226 test #2 EAQs

Which statement describes the pericardium? A. Muscular wall of the heart B. Area of the chest overlying the heart C. Tough, fibrous sac surrounding the heart

C. Tough, fibrous sac surrounding the heart (Rationale: The pericardium is a tough, fibrous, double-walled sac that surrounds the heart and protects it. It has two layers that contain a few milliliters of serous pericardial fluid. This ensures smooth, friction-free movement of the heart muscle. The myocardium is the muscular wall of the heart; it does the pumping. Precordium refers to the area on the anterior chest that overlies the heart and the great vessels. The endocardium is a thin layer of endothelial tissue that lines the inner surface of the heart chambers and the valves.)

Which organs are located at the right upper quadrant (RUQ) in the abdomen? Select all that apply. -Liver -Cecum -Stomach -Gallbladder -Duodenum

-Liver -Gallbladder -Duodenum

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? - 'Does walking for long periods of time increase your pain?' - 'Does standing without moving decrease your pain?' - 'Have you had your potassium level checked recently?' - 'Have you had any broken bones in your lower extremities?'

'Does walking for long periods of time increase your pain?' (Rationale: 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.)

When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next? A. Check the pulses with a Doppler device. B. Notify the primary health care provider. C. Notify the staff in the catheterization laboratory. D. Document the findings in the client's medical record.

A. Check the pulses with a Doppler device. (Rationale: When the nurse is unable to palpate pulses, the next action would be to determine whether pulses are audible with a Doppler device. Notification of the health care provider is not immediately necessary because decreased pulse quality is expected in clients with peripheral arterial disease.)

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

Which clinical finding would the nurse expect to identify when assessing the lower extremities of a client with varicose veins?

Ankle edema (Rationale: Ankle edema results from increased venous pressure.)

During auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest?

Apex of the heart (Rationale: The first heart sound is produced by closure of the mitral and tricuspid valves. The best location to hear the mitral valve is at the apex of the heart which is located in the 5th intercostal space along the midclavicular line.)

The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate?

Arterial insufficiency (Rationale: Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails.)

The accumulation of lymph in the breasts and upper arms is a result of an obstruction of which lymph nodes?

Axillary (Obstruction of the axillary nodes results in the accumulation of lymph in the breasts and the upper arms.)

Which angular motion involves moving the arm away from midline of the body? A. Flexion B. Abduction C. Adduction D. Extension

B. Abduction

The human heart is found in which location? A. Between the right midclavicular line and the right border of the sternum and below the clavicle to the eighth rib B. Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line C. Between the third and sixth intercostal spaces from the left midclavicular line to the left midaxillary line D. Between the first and fourth intercostal spaces from the left midaxillary line to the left posterior axillary line

B. Between the second and the fifth intercostal spaces from the right edge of the sternum to the left midclavicular line

Which information about synovial joints is correct? A. Immovable and united by cartilage B. Freely movable and lined with synovial membranes C. Slightly movable, and the bones are joined with cartilage D. Do not allow opposing surfaces to slide against one another

B. Freely movable and lined with synovial membranes

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A. Pregnancy B. Inactivity C. Aerobic exercise D. Tight clothing

B. Inactivity (Rationale A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.)

When teaching a client with peripheral arterial disease about the prescribed walking program, which action will the nurse advise if client says she experiences leg cramps while walking? A. Chew 1 aspirin to relieve pain. B. Stop to rest until the pain resolves. C. Walk more slowly while pain is present. D. Notify the health care provider about the pain.

B. Stop to rest until the pain resolves. (During an exercise program for peripheral arterial disease, the client walks to the point of claudication, stops and rests until the pain resolves, and then walks a little farther.)

To assess the status of circulation to the foot, which site would the nurse monitor for a pulse?

Dorsalis pedis artery Posterior tibial artery

Which statement by a client is consistent with a diagnosis of heart failure? A. "I see spots" B. "I am tired at the end of the day" C. "I feel bloated after a large meal" D. "I have trouble breathing when i climb a flight of stairs"

D. "I have trouble breathing when I climb a flight of stairs"

Which condition would the nurse consider as the most likely cause of pain for a client who tells the nurse, "My legs begin to hurt after walking for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking."? A. Spinal stenosis B. Buerger disease C. Rheumatoid arthritis D. Intermittent claudication

D. Intermittent claudication

Which condition involves the accumulation of sodium urate crystals in the joint space? A. Talipes equinovarus B. Achilles tenosynovitis C. Fibromyalgia syndrome D. Tophi with chronic gout

D. Tophi with chronic gout

Which bursae are between the client's elbow and the skin?

Olecranon (Rationale: Bursae are small sacs of connective tissue lined with synovial membrane and synovial fluid that decrease the friction between moving parts. Olecranon bursae are found between the olecranon process of the elbow and the skin.)

