NCLEX

A client recently admitted to the coronary care unit​ (CCU) with left heart failure complains of sudden​ dyspnea, anxiety, and feelings of​ "drowning." What is the most likely cause of these​ changes? A) Cardiogenic pulmonary edema B) Hyperglycemia C) Myocardial infarction D) Pulmonary embolism

A Rationale: A complication of left heart failure is cardiogenic pulmonary edema. Signs and symptoms include​ anxiety, orthopnea,​ pink, frothy​ sputum, dyspnea,​ hoarseness, and cough. In addition to pulmonary​ congestion, they are the result of acute overload and the inability of the heart to effectively pump blood through the body.

The nurse is reviewing treatment for a client with hypertension. Which statement regarding collaborative treatment is true​? A) Many clients require two or more medications plus lifestyle modifications to control their blood pressure. B) Most clients can control their blood pressure through lifestyle modifications alone. C) Lifestyle modifications do not help clients to control their blood pressure. D) Most clients can take medications to control their blood pressure without lifestyle modifications.

A Rationale: Medications plus lifestyle modifications are needed for most clients to maintain their blood pressure under​ 130/80 mmHg. Lifestyle modifications alone or medications alone are usually not​ enough, although both do have benefits

The nurse is assessing a client who started a statin medication. Which finding is most​ concerning? A) Generalized muscular tenderness and pain B) Nausea when taking the medicine before a meal C) Dizziness when changing positions quickly D) Small skin rash on the right arm

A Rationale: Muscular tenderness and pain might indicate myopathy and​ rhabdomyolysis, which can cause acute kidney injury and death in some clients. These symptoms indicate to the nurse that the statin may need to be discontinued. The rash and nausea are common side effects of taking​ statins, and although the nurse should follow up with the healthcare​ provider, they do not indicate that a change in medication is needed. Dizziness is not a side effect of statins.

The nurse is caring for a client diagnosed with a deep venous thrombosis. Which nursing assessment is a priority​? A) Bilateral breath sounds B) Level of consciousness C) EKG rhythm and rate D) Stroke scale assessment

A ​Rationale: Pulmonary embolism is a complication of DVT. Assessing the​ client's respiratory​ status, including auscultating bilateral breath​ sounds, is appropriate. The​ client's airway and breathing take priority. Atrial fibrillation and ischemic stroke are risk factors for development of DVT. Assessing level of consciousness and performing a stroke scale assessment are appropriate to assess for ischemic stroke. Obtaining EKG rhythm and rate is appropriate to assess for atrial fibrillation

A client has constant crushing chest pain rated at 9 out of 10 that began 30 minutes ago and is increasing in intensity. The nurse should recognize the client is at risk for which​ disorder? A) Myocardial infarction​ (MI) B) Atherosclerosis C) Stable angina D) Coronary artery disease​ (CAD)

A ​Rationale: Stable angina is the predictable form of chest pain that occurs when the heart is exerted or is exposed to cold or stress. In this​ case, the angina is​ unstable, and therefore the client is at increased risk for MI. Atherosclerosis is a​ long-term illness that would not cause the increasing pain and intensity described by the client. CAD is the cause of chest pain but is not a disorder that develops as a result of it.

A child is newly diagnosed with obsessive-compulsive disorder​ (OCD). Which precipitating factor may be​ related? A) A recent strep throat infection B) A failing test grade C) A diagnosis of diabetes D) Treatment for​ attention-deficit/hyperactivity disorder​ (ADHD)

A ​Rationale: Studies conducted by the U.S. Surgeon​ General, as well as other​ researchers, suggest that the development of OCD in some children may be linked to streptococcal infection. Failing a​ test, diabetes, and ADHD do not have a known correlation to OCD.

