NSG170 Perfusion

Which response would the nurse make to a 30-year-old client diagnosed with hyperlipidemia and hypertension who asks the nurse to explain why treatment is important, stating "I feel fine, so I don't really see the need to make any changes."? a. "Both high blood pressure and high cholesterol contribute to development of heart disease." b. "Lifestyle adaptations alone will be adequate as long as you continue to be asymptomatic." c. "Usually someone with these diagnoses will have symptoms of heart disease already." c. "You should discuss your questions about medical problems with the healthcare provider."

a. "Both high blood pressure and high cholesterol contribute to development of heart disease." Because cardiac risk factors are cumulative in their effect on the development of coronary artery disease, treatment of both risk factors is advised before development of symptoms. Although lifestyle adaptations are an initial action in management of hypertension and hyperlipidemia, treatment with medications is also frequently required. The majority of young adults with hypertension and hyperlipidemia are asymptomatic. Although the health care provider will certainly answer questions, the nurse is also responsible for teaching clients about how to manage cardiac risk factors.

Which suggestion by the nurse is an example of primary prevention? a. "Engage in daily physical exercise." b. "Get yearly physical examinations." c. "Attend hypertension screening programs." d. "Read about how to prevent diabetes complications."

a. "Engage in daily physical exercise." Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being, like engaging in daily physical exercise. Performing yearly physical examinations and providing hypertension screening programs are secondary preventions. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.

Which statement by a a client with hypertension who has been prescribed furosemide indicates a need for medication education? a. "This can decrease my vitamin K level." b. "I will take the medication in the morning." c. "I will contact my health care provider if I notice muscle weakness." d. "I plan to take the medication even when my blood pressure is normal."

a. "This can decrease my vitamin K level." Furosemide can produce hypokalemia, not vitamin K deficiency. A well-balanced diet should provide all the necessary vitamins and nutrients. Further teaching is necessary. The morning is the desirable time to take furosemide; early administration prevents nocturia. The client's statement to call the health care provider at signs of muscle weakness is appropriate because muscle weakness may indicate hypokalemia. The client's response to take the medicine even when the blood pressure is normal demonstrates an understanding that the medication should be taken as prescribed, independent of how the client feels, because hypertension is often asymptomatic.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which question when completing the initial assessment? a. 'Does walking for long periods of time increase your pain?' b. 'Does standing without moving decrease your pain?' c. 'Have you had your potassium level checked recently?' d. 'Have you had any broken bones in your lower extremities?'

a. 'Does walking for long periods of time increase your pain?' Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often experience vascular-related complications. The nurse would recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

Which client's care can the registered nurse safely delegate to unlicensed assistive personnel (UAP) based on the given data? a. Client A, with chronic hypertension and stable vitals b. Client B, with drainage from a diabetic foot c. Client C, with myocardial infarction due to atherosclerosis d. Client D, with foot ulcers from peripheral vascular disease

a. Client A, with chronic hypertension and stable vitals Care of client A can be delegated safely because the chronic hypertension with stable vitals is not generally associated with any complications. Client B with drainage from a diabetic foot is at a risk of aggravating foot issues, so this client's care cannot be delegated safely. Client C with myocardial infarction due to atherosclerosis is at a risk of cardiovascular instability, and care should not be delegated. Client D has foot ulcers due to peripheral vascular disease, so this client's care also cannot be delegated safely to the UAP.

Which information will the nurse include when teaching a client with hypertension about metoprolol? a. Do not abruptly discontinue the medication. b. Consume alcoholic beverages in moderation. c. Report a heart rate of less than 70 beats per minute. d. Increase the medication dosage if chest pain occurs.

a. Do not abruptly discontinue the medication. Abrupt discontinuation of metoprolol may cause rebound hypertension and an acute myocardial infarction. Alcohol is contraindicated for clients taking beta-adrenergic blockers such as metoprolol. The pulse rate can go lower than 70 beats per minute as long as the client is asymptomatic. Clients should never increase medications without medical direction.