Which outcome is likely if the nurse palpates a client's joints during an acute episode of rheumatoid arthritis?

Pain

Which position would the nurse place the feet and legs in when caring for a client with peripheral arterial insufficiency?

Place them slightly lower than the head and chest. (Gravity will assist the flow of blood to the dependent legs and feet)

A lateral S-shaped curvature of the thoracic and lumbar spine.

Scoliosis

Which heart sound occurs because of the closure of the semilunar valves?

Second heart sound (S2) - indicates the end of systole

Which physiological change of the musculoskeletal system would the nurse associate with aging?

Slowed movement Cartilage degeneration Increased bone prominences Decreased bone density Decreased ROM

Which organ is located in all four quadrants of the abdomen?

Small Intestine (Rationale: The abdominal wall is divided into four quadrants by imaginary vertical and horizontal lines bisecting the umbilicus. The small intestine extends from the pyloric valve of the stomach to the ileocecal valve, where it joins the colon. Thus the small intestine is located in all four quadrants.)

During auscultation of the heart, where would the nurse expect S2 to be the loudest?

The base of the heart (Rationale: S2 is produced by closure of the aortic and pulmonic valves. The aortic auscultatory area is located in the 2nd intercostal space along the right sternal border.)

In which area would the nurse place the stethoscope when taking an apical pulse?

- The mitral area - 5th intercostal space midclavicular line -Apex of the heart

While assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?

Bruit

Which arteries are described as having superficial and deep palmar arches? Select all that apply. - Ulnar artery - Radial artery - Plantar artery - Femoral artery - Popliteal artery

- Ulnar artery - Radial artery (Rationale: The brachial artery in the arm bifurcates into the ulnar and radial arteries immediately below the elbow. These arteries run distally and form two arches supplying oxygenated blood to the hand. Therefore the ulnar and radial arteries are described as having superficial and deep palmar arches.)

Which statements would the nursing instructor include in a lecture about inguinal lymph nodes? Select all that apply. - They drain the lymph of the head and the neck. - They drain the lymph of the lower extremities. - They drain the lymph of the external genitalia. - They drain the lymph of the breast and upper arm. - They drain the lymph of the anterior abdominal wall.

- They drain the lymph of the lower extremities. - They drain the lymph of the external genitalia. - They drain the lymph of the anterior abdominal wall. (Rationale: The inguinal nodes of the lymphatic system are located in the groin. These nodes drain most of the lymph of the lower extremities, external genitalia, and anterior abdominal wall. The cervical nodes drain lymph of the head and neck, and the axillary nodes drain the lymph from the breast and upper arm.)

A client with a suspected kidney disorder reports flank pain. Which nursing interventions would be conducted while performing flank assessment? Select all that apply. One, some, or all responses may be correct. - Percussing the tender flank first - Forming both hands into a clenched fist - Asking the client to assume a sitting position - Placing one hand flat on the costovertebral angle (CVA) - Delivering a firm hand thump over the lower abdomen

- Asking the client to assume a sitting position - Placing one hand flat on the costovertebral angle (CVA)

Which feature is specific to the right kidney? A. Retroperitoneal in position B. May be palpable C. Protected by posterior ribs D. Lies at the costovertebral angle

B. May be palpable (Rationale: The right kidney may be palpated sometimes because it rests 1 to 2 cm lower than the left kidney. The right kidney is slightly lower than the left kidney because of the placement of the liver. Both kidneys are retroperitoneal, which means they lie posterior to the abdominal contents. Both kidneys are also well protected by the posterior ribs. The twelfth rib forms an angle with the vertebral column, the costovertebral angle. The left kidney lies at the eleventh and twelfth ribs.)

Which blood vessel drains the blood from the head and upper extremities? A. Pulmonary vein B. Inferior vena cava C. Superior vena cava D. Internal jugular vein

C. Superior vena cava

Which client assessment data would correspond to a muscle-strength rating of 3?

Can complete range of motion (ROM) against gravity

Which information would the nurse include in teaching when a client with varicose veins has knee-length elastic support stockings prescribed? A. Pull the stockings on to mid-calf height. B. Put the stockings on before getting out of bed. C. Wear the stockings at the first sign of discomfort. D. Use elastic bandages if the stockings are too tight.

B. Put the stockings on before getting out of bed. (Rationale: To prevent distention of the veins, the stockings should be applied before the legs are placed in a dependent position. Knee-high stockings should end 2 inches (5 cm) below the knee to avoid popliteal pressure, which limits venous return. The stockings should be used preventatively before the discomfort associated with venous pressure and edema occurs. If the stockings are too tight, the client should be measured for larger stockings, because elastic bandages may slip when the client is active and be ineffective in applying adequate pressure.)

