Final Review

which interventions should the nurse discuss with the client dx with atherosclerosis? select all that apply 1. include the significant other in the discussion 2. stop smoking or using any type of tobacco products 3. maintain a sedentary lifestyle as much as possible 4. avoid stressful situations 5. daily isometric exercises are imp.

1 & 2: include the significant other in the discussion, stop smoking or using any type of tobacco products: adherence to lifestyle modifications is enhanced when the client receives support from significant others. tobacco use is the most significant modifiable risk factor that contributes to the dvelopment of atherosclerosis. a sedentary lifestyle should be discouraged; daily walking or swimming is encouraged. telling the pt to avoid stressful situations is an unrealistic intervention. the nurse needs to help the client learn ways to deal with stressful situations, not avoid the situations. isometric exercises are wt. lifting exercises, which should be discouraged; isotonic exercises, such as walking or swimming are encouraged.

the nurse is teaching the client dx with arterial occlusive disease. which interventions should the nurse include in the teaching? select all that apply 1. wash legs and feet daily in warm water 2. apply moisturizing cream to feet 3. buy shoes in the morning hours only 4. do not wear any type of knee stockings 5. wear clean white cotton socks

1,2,4,5: wash legs and feet daily in warm water: cold water causes vasoconstriction and hot water may burn the clients feet, therefore warm water should be recommended. 2. moisturizing prevents drying of the feet. 3. shoes should be purchased in the afternoon when the feet are the largest, not the morning. 4. do not wear any type of knee stockings: this will further decrease circulation to the legs. 5. clean white cotton socks: colored socks have dye, and dirty socks may cause foot irritation that may lead to breaks in the skin (option 3 can automatically be eliminated bc it has an obsolete word ONLY in it and theres very few obsoletes in the healthcare field)

the client is dx with a small abdominal aortic aneurysm. which interventions should be included in the discharge teaching? select all that apply 1. tell the client to exercise 3 times a week for 30 minutes 2. encourage the client to eat a low fat low cholesterol diet 3. instruct the client to decrease tobacco use 4. discuss the importance of losing wt with the client 5. teach the client to wear a truss at all times

1,2,4: tell the client to exercise 3 times a week for 30 minutes, encourage the client to eat a low fat low cholesterol diet, discuss the importance of losing wt. with the client.:

the hcp prescribes an ACE inhibitor for the client dx with essential hypertension. which statement is the most appropriate rationale for administering this medication? 1. ACE inhibitors prevent beta receptor stimulation in the heart 2. this medication blocks the alpha receptors in the vascular smooth muscle 3. ACE inhibitors prevent vasoconstriction and sodium and water retention 4. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle

ACE inhibitors prevent vasoconstriction and sodium and water retention: angiotensin converting enzyme: prevent the conversion of angiotensin 1 to angiotensin 2 and this in turn prevents vasoconstriction and sodium and water retention

a client was recently admitted following a motor vehicle accident, the urine specific gravity has ranged between 1.25 and 1.030 for the last 24 hrs. the nurse would assess for other defining characteristics of: 1. FVD 2. FVE 3. decreased cardiac output 4. altered tissue perfusion

FVD

enzymes produced by the pancreas

LAP (lipase, amylase, pancreatic protease) Amy's lips were a tease? lol

the client is admitted for surgical repair of an 8 cm abdominal aortic aneurysm. which s/s would make the nurse suspect the client has an expanding AAA? 1. complaints of low back pain 2. weakend radial pulse 3. decreased urine output 4. increased abdominal girth

complaints of low back pain: low back pain is present bc of the pressure of the aneurysm on the lumbar nerves, this is a serious symptom, usually indicating that the aneurysm is expanding rapidly and about to rupture. if any pulses were affected, it would be the pedal pulses, not the radial pulses. decreased urine output would not indicate an expanding AAA, but decreased urine output may occur when the AAA ruptures, causing hypovolemia. The abdominal girth would not increase but it might increase with a ruptured AAA.

