Cardiovascular System, Blood, and Lymphatic Systems EAQs
What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem (Cardizem)?
Changing positions slowly will help prevent the side effect of orthostatic hypotension. Lying down after meals can relax the esophagus and lead to acid reflux; lying down after meals may intensify this effect. Avoiding dairy products and taking the drug with an antacid are not necessary.
Which process involves replacing dead and decomposed tissue with fresh collagen tissue?
After the formation of exudates, decomposed necrotized tissue disappears and begins to fill with granulation. This replaces the dead tissue with capillaries surrounded with fibrous collagen. An incision is a surgical cut made by a sharp instrument on the skin that creates an opening into the body. An irrigation is a gentle washing of an area with a stream of solution delivered via an irrigating syringe. An evisceration involves the protrusion of internal organs through an opened incision.
The health care provider prescribes atenolol (Tenormin) for a client with angina. When instructing the client about this medication, the nurse teaches the client about which potential side effect?
Atenolol competitively blocks stimulation of beta-adrenergic receptors within vascular smooth muscles, which lowers the blood pressure. This drug does not cause headaches; this drug may be used to relieve vascular headaches. This drug may cause bradycardia, not tachycardia. This drug may cause diarrhea, not constipation.
Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply.
Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies and antigens. Such reactions result in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis result from reactions between sensitized T cells and antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.
A nurse is auscultating a client's heart sounds. Which valves close when the first heart sounds are produced?
Closure of the atrioventricular valves, the mitral and tricuspid, produces the first heart sound (S1). These are the semilunar valves; closure of these valves produces the second heart sound (S2). The other options do not close simultaneously.
A nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated?
Erythropoietin stimulates red blood cell production, thereby decreasing the pallor that accompanies anemia. It would not have a role in alleviating jaundice. It would not have an appreciable effect on pulses or deep tendon reflexes.
What medication does a nurse expect to administer to control bleeding in a child with hemophilia A?
Factor VIII concentrate
Furosemide (Lasix) has been prescribed as part of the medical regimen for a client with hypertension, and the nurse has provided related teaching. The nurse concludes that the client needs additional teaching when the client makes which statement?
Furosemide can produce hypokalemia, not vitamin K deficiency. A well-balanced diet should provide all the necessary vitamins and nutrients. Further teaching is necessary if the client's focus is on vitamin K deficiency. The morning is the desirable time to take furosemide; early administration prevents nocturia. The client's statement to call the health care provider at signs of muscle weakness is appropriate because muscle weakness may indicate hypokalemia, a potential side effect. The client's response to take the medicine even when feeling good demonstrates an understanding that the medication should be taken as prescribed, independent of how the client feels, because hypertension is generally asymptomatic.
A nurse is reviewing the health history and laboratory results of a school-age child admitted to the pediatric unit with acute nonlymphoid leukemia (acute myeloid leukemia). What clinical findings does the nurse expect? Select all that apply.
Listlessness Bone marrow depression
A client reports vomiting and diarrhea for 3 days. What clinical finding most accurately will indicate that the client has a fluid deficit?
Loss of body weight
What are the goals of care when working with families according to the family health system? Select all that apply
When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.
A client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me." What is the best response by the nurse?
Peripheral vascular rehabilitation includes exercise and walking programs that encourage new growth of vessels around the obstructed artery; this may improve peripheral perfusion and the ability to walk; eventually, walking with friends may be introduced into the walking program. Inactivity is contraindicated; elevation of the legs diminishes peripheral arterial circulation. The response "Try again tomorrow because maybe you will have a better day" provides false reassurance. The response "They are not good friends if they are not willing to walk with you" is an opinion that should be avoided; it does not focus on the client's need to improve walking ability
A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? Select all that apply.
Rapid IV infusion of 5% dextrose in water Profuse diaphoresis Perspiration contains high levels of sodium. An infusion of an electrolyte-free solution (e.g., D 5 /W) can cause dilution of serum electrolytes. Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and hypernatremia. Excess sodium intake can lead to hypernatremia. Removal of the parathyroid glands can lead to hypocalcemia.
A client with heart failure is to receive digoxin (Lanoxin) and asks the nurse why the medication is necessary. The nurse explains that digoxin does what?
Slows and strengthens cardiac contractions Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Stating that digoxin increases ventricular contractions is too general; digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema in extracellular spaces may result from the increased blood supply to the kidneys, it is not the primary reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.
A client has untreated stage 1 hypertension. What is the minimum systolic pressure the nurse expects when obtaining this client's blood pressure?
Systolic blood pressure associated with stage 1 hypertension is between 140 and 159 mm Hg. Optimal systolic blood pressure is less than 120 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg. With prehypertension, the systolic blood pressure is between 120 and 139 mm Hg.
Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")?
TIAs are temporary neurologic deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a brain attack (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?
The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
A client is diagnosed with hypertension that is related to atherosclerosis. The nurse recalls that with atherosclerosis what happens?
The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of rennin. Mobilization of free fatty acids will produce an acid-base imbalance. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue.
The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation?
Wheezing indicates anaphylactic and allergic reactions in the client who is on blood transfusion therapy. Therefore the client with wheezing should be treated first. Itching, flushing, and pruritus indicate a mild allergic reaction. Clients with itching, flushing, and pruritus can be treated after treating the client with wheezing symptoms.