Semester 2: Unit 2 exam

During the assessment of a patient suspected of anemia secondary to a nutritional deficiency, which question is important for the healthcare provider to ask the patient? "Have you noticed if your stools have changed color?" "Do you ever experience numbness or tingling of your extremities?" "Have you noticed if your gums bleed when you brush your teeth?" "What over-the counter medications do you take regularly?"

"Do you ever experience numbness or tingling of your extremities?" Bleeding gums may be related to clotting problems or gingivitis. The health care provider would want to ask about stool color changes if a hemorrhagic anemia was suspected. If the patient reports experiencing numbness or tingling (paresthesia), this would point to anemia caused by vitamin B12 deficiency.

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which affirmative statement by the leader reflects an appropriate way to manage the stress? "I will avoid protein." "I will plan a vacation." "I will get enough sleep." "I will participate in support groups.

"I will get enough sleep." Headache, hypertension, and gastrointestinal problems indicate physical stress in the leader. Stress can be managed by getting enough sleep. The leader should consume protein in moderate amounts. Planning a vacation would help in managing mental stress. Participating in support groups would help in managing emotional/spiritual stress.

Which of the following should be included in peak flow measurement teaching? "Inhale deeply, put your mouth over mouthpiece, then exhale slow and steady." "Exhale deeply, put your mouth over mouthpiece, then inhale slow and steady." "Exhale deeply, put your mouth over mouthpiece, then inhale hard and fast." "Inhale deeply, put your mouth over mouthpiece, then exhale hard and fast."

"Inhale deeply, put your mouth over mouthpiece, then exhale hard and fast."

Normal RR 1. newborns 2.infants 3. toddler 4. adolescents and adults A. 20 bpm B. 50 bpm C. 40 bpm D. 25-32 bpm

1. C 2. B 3. D 4. A

Match the following 1. Ventilation 2. Transport 3. Perfusion A. inhaling oxygen into the lungs and exhaling carbon dioxide from the lungs B. the blood transporting oxygen containing hemoglobin to the cells and returning carbon dioxide containing hemoglobin to the alveoli C. ability of hemoglobin to carry oxygen from the alveoli to the cells for metabolism and to carry carbon dioxide from the cells to the alveoli to be eliminated

1.A 2.C 3. B

Match the following : 1. Ischemia: 2. Hypoxia: 3. Anoxia: 4. Hypoxemia: A. reduced oxygenation of arterial blood. B. insufficient oxygen reaching the cells. C. total lack of oxygen in body tissues. D. insufficient flow of oxygenated blood to the tissues.

1.D 2.B 3.C 4.A

(NCLEX website)A family member, who is caring for a 2-year-old with Tetralogy of Fallot, asks you why the child will periodically squat when playing with other children. Your response is:* A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." B. "Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels." C. "Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." D. "Squatting helps to normalize systemic vascular resistance, which will increase the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels."

A Squatting is common in patient with TOF. Why? Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels.

(NCLEX website) As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply:* A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails

A, B, and D. Option C is wrong because this condition can be treated with both palliative surgery (used to help alleviate symptoms until the child is old enough for complete repair) and complete repair. All the other options are correct.

(self adaptive) Which nursing interventions are likely to help the patient to cope by addressing the mediators of stress? (Select all that apply.) A. "A divorce, while stressful, can be the beginning of a new, better phase of life." B. "You said you used to jog; getting back to aerobic exercise could be helpful." C. "Journaling gives one more awareness of how experiences have affected them." D. "Perhaps a short-term loan from your father will make your layoff less stressful." E. "Slowing your breathing by counting to three between breaths will calm you." F. "I have found a support group for newly divorced persons in your neighborhood."

A. "A divorce, while stressful, can be the beginning of a new, better phase of life." C. "Journaling gives one more awareness of how experiences have affected them." D. "Perhaps a short-term loan from your father will make your layoff less stressful." F. "I have found a support group for newly divorced persons in your neighborhood." Stress mediators are factors that can help persons cope by influencing how they perceive and respond to stressors; they include personality, social support, perceptions, and culture. Suggesting that a divorce may have positive as well as negative aspects helps the patient to alter his perceptions of the stressor. Journaling increases self-awareness regarding how life experiences may have shaped how one perceives and responds to stress (or how one's personality affects how one responds to stressors). A loan could help the patient perceive a layoff differently by reducing the financial pressures that accompany it. Participation in support groups is an excellent way to expand one's support network relative to specific issues. However, neither aerobic exercise nor breathing-control exercises, while helpful in other ways, affect stress mediators.

The nurse is providing teaching to the parents of a preschool-age client who is prescribed iron supplements for iron-deficiency anemia. Which parental statements indicate the need for further education? Select all that apply. A. "We will mix the iron with milk to enhance absorption." B. "We will mix the iron with black tea to enhance absorption." C. "We will mix the iron with orange juice to enhance absorption." D. "We will avoid giving our child green tea because it can decrease absorption." E."We will avoid feeding our child tomatoes because it can decrease absorption."

A. "We will mix the iron with milk to enhance absorption." B. "We will mix the iron with black tea to enhance absorption." The parental statements that indicate the need for further education include mixing the iron with milk and black tea to enhance absorption. Milk contains phosphorus and black tea contains tannins, both which decrease the absorption of iron. Orange juice increases the acidity of the stomach, which enhances absorption. Green tea and tomatoes (an oxalate) are avoided as both will decrease the absorption of iron.

A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? A. "Your father may be having mini-strokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion."

A. "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified.

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? A. A pulse rate irregularity B. Equal apical and radial pulse rates C. A pulse rate of 60 beats per minute D. An apical rate obtainable at the fifth intercostal space and midclavicular line

A. A pulse rate irregularity Dysrhythmias are abnormal and are associated with acute or chronic pathologic conditions. An equal apical and radial pulse is expected; the radial pulse reflects ventricular contractions. The expected range in adults is 60 to 100 beats per minute. An apical rate obtainable at the fifth intercostal space and midclavicular line are the anatomical landmarks for locating the apex of the heart; they are unaffected by aging.

Which patient has the highest risk for development of a blood clot? A. A woman who smokes and is taking estrogen-containing birth control pills. B. A distance runner. C. A man with a history of asthma. D. A woman who is taking aspirin for menstrual cramps.

A. A woman who smokes and is taking estrogen-containing birth control pills. The combination of hormones and smoking may cause a hypercoagulability state. Distance running does not increase the risk of forming a blood clot. A patient with asthma does not predispose the formation of a blood clot. A patient taking aspirin will have a decreased risk of development of a blood clot due to the antiplatelet action of aspirin.