a client has been admitted to the hosp for evaluation of the etiology of jaundice. the total bilirubin is elevated but the direct (conjugated) is not. the nurse explains to the family (after the client has been informed byt he physician that the jaundice is caused by: 1. hepatitis 2. stones blocking the common bile duct 3. a hemolytic condition 4. choecystitis

a hemolytic condition: bc elevation of indirect bilirubin but normal direct bilirubin usually indicates excessive destruction of rbc's

which assessment data would the nurse recognzie to support the dx of abdominal aortic aneurysm (AAA)? 1. shortness of breath 2. abdominal bruit 3. ripping abdominal pain 4. decreased urinary output

abdominal bruit: a systolic bruit over the abdomen is a dx indication of an AAA

which assessment data would require immediate intervention by the nurse for the client who is 6 hours postop abdominal aortic aneurysm repair? 1. absent bilateral pedal pulses. 2, c/o pain at the site of the incision 3. distended, tender abdomen 4. an elevated temp of 100

absent bilateral pedal pulses: any neurovascular abnormality in the clients lower extremities indicates the graft is occluded or possibly bleeding and requires immediate intervention by the nurse. the nurse would expect the client to have pain 6 hrs after surgery. the nurse would expect the client to have a distended, tender abdomen as a result of postop edema. a slightly elevated temp would not be uncommon in a client who has had surgery.

large intestines funciton

absorption of water, store residual to form stool

which medication should the nurse expect the hcp to order for a client dx with arterial occlusive disease? 1. an anticoagulant med 2. an antihypertensive med 3. an antiplatelet med 4. a muscle relaxant

an antiplatelet med: antiplatelets such as aspirin or clopidogrel (plavix) inhibit platelet aggregation s in the arterial blood. an anticoagulant med is prescribed for venous problems, such as DVT. (platelets are part of the arterial blood)

the client had an abdominal aortic aneurysm repair two days ago. which intervention should the nurse implement first? 1. assess the clients bowel sounds. 2. administer an IV prophylactic antibiotic 3. encourage the client to splint the incision 4. ambulate the client in the room with assistance

assess the clients bowel sounds: assessment is the first part of the nursing process and is the first intervention the nurse should implement. administering an antibiotic is an appropriate intervention, but its is not priority over assessment. the client should splint the incision when coughing and deep breathing to help decrease the pain, but this intervention isn't priority over assessment. ambulating the client as soon as possible is an appropriate intervention to help decrease complications from immobility, but it is not priority over assessment. (if the test taker has difficulty in determining the first intervention the test taker should always rely on the nursing process and select the assessment intervention if the intervention is appropriate for the disease process or condition.)

the client dx with essential hypertension asks the nurse, i dont know why the dr is worried about my bp. i feel just great, which statement by the nurse would be the most approrpiate? 1. damage can be occurring to your heart and kidneys even if you feel great 2. unless you have a headache, your bp is probably within normal limits. 3. when is the last time you saw your dr? does he know you are feeling great 4. your bp reflects how well your heart is working

damage can be occurring to your heart and kidneys even if you feel great: the bp can still be elevated, causing damage to heart, kidney and blood vessels. the bp does not necessarily reflect how well the heart is working. many other dx tests assess how well the heart is working, including an ecg, an u/s, and chest x ray

when assessing a client who is newly dx with hypothyroidism, which symptom should the nurse expect? 1. amenorrhea 2. profound wt loss 3. decreased tolerance to cold 4. moon facies and hypernatremia

decreased tolerance to cold: this is a common complaint in hypothyroidism, possibly bc of a decreased metabolic rate. amenorrhea isnt right bc menorrhagia is relatively common in hypothyroidism. wt loss wouldnt be profound but modest wt gain (about 10 lbs) and edema are common in hypothyroidsim. moon face would be with cushings, hyponatremia may be present bc of increased inappropriate ADH secretion