A postpartum client is being treated with subcutaneous enoxaparin for deep vein thrombosis of the left calf. Which client cue is of most concern to the nurse? a. Dyspnea b. Pulse rate of 62 beats/min c. Blood pressure of 136/88 mm Hg d. Positive Homan sign in the left leg

a. Dyspnea One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. A blood pressure of 136/88 mm Hg is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated, because the clot could be dislodged.

Which action will the nurse take when caring for a client with chronic arterial insufficiency of the legs who refuses the prescribed dose of aspirin (ASA) and states "My legs are not painful."? a. Explain the reason for the medication and encourage the client to take it. b. Withhold the medication at this time and return to check with the client again in 30 minutes. c. Withhold the medication and tell the client to ask for it if the legs become uncomfortable. d. Request that the client take the medication and explain that it prevents the client from being uncomfortable in the next few hours.

a. Explain the reason for the medication and encourage the client to take it. Aspirin is given to the client to prevent platelet aggregation and possible deep vein thrombosis. The client needs information to make an educated decision. Aspirin is not prescribed to relieve pain. The client should receive information and support beforemaking the decision to refuse the medication. Clients should never be pressured totake medication, especially when they do not have an understanding of the risks andbenefi ts of the medication.

The nurse is instructing a community group regarding risk factors for coronary artery disease. Which risk factor cannot be modified? a. Heredity b. Hypertension c. Cigarette smoking d. Diabetes mellitus

a. Heredity Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

Which test result would the nurse use to determine whether the daily dose is therapeutic when a client with a venous thrombosis is receiving warfarin? a. International Normalized Ratio (INR) b. Accelerated partial thromboplastin time (APTT) c. Bleeding time d. Sedimentation rate

a. International Normalized Ratio (INR) Warfarin is prescribed using INR results, with the therapeutic goal usually being an INR of 2 to 3 for clients with venous thrombosis. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.

Which integumentary manifestations can be noticed in a client with a serum creatinine value of 7 mg/dL (618.8 mmol/L) and a blood urea nitrogen (BUN) value of 240 mg/dL (85.68 mmol/L)? Select all that apply. a. Pruritus b. Clubbing c. Cyanosis d. Ecchymosis e. Uremic frost

a. Pruritus d. Ecchymosis e. Uremic frost Elevated serum creatinine and BUN levels indicate chronic kidney disease, the integumentary manifestations of which include pruritus, ecchymosis, uremic frost, decreased skin turgor, yellow-gray pallor, dry skin, purpura, and soft-tissue calcifications. Clubbing is the integumentary manifestation of heart and lung diseases from chronic hypoxia. Cyanosis is the manifestation of decreased peripheral circulation and deoxygenated blood.

Oral contraceptives are prescribed for a client who smokes heavily. Which is a major immediate risk to this client? a. Thrombophlebitis b. Cervical cancer c. Ovarian cancer d. Risk of coronary heart disease later in life

a. Thrombophlebitis Heavy smoking is a major risk factor for an increased risk of thrombosis or blood clots. Cervical cancer is associated with human papillomavirus infection, not oral contraceptive use. Oral contraceptives have a protective effect against ovarian cancer. Although there is an increased risk of coronary heart disease while taking an oral contraceptive, this risk abates when it is no longer taken and does not carry over intolater life.

Which nursing intervention would the nurse provide to an older client with hypertension? Select all that apply. a. Provide skin care. b. Advise the client to limit salt intake. c. Teach stress management. d. Instruct the client to quit smoking. e. Advise the client to eat finger foods.

b. Advise the client to limit salt intake. c. Teach stress management. d. Instruct the client to quit smoking. Proper nursing interventions for an older client with hypertension include advising the client to limit salt intake, teaching stress management, and instructing the client to quit smoking. Skin care is an appropriate intervention for clients at risk of pressure injuries. The nurse would advise a client with dementia to eat finger foods such as sandwiches because these foods are easy to eat.