A community health nurse is teaching a group of adults about the risk factors associated with peripheral vascular disease​ (PVD) and chronic venous insufficiency​ (CVI). Which risk factor should the nurse​ include? (Select all that​ apply.) A) Physical inactivity B) Increased cholesterol levels C) Excess body weight D) Male sex E) Age 45 or older

A, B, C Rationale: Risk factors associated with PVD and CVI include increased cholesterol​ levels, excess body weight or​ obesity, and physical inactivity. Clients age 50 and older are at greatest risk for developing PVD or CVI. Males and females are equally affected by these conditions.

The nurse is providing care to a client with obsessive-compulsive disorder​ (OCD). Which intervention is​ appropriate? (Select all that​ apply.) A) Including time in the daily routine to perform the ritual. B) Encouraging the client to verbalize feelings. C) Assisting the client with developing new coping mechanisms. D) Establishing a loud and fun environment for the client. E) Interrupting the​ ritual, using distraction

A, B, C ​Rationale: Verbalization of feelings will assist the client in reducing stress and anxiety. The client with OCD needs to learn new coping skills to manage the intrusive thoughts that lead to the performance of rituals. Allowing time in a​ client's daily schedule to perform the ritual will allow the client to complete the ritual and still manage daily activities. A loud environment is not recommended. Interrupting a​ client's ritual may lead to increased anxiety and is not​ recommended, unless it is harmful to the client.

The nurse is caring for a combat veteran client with posttraumatic stress disorder​ (PTSD). Which condition can be ideal for acupuncture to be an effective​ treatment? (Select all that​ apply.) A) When used for a period of 3 months or more B) When used regularly C) When used as a​ short-term therapy for a period of no more than a month D) When used as an adjunct to​ cognitive-behavioral therapy​ (CBT) and other traditional therapies E) When solely used as a primary therapy

A, B, D ​Rationale: Preliminary research shows that acupuncture may be an effective treatment for PTSD only if the treatment is regular and lasts for at least 3​ months, and is used as an additional treatment with CBT and other more traditional​ therapies, including pharmacologic agents.

African Americans are more at risk for heart failure. What are the most important risk factors in this​ population? (Select all that​ apply.) A) Obesity B) Hypertension C) Hypotension D) Renal insufficiency E) Low levels of HDL

A, B, D, E ​Rationale: Hypertension, renal​ insufficiency, obesity, and low levels of HDL​ (which increases risk of​ atherosclerosis) are all contributing risk factors for heart failure in the​ African-American population. Hypotension is not a risk factor for heart failure in any population.

Which nursing diagnosis should be used to guide the care for a client with a deep venous thrombosis​ (DVT)? (Select all that​ apply.) A) Mobility: Physical, Impaired B) Comfort, Impaired C.) Oxygenation, Ineffective D) Tissue​ Perfusion, Impaired E) Protection, Ineffective

A, B, D, E ​Rationale: Nursing diagnoses that may be appropriate for inclusion in the plan of care for a client with a DVT include Tissue​ Perfusion, Impaired​; ​Comfort, Impaired​; ​Protection, Ineffective​; and ​Mobility: Physical, Impaired. A DVT does not affect oxygenation.​ (NANDA-I ©2014)

The nurse is preparing a presentation on posttraumatic stress disorder​ (PTSD) to a group of people whose spouses have just returned from an active war zone. Which information about PTSD should the nurse include in the​ presentation? (Select all that​ apply.) A) Stressors can occur at any time or age of life. B) Traumatic events in childhood can create clinical symptoms that last into adulthood. C) Men are more susceptible than women. D) Incidence among veterans is low. E) History of psychiatric disorders is common.

A, B, E PTSD is more common among individuals with a history of psychiatric disorders. Exposure to a traumatic stressor can happen at any age or time of life. Traumatic stress in childhood can create effects that persist into adulthood. The incidence of PTSD among veterans is especially high. Women are more susceptible to the development of PTSD than are men.