A new psychiatric nurse states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement? A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

*The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). What measures should the nurse include to increase arterial blood flow to the extremities? A. Exercises that promote muscular activity B. Meticulous care of minor skin breakdown B. Elevation of the legs above the level of the heart D. Soaking the feet in hot water each day

A. Exercises that promote muscular activity Arterial blood flow is improved with exercise by fostering the development of collateral circulation. Meticulous care of minor skin breakdown is important for the person with diabetes, but it does not improve arterial blood flow. Elevating the legs above the heart reduces arterial blood flow; the legs should be kept dependent to facilitate tissue perfusion. Soaking the feet in hot water is contraindicated because it can burn the skin or cause drying; also, individuals with diabetes may have neuropathies, which alter the perception of temperature.

(powerpoints) What would the nurse educate the patient on preventing excessive bleeding ( select all that apply) A. Genetic counseling B. Smoking cessation C. Injury prevention D. Hydration E. Exercise F. Prevention of stasis

A. Genetic counseling C. Injury prevention

Which of the following are example of bleeding disorders ( select all that apply) A. Hemophilia A and B B. Leukemia C. Polycythemia D. Thrombocytopenia E. Von Willebrand's disease

A. Hemophilia A and B B. Leukemia D. Thrombocytopenia E. Von Willebrand's disease

Besides paralysis to the right side what else would you see in a patient with a left brain damaged stroke? A. Impaired right to left discrimination B. Impaired judgment C. Impaired speech D. Slow performance E. Impaired time concept F. depression/anxiety G. Impaired comprehension related to language and math H. denies/minimize problems I. Impulsive

A. Impaired right to left discrimination C. Impaired speech D. Slow performance F. depression/anxiety G. Impaired comprehension related to language and math Left brain damage--> Impaired right to left discrimination Impaired speech Slow perforamace depression/anxeity Impaired comprehension related to lanuage and math Right brain damage Left side neglect denies/minimize problems Impulsive Impaired judgment Impaired time concept

*The school nurse is assessing a 10-year-old boy with hemophilia who has fallen while playing in the schoolyard. At which site does the nurse expect to find internal bleeding? A. Joints B. Abdomen C. Cerebrum D. Epiphyses

A. Joints Activity can result in bleeding in children with hemophilia; therefore weight-bearing joints, especially the knees, are the most common site of bleeding. The abdomen is usually protected from the trauma of direct force. The cerebrum is protected by the skull and is not likely to be injured. Bleeding from bones themselves is not common without other associated trauma. Hemarthrosis → bleeding into a joint (children with hemophilia will have this)

Risk factors for hypertension: (select all that apply) A. MI B. Heart failure C. Anxiety D. Stroke E. Renal Dz

A. MI B. Heart failure D. Stroke E. Renal Dz

(powerpoints) Which medication is contraindicated in a hemorrhagic stroke? ( select all that apply) A. TPA B. Antihypertensive C. ASA D. Anticoagulants

A. TPA C. ASA D. Anticoagulants

The nurse observes that during morning care the patient is complaining of leg pain when ambulating to the bathroom. The nurse assists the patient back into bed and notices that the patient's leg pain is relieved. Further assessment reveals bilateral pedal edema. The nurse knows that the cause of the patient's leg pain is most likely which of the following: A. The pain indicates an inadequate amount of blood to transport oxygen to meet the demands of leg muscles. B. The pain indicates a muscle spasm. C. The patient is having a myocardial infarction. D. The pain is due to over-exertion during morning care.

A. The pain indicates an inadequate amount of blood to transport oxygen to meet the demands of leg muscles. Impaired perfusion often results in leg pain as related to peripheral arterial disease (PAD). PAD leg pain is often relieved with rest and worsens with walking. Leg pain that is relieved with rest is called intermittent claudication and means that there is an inadequate supply of blood being transported to the muscles. Edema also develops from the obstruction of venous blood flow.Although pain is common during a muscle spasm, it is usually not relieved with rest. During a myocardial infarction, pain is often felt in the chest and not in the lower extremities.Although pain may occur from exercise, acute leg pain with the presence of edema indicates a perfusion problem and warrants further investigation.

Which interventions are most important for preventing bleeding in patients with bleeding disorders? (Select all that apply.) A. Using a soft-bristle toothbrush B. Avoiding over-the-counter medications that contain aspirin C. Using a blade razor D. Removing obstacles that may result in a fall E. Giving medication by intramuscular injection

A. Using a soft-bristle toothbrush B. Avoiding over-the-counter medications that contain aspirin D. Removing obstacles that may result in a fall Use of a soft-bristle toothbrush decreases the trauma to the gums with oral care. Avoid the use of aspirin because of its antiplatelet effect. Decrease the fall risk to prevent bleeding from trauma. Do not use a blade razor because of the risk for nicks when shaving. Intramuscular injections are avoided in bleeding precautions due to the risk of bleeding into muscle from the trauma of the injection.

(powerpoints) Select all that statments that are true pertaining to impairment of local perfusion A. can occur if there is loss of vessel patency B. if untreated leads to ischemia, cell injury, and cell death C. If severe can lead to shock. D. Can occur if cardiac output is inadequate

A. can occur if there is loss of vessel patency B. if untreated leads to ischemia, cell injury, and cell death D. Can occur if cardiac output is inadequate Central perfusion occurs when cardiac output inadequate. If severe can lead to shock. If untreated leads to ischemia, cell injury, and cell death Impairment of tissue(local) perfusion is associated with loss of vessel patency or permeability, or adequate central perfusion . Results in impaired blood flow to the affected body tissue. If untreated leads to ischemia, cell injury, and cell death

(power points) evaluating whether the use of defense mechanisms is adaptive or maladaptive is determined for the most part by their (select all that apply) A. frequency B. onset C. intensity D. duration of use

A. frequency C. intensity D. duration of use

(powerpoints) Select all true statements in regards to gestational: development of A. hypertension after week 20 of pregnancy B. proteinuria is always seen C. Does not persist longer than 12 weeks postpartum D. usually resolves during the first postpartum week

A. hypertension after week 20 of pregnancy C. Does not persist longer than 12 weeks postpartum D. usually resolves during the first postpartum week development of hypertension after week 20 of pregnancy without proteinuria. Does not persist longer than 12 weeks postpartum and usually resolves during the first postpartum wee

Goals for COPD patient A. increase PaO2 to at least 60 B. Maintain oxygen saturation above 90%

A. increase PaO2 to at least 60 B. Maintain oxygen saturation above 90%

(E's notes) In inadequate gas exchange you will see ( select all that apply) A. increase in RR B. decrease in HR C. increase in HR D. Increase in TEM E. decrease in SaO2

A. increase in RR C. increase in HR D. Increase in TEM E. decrease in SaO2

(giddens) The extent of tissue damage from impaired perfusion depends on ( select all that apply:) A. size of the clot B. location of the blood clot C. size of the patient D. whether the blood supply is reduced or completely interrupted

A. size of the clot B. location of the blood clot D. whether the blood supply is reduced or completely interrupted

A patient is about to have an echocardiogram done. Which information should the nurse include when explaining the purpose of the test to the client? A.It monitors action of the heart valves. B. It assesses myocardial ischemia and perfusion. C. It visualizes ventricular systole and diastole. D. It identifies the adequacy of electrical conductivity.