Which is the best action for the nurse to take when a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick."? a. Educate the client about the complications associated with high blood pressure. b. Ask the client questions to determine the current understanding of high blood pressure. c. Emphasize the importance of taking blood pressure medications now to continue to feel well. d. Show the client the current blood pressure and compare that with normal blood pressure levels.

b. Ask the client questions to determine the current understanding of high blood pressure. Further assessment of the client's understanding of hypertension and treatment is important before the nurse can develop an effective plan to change the client'sbehavior. Education about complications of hypertension may be helpful, but first the nurse needs to know what the client already understands about the long-term effects of high blood pressure. An emphasis on taking medications now to ensure future health may be appropriate for this client, but further assessment is needed before using this strategy. Many clients may respond to actually seeing the difference between their blood pressures and the expected normals, but more information about the client's knowledge is needed to know if this will be a useful strategy for this client.

A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 128 seconds. Which action would the nurse take in response to this situation? a. Increase the IV rate of heparin. b. Interrupt the infusion and notify the primary health care provider of the aPTT result. c. Document the result on the medical record and recheck the aPTT in 4 hours. d. Call the primary health care provider to obtain a prescription for a low-molecular-weight heparin.

b. Interrupt the infusion and notify the primary health care provider of the aPTT result. The heparin should be withheld, because 128 seconds is almost 4 times the normal time it takes a fibrin clot to form (25-36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is 1½ to 2 times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.

Which action would the home health nurse suggest to decrease risk for injury for an older adult with peripheral arterial disease? a. Move into an assisted living community. b. Lower the thermostat setting on the hot water tank. c. Reduce fluid intake to less than 2500 mL/day. d. Limit physical activity to a short daily walk.

b. Lower the thermostat setting on the hot water tank. Because peripheral arterial disease may decrease the ability to feel extremes of heat and increases risk for burn injuries, lowering the temperature of the hot water tank can reduce injury risk. There is no indication that this client needs assistance with any activities of daily living, so there is no need to move the client to an assisted living community. Reduction of fluid intake is not indicated for clients with peripheral arterial disease. Walking is encouraged because it improves blood fl ow and encourages collateral circulation to the legs.

Which interventions should the nurse take to ensure the well-being of a community-dwelling older adult with hypertension? Select all that apply. a. Suggest that the client have annual Papanicolaou (Pap) smears and mammograms. b. Promote dietary modifications by using varied techniques. c. Assess the client's current lifestyle and promote lifestyle changes. d. Monitor the client's blood pressure and weight, and establish blood pressure screening programs. e. Teach the client about correct body mechanics and the availability of mechanical appliances.

b. Promote dietary modifications by using varied techniques. c. Assess the client's current lifestyle and promote lifestyle changes. d. Monitor the client's blood pressure and weight, and establish blood pressure screening programs. When caring for a community-dwelling older adult with hypertension, the nurse would promote dietary modifications, assess a client's current lifestyle and promote lifestyle changes, and monitor the client's blood pressure and weight and establish blood pressure screening programs. While suggesting annual Papanicolaou (Pap)smears and mammograms is beneficial, it is not specific for hypertension. When caring for a community-dwelling older adult with arthritis, the nurse would teach the client about correct body mechanics and the availability of mechanical appliances.

Which possible complication would a nurse monitor for when a client develops a venous thrombosis in the left calf? a. Embolic stroke b. Pulmonary embolism c. Myocardial infarction d. Ischemia of the left foot

b. Pulmonary embolism Because the venous system returns blood to the right side of the heart and then blood flows to the pulmonary circulation, emboli from the venous thrombosis may cause a pulmonary embolism. Embolic stroke occurs with thrombus formation in the left atrium or ventricle. Myocardial infarction occurs when thrombus forms over ruptured coronary artery plaque. Ischemia of the foot would occur with an embolus in the distal arterial system.