The nurse is teaching a client with hypertension about dietary changes. Which changes should the nurse​ include? (Select all that​ apply.) A) Switching to​ low-fat dairy products B) Limiting fat intake to saturated types of fat C) Avoiding salty foods D) Eating 4-5 servings of fruits and vegetables each day E) Eliminating cholesterol from the diet

A, C, D ​Rationale: Salt intake can cause retention of fluids and increase in blood pressure. Dairy products are​ beneficial, but reducing fats will decrease risk factors for development of atherosclerosis. Cholesterol should be lowered but not eliminated from the diet. Dietary guidelines are 4-5 servings per day for vegetables and fruits. Saturated fats should be​ limited; unsaturated fats are preferred.

The nurse is teaching a client with atrial fibrillation about deep venous thrombosis prevention. Which should the nurse instruct the client to avoid​? ​(Select all that​ apply.) A) Tight-fitting clothing B) Extreme exercise C) Prolonged standing D) Prolonged sitting E) Crossing the legs

A, C, D, E ​Rationale: Actions to prevent development of a deep venous thrombosis​ (DVT) include avoiding prolonged standing or​ sitting, avoiding crossing the​ legs, and avoiding​ tight-fitting or binding garments and stockings. Avoiding extreme exercise does not prevent development of a DVT.

The nurse is caring for a client with angina pectoris who was ruled out for having a myocardial infarction. The nurse reviews the client's laboratory results, and plans to include dietary teaching after noting that the client's lipid profile shows which values? A) Cholesterol: 120; HDL: 25; triglycerides: 220 B) Cholesterol: 220; HDL: 40; triglycerides: 190 C) Cholesterol: 190; HDL: 40; triglycerides: 160 D) Cholesterol: 180; HDL: 40; triglycerides: 220

B Explanation: A cholesterol level higher than 200 indicates elevated cholesterol; a ratio of HDL to total cholesterol of less than 1:5 indicates increased cardiovascular risk; triglycerides higher than 190 indicate increased risk. (Exception: triglycerides higher than 190 without elevated cholesterol do not indicate increased cardiac risk until they reach 250.)

The client presents to the emergency department with substernal chest pain and is diagnosed with a subendocardial infarction. The client asks the nurse what that means. Which description should the nurse use about the damage? A) On the anterior wall of the left ventricle. B) Involving the inner layer of the heart. C) On the posterior wall of the left ventricle. D) Involving the full thickness of the wall.

B Explanation: A subendocardial infarction occurs as a result of tissue necrosis which involves one-third of the inner layer of the left ventricle.

Which statement made by a client receiving dietary instruction for atherosclerosis would indicate a need for further discussion? A) "American cheese has 76 percent fat calories." B) "Margarine has less fat than butter, so I will no longer use butter." C) "I will steam, bake, or broil my foods." D) "I will increase my consumption of fruits and vegetables."

B Explanation: Both butter and margarine have 4 grams of fat, making the client's statement incorrect and in need of clarification. This statement is correct and requires no further teaching about that point.

A client is ready for discharge home after a myocardial infarction (MI). The client is asking questions about the medications, and wants to know why metoprolol (Lopressor) was prescribed. Which is the nurse's best response? A) "Lopressor helps make your heart beat stronger to supply more blood to your body." B) "Lopressor slows your heart rate and decreases the amount of work it has to do so it can heal." C) "Your heart was beating too slowly, and metoprolol increases your heart rate." D) "Lopressor helps to increase the blood supply to the heart by dilating your coronary arteries."

B Explanation: Metoprolol (Lopressor) is a beta adrenergic blocker that slows the heart rate and decreases myocardial contractility. Nitroglycerine is a drug that dilates the coronary arteries.

The nurse is preparing to teach a client with a venous stasis ulcer on the left lower leg. Which intervention should the nurse include in the teaching​ plan? A) How to keep the wound bed clean and dry B) Application of elastic compression stockings C) Purpose of antibiotic therapy D) Increased carbohydrate intake to promote wound healin

B ​Rationale: Use of elastic compression stockings is essential to healing of venous stasis ulcers. High dietary intake of​ protein, rather than​ carbohydrates, is needed for wound healing. Antibiotics are not routinely used for venous ulcers. Moist dressings are used for venous stasis​ ulcers, not dry dressings.