A.It monitors action of the heart valves. Action of the heart valves is available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole is determined by cardiac angiography. Identifying the adequacy of electrical conductivity is determined by an electrocardiogram (ECG).

(power points) What labs would most likely be ordered with a patient with impaired clotting? (select all that apply) A.PT B. PTT C. INR D. D-dimer E. RBC F. ABG G. Hemoglobin H. Hematocrit I. Platelet Count

A.PT B. PTT C. INR D. D-dimer E. RBC G. Hemoglobin H. Hematocrit I. Platelet Count

Who is at risk for stress select all that apply: A.Person from a foreign country who does not speak the native language B. A person with impaired cognition C. Person of lower socioeconomic status who is illiterate D. Homeless person E. middle aged African American male F. Multiple significant life changes

A.Person from a foreign country who does not speak the native language B. A person with impaired cognition C. Person of lower socioeconomic status who is illiterate D. Homeless person F. Multiple significant life changes (*divorce)

A man reacts to the death of a loved one by saying "No, I don't believe you" to initially protect himself from the overwhelming news. This is an example of Adaptive denial Maladaptive denial Adaptive repression Maladaptive repression

Adaptive denial Maladaptive denial --> A woman whose husband died 3 years earlier still keeps his clothes in the closet and talks about him in the present tense.

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk for the development of a pulmonary embolus? Atrial fibrillation Forearm laceration Migraine headache Respiratory infection

Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. A forearm laceration, migraine headache, or a respiratory infection does not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? A. "You do not need to wear them while you are awake, but it is important to wear them at night." B. "You will need to apply them in the morning before you lower your legs from the bed to the floor." C. "If they bother you, you can roll them down to your knees while you are resting or sitting down." D. "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

B. "You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than A. 15 minutes B. 30 minutes C. 1 hour D. 1.5 hours

B. 30 minutes

(powerpoints) Who is at risk for impaired clotting. (select all that apply) A. 7 y.o male with asthma B. 90 y.o female C. 45 y.o female with polycythemia D. 18 y.o male who smokes cigarettes

B. 90 y.o female C. 45 y.o female with polycythemia D. 18 y.o male who smokes cigarettes Risk factors for impaired clotting: Age: older adults due to expected physiological changes Genetics: genetic blood disorders Immobility: slows the return of blood to the heart and results in hemostasis Smoking: contributes to hypercoagulability

(powerpoints) 55 year old male who smokes a pack of cigarettes a day. What is the goal BP A.< 100/60 B. <130/80 C. <140/90 D.<150/90

B. <130/80 Goal is to have BP < 140/90 individuals with risk factors like DM, heart dz, use of tobacco the goal is <130/80

(giddens) Example of Clotting Disorders Local ( select all that apply) A. Von Willebrand's disease B. Arterial embolism C.Polycythemia D. Venous thromboembolism E. Disseminated intravascular coagulation

B. Arterial embolism D. Venous thromboembolism

(powerpoints) Several conditions are associated with stroke ( select all that apply) A. COPD B. Atrial fibrillation C. Cardiac valve abnormalities D. Diabetes mellitus

B. Atrial fibrillation C. Cardiac valve abnormalities D. Diabetes mellitus

Means and behavioral actions to manage internal or external situations perceived as difficult and/or beyond the individual's current resources. A. Affliction B. Coping C. Anxiety D. Stress

B. Coping

automatic coping styles that protect people from anxiety and maintain self-image by blocking feelings, conflicts, and memories A. Coping B. Defense mechanisms C. Stress D. Anxiety

B. Defense mechanisms

(powerpoint) Most common reported symptoms associated with impaired stress response include: ( select all that apply) A. Epistaxis B. Fatigue C. Shortness of breath D. Pain

B. Fatigue C. Shortness of breath D. Pain

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? A. Elevated blood pressure B. Increased blood viscosity D. Fragility of the blood cells C. Immaturity of red blood cells

B. Increased blood viscosity Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation. Hypertension usually is related to narrowing or sclerosing of arteries, not to an increased number of blood cells. The fragility of blood cells does not affect the viscosity of the blood. Erythrocyte immaturity is not related to increased viscosity.

A patient with a chronic disease has macrocytic and normochromic red blood cells. Which of the following laboratory results are characteristic of this patient's anemia? A.Reticulocytes 1% B. Increased mean corpuscular volume (MCV) C. Bands 3% D. Decreased mean concentration of hemoglobin (MCHC)

B. Increased mean corpuscular volume (MCV)

(powerpoints) What test will be ordered to diagnosis and stroke? A. CT with contrast B. Non contrast CT scan or MRI C. EKG D. Arteriogram

B. Non contrast CT scan or MRI Diagnostic studies to confirm a stroke Non contrast CT scan or MRI → can indicate the size and location of lesion and can also differentiate between ischemic and hemorrhagic * it is important to know if it is ischemic or hemorrhagic bc that will decide how to treat

A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness.

B. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

An emergency department patient has a suspected gunshot wound to the abdomen. The nurse who finds a profusely bleeding abdominal wound should anticipate which signs(s) and symptom(s) of profuse blood loss? (Select all that apply.) A. Increased blood pressure B. Rapid, weak pulse C. Cold, clammy skin D. Urine output >50 mL/hr E. Decreased blood pressure

B. Rapid, weak pulse C. Cold, clammy skin E. Decreased blood pressure

During a blood transfusion a client develops chills and a headache. What is the priority nursing action? A. Cover the client. B. Stop the transfusion at once. C. Decrease the rate of the blood infusion. D. Notify the healthcare provider immediately.

B. Stop the transfusion at once. Chills, headache, nausea, and vomiting are all signs of a transfusion reaction. The infusion must be stopped before treatment of symptoms begins. Slowing the infusion will continue the reaction, which may lead to kidney damage. The healthcare provider should be notified after the transfusion is stopped.

A 72-year-old man presents to the emergency room. The patient appears diaphoretic and anxious, and has noted peripheral edema. The patient's vital signs are blood pressure of 100/40, heart rate of 130 and irregular, and respiratory rate of 26. How does the nurse interpret these findings? A. The patient is having a myocardial infarction. B. The patient has impaired central perfusion. C. The patient has a virus. D. Pain medication should be administered to this patient.