Which clinical finding would the nurse expect for a client with hypertensive emergency? a. Increased urine output b. Severe pounding headache c. Heart rate 110 beats/minute d. Weak and thready radial pulses

b. Severe pounding headache Hypertensive emergency often causes hypertensive encephalopathy because of increased cerebral capillary permeability, leading to severe headache, nausea, vomiting, and confusion or coma. Increased urine output would not be expected because acute kidney injury can occur with hypertensive emergency. Tachycardia is not typically seen with hypertensive emergency; high blood pressure can lead to bradycardia because of increased pressure on the carotid sinus and bodies. Radial pulses would be bounding with hypertensive emergency.

Which response by the nurse is best when a client with intermittent claudication has been instructed to stop smoking and says, "I don't understand why this is necessary"? a. "Tobacco smoking causes many health problems." b. "Nicotine use is a risk factor for heart and lung diseases." c. "Nicotine makes blood vessels smaller and will worsen your pain." d. "Smoking is prohibited for both clients and staff members in the hospital."

c. "Nicotine makes blood vessels smaller and will worsen your pain." The response that nicotine decreases blood vessel size and will worsen the client's pain is truthful and addresses the specifics of the reason this client should avoid smoking. The other responses are true, but they do not address the specific reason for avoiding smoking for this client. Tobacco does cause many health problems, but this response is not specific to this individual client. Nicotine use does lead to heart and lung disease, but this client currently has only the diagnosis of peripheral arterial disease. Although smoking is prohibited for everyone in the hospital, this response does not address the individual client's concerns and also indicates that smoking can be resumed once the client is discharged.

Which information is most important for the nurse to teach a client prescribed an antihypertensive medication to be taken once in the morning and a 2-gram sodium diet? a. "Avoid adding salt to cooked foods." b. "Use less salt when preparing foods." c. "Take your medicine exactly as prescribed." d. "Measure your blood pressure every morning."

c. "Take your medicine exactly as prescribed." The most effective way to lower the blood pressure is to take the prescribed medication daily. Restricting salt in the diet will help limit fluid retention and thus reduce the blood pressure, but it is not as effective as an antihypertensive. Salt should not be added during food preparation. The natural sodium content of foods should be calculated in a 2-gram sodium diet. It is not necessary to take daily blood pressure measurements unless specifically prescribed to do so by the primary health care provider.

Which client would the nurse assess first? a. 40-year-old with 30 pack-year cigarette history who reports tingling in both feet b. 42-year-old who takes antihypertensive medication and reports bilateral 4+ ankle swelling c. 65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension d. 70-year-old with peripheral arterial disease who reports severe lower leg burning and numbness

c. 65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension The 65-year-old's risk factors of age and uncontrolled hypertension and the report of tearing pain indicate possible dissecting aortic aneurysm, which would need rapid diagnosis and treatment. The nurse would assess this client first. The 40-year-old does need assessment for peripheral arterial disease because of the cigarette smoking history but does not need urgent intervention. The 42-year-old would be assessed for use of calcium channel blockers (which may cause ankle edema) and for salt intake but does not need urgent action. The burning pain and numbness reported by the 70-year-old do require assessment and action, but the symptoms are typical for peripheral arterial disease and not an indication for urgent intervention.

Which action would the nurse perform first when prioritizing care for a hypertensive client? a. Administer oxygen (O2). b. Monitor the blood pressure (BP). c. Assess for a severe headache. d. Place the client in a semi-Fowler position.

c. Assess for a severe headache. The client should be assessed for the presence of a severe headache to determine the presence of systemic complications related to the hypertension. O 2 administration depends on the condition of the client and the O 2 saturation level. The BP is monitored every 5 to 15 minutes. Placing the client in a semi-Fowler position should be followed during care for a hypertensive client.

Which action would the nurse prioritize after applying pressure to the nose of a client who is being treated for uncontrolled hypertension and develops a nosebleed? a. Add humidity to the client's oxygen. b. Teach the client how to avoid nosebleeds. c. Assess the client's blood pressure. d. Obtain the client's pulse rate.

c. Assess the client's blood pressure. Nosebleeds in adults may indicate hypertension. The nurse would check the blood pressure and then notify the health care provider if intervention is needed to lower the blood pressure. Although oxygen can dry out the mucus membranes in the nose, the priority will be to assess for and mange hypertension. Teaching the client how to avoid nosebleeds is appropriate, but not the priority action. Blood pressure, rather than pulse rate, is the priority because of the client's known uncontrolled hypertension.

