes cyclosporine daily since a kidney transplant E) Has a history of frequent sinus infections treated with antibiotics

Ans: A, B, D Feedback: Approximately 75% to 80% of secondary hypertension in children is caused by kidney abnormalities. Coarctation of the aorta is another cause of hypertension in children and adolescents. Endocrine causes of hypertension, such as pheochromocytoma and adrenal cortical disorders, are rare. The nephrotoxicity of the drug cyclosporine, an immunosuppressant used in transplant therapy, may cause hypertension in children after kidney transplantation. Epilepsy and sinus infections do not cause hypertension.

A client with a diagnosis of chronic renal failure secondary to diabetes has seen a gradual increase in her blood pressure over the past several months, culminating in a diagnosis of secondary hypertension. Which of the following has most likely resulted in the client's increased blood pressure? A) Increased levels of adrenocortical hormones B) Activation of the renin-angiotensin-aldosterone mechanism C) Increased sympathetic stimulation by the autonomic nervous system (ANS) D) Coarctation of the client's aorta

Ans: B Feedback: Renovascular hypertension refers to hypertension caused by reduced renal blood flow and activation of the renin-angiotensin-aldosterone mechanism. It is the most common cause of secondary hypertension, accounting for 1% to 2% of all cases of hypertension. The reduced renal blood flow that occurs with renovascular disease causes the affected kidney to release excessive amounts of renin, increasing circulating levels of angiotensin II. Angiotensin II, in turn, acts as a vasoconstrictor to increase peripheral vascular resistance and as a stimulus for increased aldosterone levels and sodium retention by the kidney. One or both of the kidneys may be affected. A renal etiology is not associated with secondary hypertension due to hormonal factors, sympathetic stimulation, or coarctation of the aorta.

An elderly client newly diagnosed with systolic hypertension asks her health care provider why this happens. The most accurate response would be: A) "Everyone over the age of 50 tends to have their blood pressure creep up over the years." B) "With age, your arteries lose their elasticity and are replaced with collagen, which makes your arteries stiffer." C) "Your heart has to work harder to pump blood through your vessels as you get older." D) "If you slow down and rest more, your blood pressures will more than likely return to its normal level."

Ans: B Feedback: Systolic blood pressure rises almost linearly between 30 and 84 years of age, whereas diastolic pressure rises until 50 years of age and then levels off or decreases. This rise in systolic pressure is thought to be related to increased stiffness of the large arteries. With aging, the elastin fibers in the walls of the arteries are gradually replaced by collagen fibers that render the vessels stiffer and less compliant.

A client consistently has an elevated systolic BP greater than 150 mm Hg but a diastolic pressure in the 80s. The health care provider should be assessing for which of the following complications? A) Peripheral edema in lower legs from renal disease B) Crackles in bilateral lung bases caused by left-sided heart failure C) Ascites due to liver damage D) Confusion due to atherosclerosis of the carotid arteries

Ans: B Feedback: Systolic hypertension has been defined as a systolic pressure of 140 mm Hg or greater and a diastolic pressure of less than 90 mm Hg. Elevated pressures during systole favor the development of left ventricular hypertrophy, increased myocardial oxygen demands, and eventual left heart failure. Peripheral edema and ascites are usually associated with right-sided failure. Confusion due to blockages in carotid arteries can occur independent of hypertension.

Atherosclerotic peripheral vascular disease is symptomatic with at least 50% occlusion. The primary peripheral symptom, due to ischemia, is: A) Edema B) Calf pain C) Varicosities D) Strong pulse

Ans: B Feedback: The primary symptom of chronic obstructive arterial disease is pain with walking or claudication. Typically, persons with the disorder complain of calf pain because the gastrocnemius muscle has the highest oxygen consumption of any muscle group in the leg during walking. The extremity will be thin, dry (no edema), and have weak low-pressure pulses due to severely reduced blood flow to the distal vessels.

A client asks, "Why do I have clogged arteries but my neighbor has higher 'bad cholesterol' levels and yet he is just fine?" The health care provider bases the reply on which of the following physiological principles about lipoprotein? A) "Your neighbor probably has higher amounts of good cholesterol (HDL) as well." B) "You more than likely have small, dense type of 'bad cholesterol' (LDL)." C) "Your neighbor has larger 'bad cholesterol' particles that can move into blood vessels but park in joints/tendons." D) "You must have a genetic predisposition to having clogged arteries."