B. The patient has impaired central perfusion patient has the classic symptoms of impaired central perfusion. Central perfusion occurs when cardiac output is optimal and blood is pumped to all of the organs and tissues from the arteries, through the capillaries, and then back to the heart through the veins. The nurse needs to administer oxygen. Chest pain is often present with myocardial infarction, along with elevated blood pressure readings and electrocardiogram changes. Viral illness commonly presents with other symptoms such as body ache or gastrointestinal issues, and typically has little or no effect on the heart rate. Pain management is not indicated for patients who do not present with pain. Also, the question is asking what assessment the nurse has made, and is not asking about interventions.

The nurse knows that which assessment finding is characteristic of a deep vein thrombosis in the leg? A. Bilateral edema of the leg associated with an albumin level of 2 g/dL B. Unilateral swelling with redness over the swollen area C. Brisk reflexes in the lower extremities D. Brownish discoloration of the skin over the lower extremities

B. Unilateral swelling with redness over the swollen area A deep vein thrombosis of the leg may be associated with edema in the affected leg and erythema. Bilateral swelling of the legs associated with a low serum albumin level is related to decreased oncotic pressure. Brisk reflexes may be the result of a neurologic disorder. Brownish discoloration of the lower extremities may be related to chronic veinous insufficiency, not a deep vein thrombosis.

Who are the most susceptible to iron-decency anemia (select all that apply) A. African American men B. Very young C. those on poor diets D. women in their reproductive years.

B. Very young C. those on poor diets D. women in their reproductive years.

A patient is admitted to the medical unit with pneumonia. When reviewing home medications, which of the following medications would the nurse recognize as a risk for bleeding? A. Diltiazem (Cardizem) B. Warfarin (Coumadin) C. Acetaminophen (Tylenol) D. Metformin (Glucophage)

B. Warfarin (Coumadin) Warfarin (Coumadin) is a medication that interferes with blood clotting by interfering with the vitamin K-dependent clotting factors. Diltiazem is a calcium channel blocker. Acetaminophen is an over-the-counter medication that does not interfere with blood clotting. Metformin is a medication used for diabetes.

Which anemia requires a protein called intrinsic factor to be secreted by the GI (select all that apply) A. sickle cell B. cobalamin deficiency C. iron deficient D. pernicious

B. cobalamin deficiency D. pernicious cobalamin deficiency aka pernicious

Clinical manifestations of PAD (select all that apply) A. edema B. intermittent claudication C. paresthesia D. decreased to absent peripheral pulses E. cool skin temperature F. loss of hair and thin taut/shiny skin on affected extremities G. dull or achy pain to affected extremity H. redness to affected extremity

B. intermittent claudication C. paresthesia D. decreased to absent peripheral pulses E. cool skin temperature F. loss of hair and thin taut/shiny skin on affected extremities Venous Clots - dull/achey pain, redness, and edema with an increased circumference of affected extremity

Select physiologic types of stress A. anxiety B. muscle tension/HA C. overeating D. elevated HTN and heart rate E. smoking/ substance abuse

B. muscle tension/HA D. elevated HTN and heart rate Emotional→ anxiety, angry, irritable, frustration Psychological→ muscle tension, HA, elevated HTN, and elevated heart rate Behavioral → overeating, smoking, substance abuse

The nurse is developing a plan of care for a patient who is at high risk for DVT and is being treated with warfarin. Which intervention will be included in the nursing care plan? A. Assign the patient to a private room. B.Avoid intramuscular (IM) injections. C. Use rinses rather than a soft toothbrush for oral care. D. Restrict activity to passive and active range of motion

B.Avoid intramuscular (IM) injections. IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

What is most important for a nurse to monitor after a client has an endarterectomy in a lower extremity? A.Appetite B.Skin color C.Bowel habits D.Tissue turgor

B.Skin color After removal of an arterial obstruction by endarterectomy, adequate circulation should be monitored by assessing bilateral peripheral pulses, skin color, and skin temperature. Appetite does not change as a result of vascular surgery. Bowel habits will not be altered after this surgery. Turgor is affected by changes in hydration, which generally is not altered with this surgery.

(NCLEX website)As the registered nurse you are developing a plan of care for a patient with Tetralogy of Fallot. Select all the appropriate nursing diagnoses below that would be specific to this patient:* A. Risk for deficient fluid volume B. Ineffective airway clearance C. Activity Intolerance D. Failure to thrive E. Risk for impaired liver function

C and D. A patient with TOF will have activity intolerance because remember this is a cyanotic heart defect where there is not enough oxygen in the blood (due to the structural defect of the heart) and any activity (feeding, crying, play etc.) can increase the demands for oxygen. Therefore, the patient will experience activity intolerance. In addition, the patient can experience failure to thrive because the constant hypoxemia (low oxygen in the blood) experienced can lead the child to have poor growth, weight loss, clubbing of the nails etc. Remember organs need plenty of oxygen to work and grow but in TOF this isn't happening very well. Options A, B, and E are not appropriate nursing diagnoses. TETS spell--> knee to chest

A cardiac catheterization is performed on an infant. After the procedure, the leg used for the catheter insertion site becomes mottled. What is the best action by the nurse? A. Elevating the leg B. Covering the leg with a blanket C. Checking the pulse in the extremity D. Notifying the primary healthcare provide

C. Checking the pulse in the extremity Some mottling is expected because of circulatory disruption and arterial spasm. Further assessment (e.g., palpation of the pedal pulse) is performed to rule out arterial occlusion. Elevation of the leg is contraindicated; elevation may induce bleeding from the puncture site. A blanket will interfere with inspection. Other observations should be made before the primary healthcare provider is notified.

A patient informs the nurse that he is having severe chest pain. He took two nitroglycerin tablets more than 1 hour ago with no relief. On further assessment the nurse notices that the patient is diaphoretic and also complains of feeling dizzy. The nurse would expect which diagnostic test or tests to be ordered: A. Vitamin B12 test B. Cardiac stress test C. Creatine kinase-myoglobin (CK-MB) and C-reactive protein (CRP) D. Complete blood count (CBC) and basic metabolic panel (BMP)

C. Creatine kinase-myoglobin (CK-MB) and C-reactive protein (CRP) Pain, diaphoresis, and dizziness are all symptoms of someone experiencing acute coronary syndrome, which likely precipitates a myocardial infarction (MI). Patients with angina pectoris often take nitroglycerin to relieve the chest pain, which accompanies impaired tissue perfusion. Because the patient's chest pain is unrelieved by the nitroglycerin, this alerts the nurse that he is experiencing unstable angina, possibly advancing to MI. Enzymes and markers such as CK, present in the myocardium, are often evaluated as a diagnostic measure for an MI because enzymes that are released from damaged cells circulate in the blood and can be detected to confirm the presence of impaired perfusion. Although vitamin B12 deficiencies can elevate homocysteine (Hcy) levels, it is more likely that Hcy levels will be measured, rather than a laboratory test for vitamin B12 levels. A cardiac stress test may be used to measure vital signs during exercise on a treadmill. A cardiac stress test is not recommended if a patient is experiencing signs of an MI. Although a CBC and BMP may be ordered to evaluate a patient's overall functioning, it would not be used as a diagnostic tool to diagnose an MI.