Which clinical condition is the result of changes in the integrity of arterial walls and small blood vessels? a. Contusion b. Thrombosis c. Atherosclerosis d. Tourniquet effect

c. Atherosclerosis In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood fl ow to areas below the site of constriction.

Which laboratory result will be important for the nurse to review when a client is admitted to the hospital with a long history of uncontrolled hypertension? a. Blood glucose level b. White blood cell count c. Blood urea nitrogen d. Lactic dehydrogenase

c. Blood urea nitrogen Hypertension leads to changes in renal blood flow and eventually to decreased renal function, which is tested with blood urea nitrogen levels. All of the other results would also be reviewed by the nurse, but they are not associated with complications of hypertension. Changes in blood glucose level are not associated with hypertension, although if the client also has diabetes then there will be more risk for kidney disease. White blood cell count is not affected by hypertension, but it would be assessed for any possible infectious or inflammatory process. Lactic dehydrogenase is an enzyme associated with multiple other diagnoses, but it is not affected by hypertension.

Which action would the nurse take after noting that a client who has been on anticoagulant therapy after hip surgery is being discharged with no anticoagulant prescription? a. Explain to the client that anticoagulant therapy will no longer be needed. b. Suggest that the client take aspirin daily to prevent venous thrombosis. c. Contact the health care provider to clarify whether anticoagulant therapy is needed. d. Instruct the client to call the health care provider to ask about anticoagulant medications.

c. Contact the health care provider to clarify whether anticoagulant therapy is needed. Because it is unclear what the anticoagulant needs are for this client, the nurse would contact the health care provider for clarification. The nurse would not tell the client that no anticoagulant was needed without further clarification. Daily aspirin use is not adequate to prevent venous thrombosis in clients at high risk, such as those who have had orthopedic surgery. The nurse would not place the responsibility for clarification about anticoagulant use on the client, because it is a nursing responsibility to clarify discharge medications and instructions.

Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities? a. Thermography b. Plethysmography c. Duplex venous Doppler d. Somatosensory evoked potential

c. Duplex venous Doppler Duplex venous Doppler records an ultrasound of the veins, including blood flow abnormalities of the lower extremities, aiding detection of deep vein thrombosis. Thermography, which measures the heat radiating from the skin surface, is used to determine client response to anti-inflammatory medication therapy and inflamed joints. Plethysmography is used to record variations in volume and pressure of blood passing through tissues; the test is nonspecific. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease.

Which topic would be the most important to include in teaching when an obese client receives a diagnosis of high blood pressure? a. Causes of hypertension b. Symptoms of hypertension c. Effect of weight loss in hypertension d. Effect of lowering alcohol intake in hypertension

c. Effect of weight loss in hypertension Weight loss is among the most powerful lifestyle modifications in lowering blood pressure. Because teaching should be individualized to the client, the effect of weight loss would be emphasized for this obese client. The other topics might also be addressed, but they are not as specific to the client.

The nurse is counseling a 34-year-old client who has requested a prescription for oral contraceptives. Which condition would warrant additional discussion? a. Anemia b. Depression c. Hypertension d. Dysmenorrhea

c. Hypertension One of the side effects of oral contraceptives is hypertension; therefore they are contraindicated for any woman who already has hypertension, particularly at the client's age or older. Anemia is not a contraindication for women who want to take oral contraceptives because oral contraceptives may help this condition by decreasing bleeding. Depression is not a contraindication for women who want to take oral contraceptives. Oral contraceptives may be prescribed for women with menstrual difficulties such as dysmenorrhea.