the nurse is teaching a class on atherosclerosis. which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? 1. glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues. 2. diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis 3. diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels 4. the increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels

diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels: when glucose combines with the hemoglobin in a lab test called glycosylated hemoglobin, the result can determine the clients average glucose level over the past 3 months. glucose does not combine with carbon monoxide. vasoconstriction is not a risk factor for developing atherosclerosis (the nurse must understand the reason "why", or the scientific rationale, for teaching in addition to nursing interventions. this is critical thinking)

the nurse and UAP are caring for a 64 y/o client who is 4 hours postop bilateral femoral popliteal bypass surgery. which nursing task should be delegated to the UAP? 1. monitor the continuous passive motion machine 2. assist the client to the bedside commode 3. feed the client the evening meal 4. elevate the foot of the clients bed

elevate the foot of the clients bed: after the surgery, the clients legs will be elevated to help decrease edema. the surgery has corrected the decreased blood supply to the lower legs. there is nothing stating the client cant feed themself, this should be encouraged.

bile is stored where?

gall bladder

the nurse is assessing the client dx with long term arterial occlusive disease. which assessment data support the dx? 1. hairless skin on the legs 2. brittle, flaky toenails 3. petechiae on the soles of feet 4. nonpitting ankle edema

hairless skin on the legs: the decreased oxygen over time causes the loss of hair on the tops of the feet and ascending both legs. the toenails are usually thickened due to hypoxemia. petechiae are tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal layer; not seen with arterial occlusive disease. there may be edema but it is usually pitting, nonpitting resolves with elevation, but not in clients with arterial occlusive disease

the nurse expects to find which of the most commonly altered lab findings in a client with hypothyroidism: 1. hemoglobin level of 9 2. sodium level of 152 3. cholesterol level 200 4. serum amylase of 50-190

hemoglobin level of 9: anemia often results in hypothyroidism bc of menorrhagia, decreased oxygen demand by the tissues, and decreased erythropoietin production

the wife of a client with arterial occlusive disease tells the nurse, my husband says he is having rest pain. what does that mean? which statement by the nurse would be most appropriate? 1. it describes the type of pain he has when he stops walking 2. his legs are deprived of oxygen during periods of inactivity 3. you are concerned that your husband is having rest pain 4. this term is used to support that his condiiton is getting better

his legs are deprived of oxygen during periods of inactivity: rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs arent getting enough oxygen when the client is resting to prevent muscle ischemia. The pain stops when the client quits walking

which client problem would be priority in a client dx with arterial occlusive disease who is admitted to the hosp with a foot ulcer? 1. impaired skin integrity 2. activity intolerance 3. ineffective health maintenance 4. risk for peripheral neuropathy

impaired skin integrity: the client has a foot ulcer, therefore, the protective lining of the body, the skin, has been impaired. 4: the client has peripheral neuropathy not a risk for it, this is the primary pathological change in a client with arterial occlusive disease. (remember maslows hierarchy of needs; physiological needs are priority)

a 40 y/o man is admitted to the unit with addisonian crisis. he has stabilized and is started PO corticosteroid replacement therapy. which of the following client teaching explanations given byt he nurse would be most appropriate for this client? 1. eat a healthy diet but monitor fat intake 2. use alcohol free products on your skin 3. do not let your disease alter your lifestyle. stay active 4. muscle weakness and fatigue are not normal see your physician

use alcohol free products on your skin: skin care is crucial for the client with addisons disease. alcohol free products can reduce skin drying and irration. muscle weakness and fatigue are normal for addisons

the hcp ordered a femoral angiogram for the client dx with arterial occlusive disease. which intervention should the nurse implement? 1. explain that this procedure will be done at the bedside 2. discuss with the client that he or she will be on bedrest with bathroom privileges 3. inform the client that no iv access will be needed 4. inform the client that fluids will be increased after the procedure

inform the client that fluids will be increased after the procedure: fluids will help flush the contrast dye out of the body and help prevent kidney damage. this procedure will be done in a cath lab or special room, not at bedside, bc machines are used to visualize the extent of the arterial occlusion. the client will have to keep the leg straight for at least 6 hrs after the procedure to prevent bleeding from the femoral artery. An IV contrast medium is injected and vessels are visualized using fluoroscopy and xrays. (angio means vessel, which could help eliminate optioin 3 bc some form of dye would have to be used to visualize a vessel. anything done in the femoral artery would require pressure at the site to prevent bleeding. very few dx tests are done at the bedside)

bile is produced where?