Ans: B Feedback: There are different types of LDL, and some people with markedly elevated LDL do not develop atherosclerotic vascular disease, whereas other people with only modest elevations in LDL develop severe disease. Small, dense LDL is more toxic or atherogenic to the endothelium than large, buoyant LDL. It is more likely to enter the vessel wall, become oxidized, and trigger the atherosclerotic process.

The most important complication of atherosclerosis that may cause occlusion of small heart vessels is: A) Ulceration B) Thrombosis C) Fatty streaks D) Fibrous plaque

Ans: B Feedback: Thrombus formations on complicated atherosclerotic lesions are the result of sluggish blood flow and turbulence in the ulcerated plaque region. Fatty streaks are preatherosclerotic plaque changes in vessels. Fibrous plaque is part of the atherosclerosis formation, not a complication of it.

A client with a history of disabling claudication now is in the emergency department with a lower limb that is turning dark purple to black associated with faint Doppler pedal pulses. The client will more than likely undergo: A) Surgery to remove the saphenous vein B) Percutaneous transluminal angioplasty and stent placement C) Injection of a potent anticoagulant into lower leg veins D) Whirlpool therapy with tight wrapping of lower legs immediately following

Ans: B Feedback: Treatment includes measures directed at protection of the affected tissues and preservation of functional capacity. Percutaneous or surgical intervention is typically reserved for the client with disabling claudication or limb-threatening ischemia. Surgery (i.e., femoropopliteal bypass grafting using a section of the saphenous vein) may be indicated in severe cases. Percutaneous transluminal angioplasty and stent placement, in which a balloon catheter is inserted into the area of stenosis and the balloon inflated to increase vessel diameter, is another form of treatment.

Because of its location, the presence of an abdominal aortic aneurysm may first be manifested as: A) Constipation B) Indigestion C) A pulsating mass D) Midabdominal pain

Ans: C Feedback: An abdominal aortic aneurysm may be noticed as a pulsating mass when the client is lying flat, once the aneurysm is rather large already. Although there may be pressure on the abdominal organs by the mass, it is not associated with constipation or indigestion. Severe midabdominal pain is a late sign of impending rupture.

Which of the following clients should most likely be assessed for orthostatic hypotension? A) A 78-year-old woman who has begun complaining of frequent headaches unrelieved by over-the-counter analgesics B) A 65-year-old client whose vision has become much less acute in recent months and who has noticed swelling in her ankles C) An 80-year-old elderly client who has experienced two falls since admission while attempting to ambulate to the bathroom D) A 42-year-old client who has a history of poorly controlled type 1 diabetes

Ans: C Feedback: Dizziness and syncope 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.

A client with persistent, primary hypertension remains apathetic about his high blood pressure, stating "I don't feel sick, and it doesn't seem to be causing me any problems that I can tell." How could the nurse best respond to this client's statement? A) "Actually, high blood pressure makes you very susceptible to getting diabetes in the future." B) "That's true, but it's an indicator that you're not taking very good care of yourself." C) "You may not sense any problems, but it really increases your risk of heart disease and stroke." D) "You're right, but it's still worthwhile to monitor it in case you do develop problems."

Ans: C Feedback: Hypertension is a highly significant risk factor for heart disease and stroke. It would be inappropriate to promote monitoring without promoting lifestyle modifications or other interventions to lower the client's blood pressure, or teaching the client about the deleterious effects of hypertension. It is likely unproductive to simply characterize the client's hypertension as demonstrating that he does not "take care" of himself. Hypertension is not a risk factor for the development of diabetes mellitus.

A client asks why his blood pressure pills seem to make him go to the bathroom to urinate frequently when they are not water pills (diuretics). Which of the following physiologic processes explains the long-term regulation of blood pressure most accurately? A) Actions of the renin-angiotensin-aldosterone system B) Release of antidiuretic hormone (vasopressin) by the posterior pituitary C) Renal monitoring and adjustment of extracellular fluid volume D) Integration and modulation of the autonomic nervous system (ANS)

Ans: C Feedback: Long-term maintenance and control of blood pressure is accomplished primarily through the renal control of fluid balance. These mechanisms function largely by regulating the blood pressure around an equilibrium point, which represents the normal pressure for a given individual. Accordingly, when the body contains too much extracellular fluid, the arterial pressure rises and the rate at which water and sodium are excreted by the kidney is increased. When blood pressure returns to its equilibrium point, water and sodium excretion returns to normal. Hormonal influences, such as those of ADH and the RAA system, and neural controls are utilized in the shorter-term control of blood pressure.