An​ OB/GYN nurse is counseling women with heart failure about pregnancy and risk factors. The nurse recommends that the women prevent pregnancy. Which is the most important risk factor that contributes to this​ recommendation? A) Previous miscarriages B) Ejection fraction​ (EF) of​ 38% C) Cholesterol level of 220​ mg/dL D) Blood pressure of​ 126/80 mmHg

B ​Rationale: A normal EF is 50-​75%. An EF of less than​ 40% is a maternal risk factor for major cardiac complications. A blood pressure of​ 126/80 mmHg is within normal range. Previous miscarriages and a high cholesterol level of 220​ mg/dL would not necessarily contraindicate pregnancy.

Evidence that the outcome of increased arterial blood supply to the extremity has been met in a client with peripheral arterial disease includes which of the following? A) Increased rubor B) Decreased hair on the extremity C) Reduced muscle pain D) Reduced sensation to touch

C Explanation: Pain of arterial occlusive disease is related to interrupted blood flow, which causes tissue hypoxia. An increase in blood supply, then, should reduce the client's ischemic pain. The other options list additional manifestations of peripheral arterial disease.

A client with obsessive-compulsive disorder (OCD) ritualistically washes the hands numerous times per day. The client reports feeling inadequate and makes statements such as "I can't do my job at work anymore, and I am not even a good parent or family member anymore." What would be the most appropriate nursing diagnosis for this client? A) Ineffective Thought Processes B) Impaired Family Relationships C) Ineffective Role Performance D) Role Overload

C Explanation: The client does not describe having too many roles, but rather being unable to perform the roles satisfactorily. The client's description does not include anything about thought processes. However, if the client had described thought patterns, it is not likely that they would have been described as irrational. Instead the client probably would have described them as repetitive, persistent, and illogical. This client describes dissatisfaction with both ascribed and assumed roles. The client's statement does not describe family relationship patterns, but rather the client's dissatisfaction with carrying out his or her own roles in the family.

A client with heart failure is prescribed an​ angiotensin-converting enzyme​ (ACE) inhibitor. What is the most important side effect that may interfere with​ compliance? A) Visual disturbances B) Rash C) Dry cough D) Diarrhea

C Rationale: Clients taking an ACE inhibitor may experience persistent dry cough. They may perceive this as annoying and stop the medication. It is important to advise them to continue with the medication and contact their healthcare provider. ACE inhibitors do not cause​ diarrhea, rash, or visual disturbances.

What should the nurse assess in a client who is at high risk for developing deep vein thrombosis? A) Cyanotic extremity and numbness B) Absent pulse and pale extremity C) Leg swelling and calf pain D) Ulcerated toes and rubor

C he classic manifestations of a deep vein thrombosis are calf or groin pain, which might or might not be associated with leg swelling. The other options describe symptoms of arterial disease.

The nurse is teaching a client about the endarterectomy she will undergo soon for peripheral atherosclerosis. Which statement should the nurse include in the​ teaching? A) An endarterectomy allows for the placement of a bypass graft. B) The purpose of an endarterectomy is to vaporize the occluding material. C) The purpose of an endarterectomy is to remove plaque from the artery. D) An endarterectomy is the first choice of treatment for peripheral atherosclerosis.

C ​Rationale: An endarterectomy is performed to remove plaque from an occluded artery. Laser or thermal angioplasty is used to vaporize occluding material. Surgery is not a first​ choice, but is performed if symptoms are​ progressive, severe, or disabling. Bypass grafts are placed during bypass graft surgery.

The nurse is caring for a client who is scheduled for placement of a filter in the vena cava. The nurse should intervene if the client makes which​ statement? A) "The filter will trap clots to prevent them from reaching my​ lungs." B) ​"Local anesthesia will be used for the placement of the​ filter." C) ​"The filter will increase my risk of​ bleeding." D) ​"The procedure has a low risk of​ mortality."