The nurse knows that primary prevention strategies to prevent impaired perfusion in the patient include which of the following recommendations by the American Heart Association (AHA): A. Routine blood pressure monitoring B. Administering furosemide (Lasix) to a patient with active congestive heart failure (CHF) symptoms C. Eating a healthy diet and exercising most days of the week D. Monitoring routine serum lipids

C. Eating a healthy diet and exercising most days of the week Primary prevention strategies include measures that promote health and prevent disease from developing. The American Heart Association recommends eating a heart-healthy diet, exercising most days of the week, taking a low-dose aspirin, and not smoking. Routine blood pressure monitoring is considered secondary prevention, which also includes screening and early diagnosis of health issues.Although administering a diuretic such as furosemide to a patient who presents with active CHF symptoms is considered an optimal treatment of symptoms, this is not considered a primary prevention strategy. Testing for routine serum lipids is considered secondary prevention.

A patient with emphysema may present with all of the following symptoms EXCEPT?* A. Barrel chest B. Hyperinflation of the lungs C. Hypoventilation D. Hypercapnia

C. Hypoventilation

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? A. Hypocapnia B. Hyperkalemia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response? A. Its just a routine part of our assessment. All clients are asked these same questions. B. Why are you concerned about these types of questions? C. Psychological factors, like excessive stress, have been found to affect medical conditions. D. We can skip these questions, if you like. It isnt imperative that we complete this section

C. Psychological factors, like excessive stress, have been found to affect medical conditions.

A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, "I work hard to provide for my family. I don't see why I can't drink to relax." The nurse recognizes the use of which defense mechanism? A. Denial B. Projection C. Rationalization D. Repression

C. Rationalization

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch

C. The employee criticizes a coworker The client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? A. Bradycardia B. Flushed face C. Unilateral chest pain D. Decreased blood pressure

C. Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.

Why may the elderly be at risk for poor coping A. self efficacy typically doesn't match actual age B. at increased risk for high risk behaviors C. may lack social support and resources

C. may lack social support and resources Children→ self efficacy/self control may not refelct age Adolescents→ poor coping increases risk for high risk behaviors Elderly → may lack soical support and resources

(power points) Pt comes into the ER due to wheezing and after some time you notice the audible wheezing has stopped. What should the nurse due next A. discontinue nebulizer treatment since wheezing has stopped B. Teach the patient breathing exercises for at home C. reassessment the lungs for air exchange D. let the provider know patient is ready for discharge

C. reassessment the lungs for air exchange severe attacks can have no audible wheezing due to constriction of air flow. Silent chest is an ominous sign of impending respiratory failure

Mom comes in with 8-month old infant and states, "My baby has not been acting the same. She is always fussy and seems in pain. Her hands have been swelling as well". What should the nurse suspect? A. pernicious anemia B. hemophilia B C. sick cell anemia D. thrombocytopenia

C. sick cell anemia

(giddens) Example of Clotting Disorders Systemic ( select all that apply) A. Von Willebrand's disease B. Arterial embolism C.Polycythemia D. Venous thromboembolism E. Disseminated intravascular coagulation

C.Polycythemia E. Disseminated intravascular coagulation

While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? Place the client in the supine position Spread a clamp in the insertion site to hold the site open Obtain a sterile Vaseline gauze to cover the opening Cover the opening with the cleanest material available

Cover the opening with the cleanest material available This emergency situation requires covering the opening with the cleanest material available to prevent atmospheric air from entering the thoracic cavity; the client's respiratory status takes priority over the potential for infection. Placing the client in the supine position is useless and will impair further the client's breathing. Using a clamp to hold the insertion site open is unsafe because it allows atmospheric air to enter the thoracic cavity. Although an occlusive dressing is desirable, atmospheric air will enter the thoracic cavity while time is taken to obtain the occlusive dressing.

A client with the diagnosis of primary hypertension is started on a regimen of hydrochlorothiazide. The nurse is providing instructions regarding this medication. What information should the nurse include? A. A common side effect is decreased sexual libido. B. One dose should be omitted if dizziness occurs when standing up. C. The client should adjust the dosage daily based on his blood pressure. D. An antihypertensive medication will likely be required for the remainder of life.

D. An antihypertensive medication will likely be required for the remainder of life. If medication is necessary to control primary hypertension, usually it is a lifetime requirement. The client should not adjust the dosage without the healthcare provider's direction. Impotence may occur with some antihypertensive medications but not with hydrochlorothiazide. The drug should not be stopped; orthostatic hypotension can be controlled by a slow change of body position.

Which site should be monitored for a pulse to assess the status of circulation to the foot? Select all that apply. A.Carotid artery B. Femoral artery C. Popliteal artery D. Dorsalis pedis artery E. Posterior tibial artery

D. Dorsalis pedis artery E. Posterior tibial artery The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid pulse, located along the medial edge of the sternocleidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal artery pulses are helpful in assessing the circulation to the lower leg.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen) B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid C. Encourage coughing and deep breathing to clear the airway D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min

D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? A. Decreases chest pain B. Conserves energy C. Increases oxygen saturation D. Promotes elimination of CO 2

D. Promotes elimination of CO 2 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO 2. It also helps clients to slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? A. Serum sodium of 139 mEq/L (139 mmol/L) B. Serum chloride of 100 mEq/L (100 mmol/L) C. Serum calcium of 10.2 mg/dL (2.55 mmol/L) D. Serum potassium of 7.2 mEq/L (7.2 mmol/L)

D. Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).

A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question? A. The arterial blood supply is inadequate. B. There is delayed healing in the area after an injury. C. The production of melanin in the area has increased. D. There is leakage of red blood cells (RBCs) through the vascular wall.

D. There is leakage of red blood cells (RBCs) through the vascular wall. Increased venous pressure alters the permeability of the veins, allowing extravasation of RBCs; lysis of RBCs causes brownish discoloration of the skin. Varicose veins do not affect the arterial circulation. Although healing may be delayed, the brownish discoloration does not result from trauma. There is no increase in melanocyte activity in individuals with varicose veins.

(powerpoints) Which interrelated concept should the nurse be worried about the MOST if patient has a blood clot A. Intracranial regulation B.Patient education C. Mobility D. Pain E. Perfusion F. Gas exchange

E. Perfusion Perfusion is most closely related to clotting. Perfusion is impaired because blood clots slow or stop blood flow. In addition, uncontrolled bleeding or hemorrhage can lead to excess blood loss and this threatens adequate volume of blood needed to profuse oxygenated to body organs.