A 52-year-old man who is moderately obese has recently been diagnosed with hypertension by his primary care provider. Which of the client's following statements indicates a need for further health promotion teaching? A) "I've starting going to the gym before work three times a week." B) "I'm trying to cut back on the amount of salt that I cook with and add to my food." C) "I'm resolving to eat organic foods from now on and to drink a lot more water." D) "I'm planning to lose 15 pounds before the end of this year."

Ans: C Feedback: Weight loss, exercise, and salt reduction are all useful strategies in the management of hypertension. An organic diet and increased fluid intake are not known to reduce blood pressure.

A postsurgical client reports calf pain combined with the emergence of swelling and redness in the area, which have culminated in a diagnosis of deep vein thrombosis. What treatment options will be of greatest benefit to this client? A) Analgesics and use of a pneumatic compression device B) Massage followed by vascular surgery C) Frequent ambulation and the use of compression stockings D) Anticoagulation therapy and elevation of the leg

Ans: D Feedback: Anticoagulants, immobilization, and elevation of the affected extremity are used in the treatment of DVT. Interventions that are used to prevent DVT (ambulation; compression stockings; compression devices) may be harmful when a DVT is present. Surgery is not normally required, and massage has the potential to dislodge a DVT.

Which elevated serum marker for systemic inflammation is now considered a major risk factor for atherosclerosis and vascular disease? A) Leukocytosis B) Homocysteine C) Serum lipoprotein D) C-reactive protein

Ans: D Feedback: CRP is an acute-phase reactant synthesized in the liver that is a marker for systemic inflammation. A number of population-based studies have demonstrated that baseline CRP levels can predict future cardiovascular events among apparently healthy individuals. High-sensitivity CRP (hs-CRP) may be a better predictor of cardiovascular risk than lipid measurement alone. Homocysteine and serum lipoprotein are also serum markers, but they do not identify inflammation. Leukocytosis is an indicator of infection rather than inflammation alone.

A health care provider was asked by a client, "Why do my hands turn blue when I drive my car in the winter without gloves?" Which of the following is the best response? A) "Nothing to worry about. We all develop this as we age." B) "We better order a CT scan. It might be due to a blood clot in your radial artery." C) "This sounds like an inflammation in the lining of your veins. You need to take some NSAIDs." D) "Your arteries in your hands/fingers are going into spasm, which decreases blood flow and circulating oxygen."

Ans: D Feedback: Raynaud disease is caused by vasospasms of small distal arteries; thromboangiitis obliterans is caused by an inflammatory process that affects veins and nerves.

In addition to direct invasion of the vascular wall by an infectious agent, this pathogenic mechanism is a common cause of vasculitis? A) Necrotizing granulomatous B) Tissue necrosis C) Mononuclear cells D) Immune-mediated inflammation

Ans: D Feedback: The two most common pathogenic mechanisms of vasculitis are direct invasion of the vascular wall by an infectious agent and immune-mediated inflammation. The most common mechanisms that initiate noninfectious vasculitis are pathological immune responses that result in endothelial activation, with subsequent vessel obstruction, and ischemia of the dependent tissue. In almost all forms of vasculitis, the triggering event initiating and driving the inflammatory process is unknown. Medium-size vessel vasculitides produce necrotic tissue damage. Large-vessel vasculitides involve mononuclear cells. Wegener granulomatosis is characterized by a triad of acute necrotizing granulomatous lesions of the upper respiratory tract (ear, nose, sinuses, and throat), necrotizing vasculitis of the affected small- to medium-sized vessels of the lungs and respiratory airways, and renal disease in the form of focal necrotizing glomerulonephritis.

The client is immobilized following a hip injury and has begun demonstrating lower leg discoloration with edema, pain, tenderness, and increased warmth in the midcalf area. He has many of the manifestations of: A) Stasis ulcerations B) Arterial insufficiency C) Primary varicose veins D) Deep vein thrombosis

Ans: D Feedback: Venous insufficiency with deep vein thrombus formation is characterized by discoloration, edema, pain, tenderness, and warmth most commonly in the mid- or lower calf area of the legs. 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.