C ​Rationale: Vena cava filters will not increase the​ client's risk of bleeding. Placement of vena cava filters has a low mortality and morbidity and is completed under local anesthesia. The purpose of the filter is to trap thrombi before they enter the lungs and cause pulmonary embolism.

The nurse is teaching the client and the family about eye movement desensitization and reprocessing​ (EMDR) therapy, which has been successful in the treatment of posttraumatic stress disorder. Which teaching should the nurse​ include? (Select all that​ apply.) A) Effective pharmacologic therapy B) Telehealth strategy C) External focus on a different stimulus D) Reprocessing the trauma E) Effective nonpharmacologic therapy

C, D, E ​Rationale: The largest number of studies on psychotherapy for PTSD indicates that​ cognitive-behavioral therapy​ (CBT), as well as eye movement desensitization and reprocessing​ (EMDR), are the most effective therapies for PTSD. EMDR includes aspects of CBT and​ body-centered therapy. In this type of​ therapy, the client reprocesses the trauma by focusing internally on the traumatic event while focusing externally on a different stimulus. EMDR is a nonpharmacologic therapy that is used to treat​ PTSD, not a telehealth strategy. Telehealth is the delivery of​ health-related services and information via telecommunication technologies. Effective pharmacologic therapy is not a consideration in eye movement desensitization and reprocessing​ (EMDR) therapy.

The nurse would look for which characteristics in the behavior of a client diagnosed with obsessive-compulsive disorder (OCD)?Select all that apply. A) Eccentric B) Erratic C)Ritualistic D) Dramatic E) Anxious

C, E Explanation: Clients with a Cluster B personality disorder appear dramatic or erratic. Individuals with a Cluster A personality disorder appear odd or eccentric. A client with OCD, a Cluster C personality disorder, experiences anxiety and uses compulsive behaviors to reduce anxiety. A client with OCD may engage in rigid ritualistic behaviors to reduce anxiety.

The nurse explains to a client that which is a goal of anticoagulant therapy for clients with deep vein thrombosis? A) Dissolve the clot. B) Allow immediate ambulation. C) Prevent infection. D) Prevent embolization.

D Explanation: Anticoagulant therapy is used for deep vein thrombosis to prevent propagation of the clot, development of a new thrombi, and embolization. Anticoagulant therapy does not dissolve the clot. Anticoagulant therapy does not allow for immediate ambulation. Anticoagulant therapy has no effect on infection.

The client presents with a total cholesterol level of 325 mg/dL. In teaching the client about risk factors for coronary artery disease (CAD), how would the nurse best describe cholesterol? A) The food that causes the blood vessels to get soft and pliable B) The number one cause of heart failure C) Something that deposits in the veins and prevents absorption of nutrients D) A substance that sticks to the inside of blood vessels, decreasing blood flow

D Explanation: Cholesterol is the substance carried by lipids that deposits along the arterial walls causing stiffening and narrowing of the vessel. These atherosclerotic plaques lead to coronary artery disease. This is an inaccurate description.

The nurse is caring for a client diagnosed with a deep venous thrombosis. Which client statement requires an​ intervention? A) ​"I should increase my fluid​ intake." B) ​"I will keep my legs elevated with my knees​ flexed." C) ​"I will reposition myself​ frequently." D) "I should wash my leg in an​ alcohol-based solution​ daily."

D ​Rationale: Mild soaps and lotions should be used to clean the affected leg and foot daily. Alcohol can cause the skin to dry and​ crack, increasing the risk for infection. Increased fluid and dietary fiber intake should be encouraged because constipation is a common complication of immobility. Frequent position changes while awake will reduce skin breakdown. Elevation of the extremities promotes venous return and reduces peripheral edema. Knee flexion promotes muscle relaxation.