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common? Increased urinary output Increased cardiac workload Decreased oxygen saturation Decreased arterial blood pressure

Increased cardiac workload With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system. Urinary output is not increased; it may be decreased to maintain blood volume in anemia and decrease blood viscosity in polycythemia. The percent of hemoglobin molecules saturated with oxygen is not affected. Clients with polycythemia will have increased blood pressure because of increased viscosity of the blood.

A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health?

Mental health is successful adaptation to stressors in the internal and external environment.

(med surg book) Which patient has an increased risk for the development of anxiety and will require frequent assessment by the nurse? Select all that apply. a. Exacerbation of asthma signs and symptoms b. History of peanut and strawberry allergies c. History of chronic obstructive pulmonary disease d. Current treatment for unstable angina pectoris e. History of a traumatic brain injury

a. Exacerbation of asthma signs and symptoms c. History of chronic obstructive pulmonary disease d. Current treatment for unstable angina pectoris e. History of a traumatic brain injury

(med surg) A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to a. candidiasis. b. aspergillosis. c. histoplasmosis. d. coccidioidomycosis.

a. candidiasis.

( med surg) When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using sequential compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

b. using sequential compression devices.

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

d. Discontinue heparin and flush intermittent IV lines using normal saline. The heparin can be discontinued because the patient is now at therapeutic levels. warfarin will sustain the patient in the outpatient setting. A LMWH may be used with heparin if the patient has not achieved therapeutic levels with heparin or warfarin. Platelet transfusions are not indicated for DVT.

If patient has PAD should extremity be in independent or dependent position?

dependent

(NCLEX website)You are assessing the heart sounds of a patient with a severe case of Tetralogy of Fallot. You would expect to hear a __________ murmur at the _______ of the sternal border?* A. diastolic; right B. systolic; left C. diastolic; left D. systolic; right

B. The patient will have a harsh systolic murmur due to pulmonary stenosis, which would lead you to find the murmur at the LEFT of the sternal border (the sound location of the pulmonary valve).

Which medications would help control bleeding (select all that apply) A. Demospressin acetate B. Tenecteplase C. Platelet growth factor D. Platelet transfusion E. Warfarin

A. Demospressin acetate C. Platelet growth factor D. Platelet transfusion Pharmacotherapy for clotting: Warfarin Heparin Low-molecular weight heparin Aspirin Clopidogrel Streptokinase Alteplase Tenecteplase Reteplase

Signs of moderate anemia: (select all that apply) A. HGB between 6-10 B. bounding pulse C. scleral icterus D. dyspnea E. tachypnea F. "roaring in the ears" G. fatigue

A. HGB between 6-10 B. bounding pulse D. dyspnea F. "roaring in the ears" G. fatigue HGB: 10-12 mild anemia → typically no sx....if there are its bc the patient has another underlying dz. May see palpitations, exertional dyspnea, mild-no fatigue HGB: 6-10 → cardiopulmonary sx are increased..bounding pulse, dyspnea, "roaring in the ears", fatigue HGB: >6 → scleral icterus, pale, jaundice, SOB, fatigue, syncope, dizziness, palpitations, HA, bone pain, sensitivity to cold, weight loss, lethargy, tachypnea, pruritus

Exercise and activity are included in a cardiac rehabilitation program for which purposes? (Select all that apply.) A. Increase cardiac output B. Increase serum lipids C. Increase blood pressure D. Increase blood flow to the arteries E. Increase muscle mass F. Increase flexibility

A. Increase cardiac output D. Increase blood flow to the arteries E. Increase muscle mass F. Increase flexibility A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure.

Which foods would be recommended to a patient with iron deficiency anemia? A. Liver and muscle meats, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, beans B. Red meats, especially liver, eggs, enriched grain products, milk and dairy foods, fish C. Peanut butter, beans, meats, avocado; enriched and fortified grains D. Green leafy vegetables, liver, meat, fish, legumes, whole grains, orange juice, peanuts, avocado

A. Liver and muscle meats, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, beans B. Red meats, especially liver, eggs, enriched grain products, milk and dairy foods, fish--> high in B12

A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply. A. Obesity B. Hypertension C. Diabetes insipidus D. Asian-American ancestry E. Increased high-density lipoprotein (HDL)

A. Obesity B. Hypertension Obesity increases cardiac workload associated with vascular changes that lead to ischemia, which causes an MI. Hypertension damages blood vessels and increases peripheral resistance and cardiac workload, which may lead to an MI. Diabetes mellitus, not insipidus, is a risk factor for an MI. The risk is higher for African-Americans, not Asian-Americans. Increased levels of low-density lipoprotein (LDL), not HDL, increase the risk for heart disease.

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit? A. Radial and apical pulse B. Apical and carotid pulse C. Radial and brachial pulse D. Apical and temporal pulse

A. Radial and apical pulse Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

(powerpoints) Frequent epistaxis are an example of A. Systemic prolonged bleeding problem B. Localized prolonged bleeding problem C. Systemic inefficient bleeding problem D. Localized inefficient bleeding problem

A. Systemic prolonged bleeding problem Localized -Ecchymosis -Petechia -Bleeding or ecchymosis at an injury site -Purpura -intracranial bleeding systemic -Bleeding at a surgical site -Frequent nosebleeds -Blood in stool, urine, emesis -Bleeding gums -Bleeding within joints -Excessive menstrual bleeding

(NCLEX website) You're providing an in-service to a group of new nurses who will be caring for patients who have Tetralogy of Fallot. Which statement below is INCORRECT concerning how the blood normally flows through the heart?* A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium. B. The pulmonic valve receives blood from the right ventricle and allows blood to flow to the lungs via the pulmonary artery. C. The left atrium allows blood to flow down through the bicuspid valve (mitral) into the left ventricle. D. Oxygenated blood leaves the left ventricle and flows up through the aortic valve and aorta to be pumped to the rest of the body.

A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium.

In addition to assessing blood pressure, alert nurses are often the first to note subtle clinical changes indicating preeclampsia, such as A. sudden weight gain B. epistaxis C. edema D. headache E. oliguria F. right-sided pain G. fetal distress.