liver

the nurse is discussing discharge teaching with the client who is 3 days postop abdominal aortic aneurysm repair. which discharge instructions should the nurse include when teaching the client? 1. notify hcp of any redness or irritation of the incision. 2. do not lift anything that weighs more than 20 lbs 3. inform client there may be pain not relieved with pain medication 4. stress the importance of having daily bowel movements

notify hcp of any redness or irritation of the incision: this indicates infection and should be reported asap. the client should not lift anything heavier than 5 lbs bc it may cause dehiscence or evisceration of the bowel. the pain med should keep the client comfortable, if it doesnt the client should call the hcp. some clients do not have daily bm's, but the nurse should instruct the client not to allow them to become constipated, which will increase pressure on the incision. ( remember the test taker should not eliminate an option as a possible answer just bc he or she thinks it is too easy an answer)

the client dx with peripheral vascular disease is overweight, has smoked two pack of cigs a day for 20 yrs, and sits behind a desk all day. whats the strongest factor int he development of atherosclerotic lesions? 1. being over wt. 2. sedentary lifestyle 3. high fat, high cholesterol diet 4. smoking cigs

smoking cigs: tobacco use is the strongest factor in the development of atherosclerotic lesions. nicotine decreases blood flow to the extremities and increases heart rate and bp. it also increases the risk of clot formation by increasing the aggregation of platelets. there is nothing specifying their diet in the question. (the test taker should look at the answer options closely to determine if any are similar. this will help eliminate two options 1 and 3 as possible answers. an unhealthy diet will cause the client to be over wt.)

which hcp order should the nurse question in a client dx with an exapanding abdominal aortic aneurysm who is scheduled for surgery in the morning? 1. type and crossmatch for 2 units of blood 2. tap water enema until clear fecal return 3. bedrest with bathroom privileges 4. keep npo after midnight

tap water enema until clear fecal return: increased pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture. The client is at risk for bleeding so you will need a type and crossmatch for 2 units of blood. the client should be able to ambulate to the bathroom without any problems. clients are NPO prior to surgery to help prevent aspiration or problems from general anesthesia. (an exapanding AAA should cause the test taker to realize that no additional pressure should be placed on the AAA and that, therefore, selecting option 2 would be the most appropriate answer. Remember basic concepts)

a 26 y/o client has been dx with membranous proliferative glomerulonephritis. when planning the care for this client, the nurse writes an outcome to detect hypovolemia. the most appropriate outcome for such a purpose might be: 1. the pulse rate will remain WNL 2. the bp will remain WNL 3. no signs of edema will be present 4. urine specific gravity will reman WNL

the bp will remain WNL: a change in bp, wheter in the compensatory stage of shock or following compenstion, would probably be the first sign that fluid was being lost from the plasma compartment

the HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. which should the nurse teach the client about this med? 1. take this med on an empty stomach 2. this med should be taken in the evening 3. do not be concerned if muscle pain occurs 4. check your cholesterol level daily

this med should be taken in the evening: statin medications should be taken in the evening for best results bc the enzyme that destroys cholesterol works best in the evening and the medication enhances this process. a statin med can be taken with food or on an empty stomach. cholesterol reducing meds can cause serious liver problems, and if a client has muscle pain, it is an adverse effect that should be reported to the hcp. the cholesterol level is checked every few months, not on a daily basis.