Which statement by the nurse indicates effective technique in assessment of a client's renal system? A. 'I must first palpate the abdomen of the client if a tumor is suspected.' B. 'I must first listen for normal pulses at the client's wrist region.' C. 'I must first auscultate the client's abdomen and then proceed to percussion and palpation.' D. 'I must first examine tender abdominal areas and then proceed to non-tender areas.'

C. 'I must first auscultate the client's abdomen and then proceed to percussion and palpation.' (Palpation and percussion can cause an increase in normal bowel sounds and hide abdominal vascular sounds. Perform auscultation before percussion and palpation during clinical assessment of the renal system.)

Which term describes the thin layer of endothelial tissue that lines the inner surface of the heart and the valves? A. Myocardium B. Epicardium C. Endocardium D. Pericardium

C. Endocardium (Rationale The endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and the valves. The myocardium is the muscular wall of the heart; it does the pumping. The visceral pericardium, which is continuous with the serous layer, is sometimes known as the epicardium. The pericardium is a tough, fibrous, double-walled sac that surrounds and protects the heart and has two layers.)

In which sequence of techniques would the nurse assess a client's abdomen?

1. Inspection 2. Auscultation 3. Percussion 4. Palpation (The order of an abdominal assessment begins with inspection of the contour, symmetry, and surface motion of the abdomen. The nurse will note any masses, bulging, or distention. The second step is auscultation, which is done before palpation to reduce the chance of altering the frequency and character of bowel sounds. The third step is percussion, which is used to assess kidney inflammation. The fourth step is palpation, which detects areas of abdominal tenderness, distention, or masses.)

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. Which technique would be the nurse's next assessment? A. To assess for any reduced hair growth B. To assess for swelling, warmth, and muscle firmness C. To assess for any history of ulcer formation around the calf muscle D. To assess for venous distension in the posterolateral part of ankle

C. To assess for any history of ulcer formation around the calf muscle

Which instruction will the home health nurse include when teaching a client with peripheral artery disease? Select all that apply. One, some, or all responses may be correct. - "Avoid crossing your legs." - "Inspect your feet daily." - "Change positions slowly." - "Do not use compression stockings." - "Avoid green leafy vegetables in your diet."

- "Avoid crossing your legs." - "Inspect your feet daily." - "Do not use compression stockings." (Rationale: Crossing the legs and using compression stockings will restrict blood flow, so these actions should be avoided in clients with peripheral artery disease. Inspection of the feet is done daily to detect injury, infection, or skin breakdown.)

Which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis when caring for a client hospitalized with deep vein thrombosis? A. Daily use of aspirin B. Frequent ambulation C. Warm soaks to legs D. Avoidance of cold

B. Frequent ambulation (Frequent ambulation decreases venous stasis and helps prevent recurrent venous thrombosis.)

Which term would the nurse use to document reports of a client with heart failure waking suddenly and feeling short of breath during the night? A. Orthopnea B. Sleep apnea C. Exertional dyspnea D. Paroxysmal nocturnal dyspnea

D. Paroxysmal nocturnal dyspnea (Paroxysmal nocturnal dyspnea occurs in left ventricular failure due to fluid shifts at night that result in movement of fluid from pulmonary capillaries into the alveoli, causing the client to awaken suddenly with breathlessness.)

Which clinical finding would the nurse expect when completing the admission assessment of a client with a large abdominal aortic aneurysm who is admitted for elective surgery? A. Elevated heart rate B. Visible peristaltic waves C. Radiating abdominal pain D. Pulsating abdominal mass

D. Pulsating abdominal mass (With an abdominal aortic aneurysm, a pulsating midline mass can be palpated with each heartbeat.)

Which activity might cause chest pain in a client with stable angina? Select all that apply. One, some, or all responses may be correct. - Deep breathing during meditation - Walking outside on a cold day - Sexual activity - Taking an afternoon nap - Smoking a cigarette - Use of an oral decongestant

-Walking outside on a cold day -Sexual activity -Smoking a cigarette -Use of an oral decongestant (Rationale: Clients with stable angina experience chest pain (or other angina equivalents) in response to activities that increase cardiac workload or decrease blood flow and oxygen availability to the heart. Cold temperatures cause vasoconstriction, increasing the cardiac workload during systole. Sexual activity increases heart rate and force of contraction, leading to increased cardiac workload. Tobacco use stimulates catecholamine release, increasing heart rate and causing vasoconstriction, and resulting in increased cardiac workload. In addition, tobacco use transiently increases carbon monoxide levels, resulting in a decrease in available oxygen for cardiac tissues. Oral decongestants are sympathetic nervous system stimulants, which increase heart rate and force of contraction and cause vasoconstriction, leading to increased cardiac workload.)