A. sudden weight gain C. edema D. headache E. oliguria F. right-sided pain G. fetal distress.

(NCLEX website) A 4-month-old is diagnosed with Tetralogy of Fallot. You're providing an illustration to the parent to help him understand the pathophysiology of this condition. What defects must be present in the illustration to help the parent understand their child's condition? Select all that apply:* A. Aortic stenosis B. Ventricular septal defect C. Coarctation of aorta D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis G. Patent ductus arteriosus

B, D, E, and F. Let the condition's name help you: "TETRAOLOGY"...this means there will be FOUR problems with this heart defect. Remember from the lecture the mnemonic RAPS: Right ventricular hypertrophy, Aorta displacement, Pulmonary stenosis, Septal defect (ventricular)

Which patients are at risk for excessive clotting (select all that all) A. 54 y.o female with Thrombocytopenia B. 50 y.o male with A-Fib C. 66 y.o female with polycythemia D. 17 y.o male with hemophilia

B. 50 y.o male with A-Fib C. 66 y.o female with polycythemia

A nurse is caring for a client who had a total hip replacement. Which nursing action should be incorporated into the plan of care to prevent thrombus formation? A. Turning the client from side to side B. Encouraging the client to perform ankle exercises C. Elevating the knee gatch to 15 degrees for comfort D. Getting the client up to sit in a chair for as long as tolerated

B. Encouraging the client to perform ankle exercises Ankle movement, particularly dorsiflexion of the foot, allows muscle contraction, which compresses veins, reducing venous stasis and the risk for thrombus formation. Because the client is being turned, the client's muscles are not contracting to compress the veins and prevent venous stasis. The client must be turned at least every 2 hours to help prevent skin breakdown and pneumonia. Elevating the knee gatch will promote thrombus formation. Sitting for long periods is contraindicated, because pressure on the popliteal space and the dependent position of the lower extremities increase venous stasis

A 10-year-old child with sickle cell anemia is admitted to the unit in vaso-occlusive crisis (VOC). After the child has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis? A. Isotonic exercises B. Intravenous fluids C. Oxygen by nasal cannula D. Cold compresses to affected areas

B. Intravenous fluids Because the kidneys of children with sickle cell anemia do not concentrate urine as well as do healthy kidneys, it is important to maintain adequate hydration. Hydration with IV fluids supplementing oral fluids can minimize the occurrence of a crisis because hemodilution helps prevent sickling. During a VOC bed rest is preferred, with the only exercise being passive range of motion. Oxygen may be used if the child has respiratory distress, but it does not help resolve a VOC because it decreases erythropoiesis. Cold compresses are contraindicated because cold causes vasoconstriction. Heat usually is applied to the affected areas.

(powerpoints) What would the nurse educate the patient on to preventing clotting ( select all that apply) A. Genetic counseling B. Smoking cessation C. Injury prevention D. Hydration E. Exercise F. Prevention of stasis

B. Smoking cessation D. Hydration E. Exercise

An older nursing home resident with the diagnosis of early-onset dementia likes to talk about the old days and at times has a tendency to confabulate. What does the nurse determine is the purpose of the client's confabulation? A.Prevent regression B.Increase self-esteem C. Attract the attention of others D. Help him reminisce about achievements

B.Increase self-esteem Confabulation is used as a defense mechanism against embarrassment caused by a lapse of memory; the client fills in the blanks in memory by making up details, thus maintaining self-esteem. Regression is a defense mechanism in which the individual moves back to earlier developmental defenses; the client is not regressing at this time. Although older adults fear being forgotten or losing others' affection, this is not the reason for confabulation. Confabulation is not used to reminisce about past achievement.

The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse? Supplemental iron will not be needed for the first year. Solid foods need not be introduced until 7 or 8 months of age. Anemia will not develop as long as the infant is gaining weight. Baby cereal or an iron supplement should be given around 4 months of age.

Baby cereal or an iron supplement should be given around 4 months of age. Baby cereals are fortified with iron. The breastfed infant is ready to have this food introduced by about 4 months; if solid foods are not offered by this age, an iron supplement is needed. Maternally derived iron stores are adequate for the first 5 to 6 months in a full-term infant. After this time iron supplementation is necessary to meet the infant's growth demands.

(med surg) Thrombocytopenia is a reduction of platelets below A. 100,000/µL (150 × 109/L) B. 130,000/µL (150 × 109/L) C. 150,000/µL (150 × 109/L) D. 170,000/µL (150 × 109/L)

C. 150,000/µL (150 × 109/L)

Mom notes her 6 y/o son has been banging his head, waking up in the middle of the night crying, and he complains of blurred vision . The nurse suspects the child has: A. acid base imbalance B. anxiety C. HTN D. impaired gas exchange

C. HTN UA, renal function, lipid profile, CBC, and electrolytes should be checked

Pt with polycythemia should avid which foods? A. Milk, cheese, yogurt B. sunflower seeds, peanuts, orange juice C. Kale, spinach, blueberries, and brussel sprouts D. olive oil, walnuts, avocados

C. Kale, spinach, blueberries, and brussel sprouts these foods are high in vitamin K which will contribute to clotting

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A. Ischemia B. Pneumonia D. Peptic ulcer disease

C. Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.

A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical? A. Edema of the feet and ankles B. Reddened and painful areas on the calves C. Pain when exercising and thickening of the toenails D. Ulcers around the ankles and reports of a dull ache in the legs

C. Pain when exercising and thickening of the toenails Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. A.Radial pulse: 70 B. Temperature: 37 °C C. Respiratory rate: 14 D. Blood pressure: 110/70 E. Oxygen saturation: 96%

C. Respiratory rate: 14 D. Blood pressure: 110/70 E. Oxygen saturation: 96% The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 80% to 96% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD.

(NCLEX website)While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to?* A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction . C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.

C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. The patient is experiencing a "tet spell". This is where during any type of activity like feeding, crying, playing etc. the child's heart (due to Tetralogy of Fallot) is unable to maintain proper oxygen levels in the blood (these activities place extra work on the heart and it can't keep up). Therefore, there are low amounts of oxygen in the blood, and the skin will become cyanotic (bluish tint) and the respiratory rate will increase (this is the body's way of trying to increase the oxygen levels in the body but it doesn't work because it's not a gas exchange problem in the lungs but a heart problem). The nurse would want to place the infant in the knee-to-chest position. WHY? This increases systemic vascular resistance (which will help decrease the right to left shunt that is occurring in the heart...hence helps replenish the body with oxygenated blood). In addition, the nurse would want to place the patient on oxygen.

client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? A.The fat-forming ketoacids were broken down. B. The irregular heartbeat produced oxygen deficit. C. The decreased tissue perfusion caused lactic acid production. D. The client received too much sodium bicarbonate during resuscitation efforts.

C. The decreased tissue perfusion caused lactic acid production. Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a PO 2 of 85 mm Hg, a PCO 2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be prescribed? Select all that apply. Coughing Deep breathing Bronchodilators Humidified oxygen Bronchial suctioning

Coughing moves secretions toward the mouth to be expectorated. Deep breathing expands the alveoli and increases the amount of oxygen being delivered to the alveolar capillary beds. Humidified oxygen increases the amount of oxygen that is being delivered to the alveolar capillary beds. Bronchodilators are not indicated at this time because the x-ray, PCO 2, and pH are still within acceptable limits. Bronchial suctioning is not indicated at this time because the x-ray, PCO 2, and pH results are still within acceptable limits.