Which physical findings that are typical in older adults would the nurse include when preparing to teach a community health program for senior citizens? a. Increased skin elasticity and an increase in testosterone production b. Impaired fat digestion and an increase in pepsin production c. Increased blood pressure and decreased cardiac output c. An increase in body warmth and some swallowing diffi culties

c. Increased blood pressure and decreased cardiac output With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse medication reactions

Which action will the nurse take when the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6? a. Administer the scheduled dose of warfarin. b. Offer the client foods that are high in vitamin K. c. Notify the health care provider of the laboratory results. d. Warn the client about risk for spontaneous hemorrhage.

c. Notify the health care provider of the laboratory results. The therapeutic level for INR when treating a venous thrombosis is 2 to 3, so the nurse would notify the health care provider and anticipate a decrease in warfarin dosage. Administration of a scheduled warfarin dose would further increase the INR. Although vitamin K can decrease warfarin effectiveness, dietary vitamin K is not used to reverse high INR levels. Although higher INR levels may lead to spontaneous bleeding, an INR of 4.6 would not cause hemorrhage.

Which action by the nurse is the priority when a client who had abdominal surgery 24 hours ago develops pain, redness, and swelling in the left calf? a. Elevate the legs. b. Document the findings. c. Notify the health care provider. d. Give the prescribed pain medication.

c. Notify the health care provider. The history and clinical findings are consistent with venous thrombosis, and the nurse would notify the health care provider rapidly so that diagnostic testing and interventions can be implemented. The legs would be elevated, but this is not the highest priority because further diagnosis and treatment are needed. The findings would be documented, but this can be done after notification of the health care provider. Pain medication administration is important, but will not help in further diagnosis and treatment of the venous thrombosis.

Which response would the nurse make when postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched."? a. "I'll get pillows for you. I want you to be as rested as possible." b. "It's not a good idea, but you do look uncomfortable. I'll get you a pillow." c. "We don't allow pillows under the legs because you will get too warm." d. "A pillow under the knees can result in clot formation because it slows blood flow."

d. "A pillow under the knees can result in clot formation because it slows blood flow." Flexing the hips and pressure against the popliteal space impedes venous return, increasing the risk for clot formation. Although comfort and rest should be encouraged, placing pillows under the knees is contraindicated due to the risk for venous thrombosis of the calves. Pillows under the knees produce pressure, not warmth.

Which blood pressure is optimal for an adolescent? a. 85/54 mm Hg b. 95/65 mm Hg c. 105/65 mm Hg d. 110/65 mm Hg

d. 110/65 mm Hg The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure of an infant is 85/54 mm Hg. The average optimal pressure of a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 years is 105/65 mm Hg.

A 31-year-old client is seeking contraceptive information. While obtaining the client's history, which factor indicates to the nurse that oral contraceptives are contraindicated? a. Older than 30 years b. Current hypothyroidism c. Two multiple pregnancies d. Blood pressure 162/110

d. Blood pressure 162/110 Oral contraceptives may cause or exacerbate hypertension; even borderline hypertension places the client at risk for a brain attack. Oral contraceptives are not contraindicated for women older than 30 years of age if there are no known risk factors. There is no relationship between oral contraceptives and multiple births. Contraceptives are not contraindicated in clients who have hypothyroidism.

After consistently obtaining a blood pressure of 140/76 mm Hg for a client, which stage of hypertension will the nurse document? a. Normal b. Elevated c. Stage 1 d. Stage 2

d. Stage 2 According to the current American College of Cardiology guidelines, systolic blood pressure greater than or equal to 140 mm Hg is classified as stage 2 hypertension. Although the diastolic pressure of 76 mm Hg is normal, elevation of either the systolic or diastolic pressure results in a hypertension diagnosis. Normal blood pressure would be less than 120/80 mm Hg. Systolic pressures between 120 to 129 mm Hg and a diastolic pressure less than 80 mm Hg would be classified as elevated blood pressure. Stage 1 hypertension would be documented for systolic pressures between 130 to 139mm Hg or diastolic between 80 to 89 mm Hg. Hypertensive crisis would be diagnosed for systolic pressures over 180 mm Hg and/or diastolic pressures over 120 mm Hg.