(NCLEX website)You're caring for a newborn who has Tetralogy of Fallot with severe cyanosis. You anticipate the newborn will be started on ___________?* A: Indomethacin B. Diclofenac C. Celecoxib D. Alprostadil

D. Alprostadil, prostaglandin E, will keep the ductus arteriosus open after birth. This will help with keeping the oxygen levels up because it allows more blood to flow to the lungs that is oxygenated via the ductus arteriosus. Remember this usually closes shortly after birth, but in a patient with severe Tetralogy of Fallot this opening needs to stay opened until surgery can be performed.

A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse? A. "The pacemaker prevents a rapid heart rate." B. "It provides access for defibrillation." C. "The pacemaker will maintain a constant cardiac rhythm." D. "It manages an abnormally slow heart rate."

D. "It manages an abnormally slow heart rate." Vagal stimulation during surgery may cause a severe bradycardia; in anticipation, pacemaker wires are inserted into the right atrium to be used to initiate impulses if the natural rate decreases below the preset rate of the pacemaker; this will ensure that the heart beats at the rate set for the pacemaker. This pacemaker initiates an impulse if the heart rate drops below a certain rate; the concept underlying this pacemaker is to speed up the heart, not to slow it down. There are no data to support the fact that this is a defibrillator pacemaker. The pacemaker wires are not used for defibrillation; defibrillator paddles are placed so that electricity affects the entire heart muscle. The rhythm can be irregular; however, if the pause between two beats is too long, the pacemaker will initiate an impulse.

The nurse knows that including teaching on modifiable risk factors for impaired perfusion in the patient's plan of care includes which of the following: A. Impaired perfusion increases with age. B. Genetics play a role in impaired perfusion. C. Exercise should be kept at a minimum to prevent a myocardial infarction. D. A smoking cessation plan should be in place.

D. A smoking cessation plan should be in place. The importance of distinguishing between modifiable versus nonmodifiable risk factors is imperative when determining what sort of lifestyle changes can be discussed when formulating the patient's plan of care. Impaired perfusion can affect all people and age groups regardless of gender, race, or economic status. Smoking cessation is an example of a modifiable risk factor for impaired perfusion that can be included in the patient's plan of care. Modifiable risk factors can be changed by the patient through teaching from the nurse. Although impaired perfusion can increase with age, this is an example of an unmodifiable risk factor (something that the patient cannot change). Genetics is an example of an unmodifiable risk factor for impaired perfusion. A sedentary lifestyle can lead to obesity, which would then become a modifiable risk factor for impaired perfusion.

A patient had a hip replacement 3 days ago. The patient states that the right leg is swollen below the knee and is warm to the touch. The patient has the diagnosis of deep vein thrombosis. Which intervention is appropriate for the patient? A. Massage the extremity to decrease pain. B. Place the leg in a dependent position. C. Apply ice bags to the lower leg. D. Elevate the right lower leg when the patient is in the sitting position.

D. Elevate the right lower leg when the patient is in the sitting position. A patient with a deep venous thrombosis elevates the extremity when sitting or lying to enhance venous return to the heart. Massaging the extremity may dislodge a thrombus. If the leg is in the dependent position, blood return from the venous system will not be enhanced. Applying ice bags to the extremity may cause tissue injury.

A 1-month-old infant with a ventricular septal defect (VSD) is examined in the cardiology clinic. What sign related to this disorder does the nurse expect to find when assessing this infant? A. Bradycardia at rest B. Activity-related cyanosis C. Bounding peripheral pulses D. Murmur at the left sternal border

D. Murmur at the left sternal border A murmur at the left sternal border is the most characteristic finding in infants and children with a VSD. A left-to-right shunt is caused by the flow of blood from the higher pressure left ventricle to the lower pressure right ventricle. Children with VSDs generally have tachycardia and are often acyanotic. A bounding peripheral pulse is not a common finding in children with a VSD.

A 75-year-old client has a baseline blood pressure of 140/90 mm Hg. The nurse obtains a sitting blood pressure in the client's left arm, and the reading is 160/100 mm Hg. What action should the nurse take next? A. Advise the client to restrict fluid and sodium intake, then begin to develop a teaching plan for the client. B. Contact the primary healthcare provider immediately to report the blood pressure reading. C. Record the findings, recognizing that the result is expected for an older adult. D. Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing.

D. Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing. Further assessment is necessary before the nurse can plan a course of action. Advising the client to restrict fluid and sodium intake is not an initial nursing action; further assessment is the priority. The nurse must gather more data before consulting with the primary healthcare provider. This is not an expected blood pressure for an older adult; both systolic and diastolic pressures are elevated.

The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. open a window to let fresh air into the room. B. use nasal strips to assist with breathing. C. sleep in a side-lying position. D. use pillows to prop yourself up while sleeping.

D. use pillows to prop yourself up while sleeping. Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat.

The nurse plans to teach a client to use healthier coping behaviors that can consciously be used to reduce anxiety. What might these include? Eating, dissociation, fantasy Sublimation, fantasy, rationalization Exercise, talking to friends, suppression Repression, intellectualization, smoking

Exercise, talking to friends, suppression Exercise, talking to friends, and suppression are positive coping behaviors that can be used consciously to promote mental health. Eating, dissociation, and fantasy; sublimation, fantasy, and rationalization; and repression, intellectualization, and smoking are not healthy coping behaviors, and their frequent use can lead to distortions of reality. Also, they are usually not under conscious control.

A patient has aquired cobalamin anemia after having gastric bypass. What is the best treatment plan A. Educate the patient to increase red meats, especially liver, eggs, enriched grain products, milk and dairy foods, fish B. The patient needs to received B12 IM or sublingual for life

Parenteral vitamin B12 (cyanocobalamin or hydroxocobalamin) or intranasal cyanocobalamin (Nascobal, CaloMist) is the treatment of choice. (Regardless of how much is ingested, the patient is not able to absorb cobalamin if IF is lacking or if absorption in the ileum is impaired. For this reason, increasing dietary cobalamin does not correct this anemia. However, instruct the patient on adequate dietary intake to maintain good nutrition)

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? a. An overproduction of the antiprotease α1-antitrypsin b. Hyperinflation of alveoli and destruction of alveolar walls c. Hypertrophy and hyperplasia of goblet cells in the bronchi d. Collapse and hypoventilation of the terminal respiratory unit

b In COPD there are structural changes that include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

An individual who lives at a high altitude may normally have an increased Hgb and RBC count because a. high altitudes cause vascular fluid loss, leading to hemoconcentration. b. hypoxia caused by decreased atmospheric O2 stimulates erythropoiesis. c. the function of the spleen in removing old RBCs is impaired at high altitudes. d. impaired production of leukocytes and platelets leads to proportionally higher red cell counts.

b. hypoxia caused by decreased atmospheric O2 stimulates erythropoiesis.