An​ 86-year-old man visits the clinic and asks about risk factors for heart disease. Which modifiable risk factors would the nurse discuss with this​ client? (Select all that​ apply.) A) Ethnicity B) Sex C) Exercise D) Smoking E) Nutrition

C, D, E ​Rationale: Older adults are more at risk for cardiac events such as heart failure as they​ age, as a result of changes in the vascular system. Modifiable risk factors are those that the client can control such as​ diet, exercise, and smoking. Sex and ethnicity are nonmodifiable risk factors.

The nurse in the emergency room is administering tPA (Activase) for an acute myocardial infarction. In order to avoid a serious complication of this treatment, what should the nurse plans to do? A) Assess the client's neurological status frequently. B) Monitor the client's PTT. C) Teach the client to use a soft toothbrush. D) Test stools, urine, and blood for occult blood.

A Explanation: A cerebrovascular accident (CVA) is a very serious complication of thrombolytic therapy. The most important intervention to detect this complication is frequent assessment of neurological status. Testing for occult blood is important with these clients to detect GI or urinary tract bleeding, a less serious complication. PTT monitoring does not detect a specific area of bleeding. Teaching a client to use a soft toothbrush is important to prevent bleeding gums, a minor complication of this therapy.

What should the nurse emphasize when teaching a group of middle-aged men concerned about hypertension? A) Adequate intake of dietary calcium, magnesium and potassium B) Use of herbal therapy containing licori C) Alcohol consumption does not have an effect on reducing high blood pressure D) Exercise must be high intensity to be beneficial

A Explanation: Adequate intake of Potassium increases the amount of salt excreted through the urine which helps to decrease blood pressure. Calcium and Magnesium helps to dilate blood vessels which help to reduce blood pressure. Alcohol consumption may increase blood pressure. Herbal therapy containing licorice can elevate blood pressure and may lead to abnormal heart rhythms. Any exercise will be beneficial in reducing blood pressure

The nurse is creating a plan of care for a client diagnosed with a deep venous thrombosis​ (DVT). Which intervention should be included in the care​ plan? A) Assess regularly for pain and treat as needed. B) Assist the client to ambulate at least twice daily. C) Assess skin at admission and again at discharge. D) Apply cold compresses 4 times daily.

A Rationale: Pain is common with DVT and should be assessed and treated regularly. Increased pain should be reported to the healthcare provider.​ Warm, moist compresses should be used. Skin should be assessed daily. The client will most likely be on​ bedrest, as increased mobility could cause the thrombus to dislodge and travel to the lungs.

A nurse is preparing to admit a client with restrictive cardiomyopathy to the hospital for the management of worsening heart failure. What would be the most appropriate nursing diagnosis for this client? A) Activity intolerance related to decreased cardiac output B) Knowledge deficit related to medication regime C) Hopelessness related to lack of cure and debilitating symptoms D) Fear related to new onset of symptoms

A Explanation: Although some clients might have fear, hopelessness, or knowledge deficit related to their disease progression, most clients with cardiomyopathy are likely to have decreased cardiac output and corresponding activity intolerance. More data would be needed to determine whether the other nursing diagnoses apply.

The physician has diagnosed a client had a myocardial infarction on the basis of ECG changes for a client in the emergency department. The nurse assessing the client notes that the client seems forgetful, making the nurse repeat explanations about the ECG and non-invasive blood pressure monitors. The nurse concludes that the client's response is most likely due to which reason? A) The client is showing signs of fear and anxiety B) Memory lapses are common with clients experiencing myocardial infarctions C) The client is showing signs of Alzheimer's disease D) Nurses in the emergency department are too busy to properly explain the purpose of equipment

A Explanation: Anxiety and fear are common responses to a diagnosis of myocardial infarction, because of the possibility of death. This prevents the client and family from absorbing the detailed explanations about the care being provided. Memory lapses are not a common symptom of myocardial infarction, and there is not adequate information to determine that this memory lapse is associated with Alzheimer's disease. Nurses in the emergency department are capable of explaining procedures well to their clients.

A client on the telemetry unit with a diagnosis of congestive heart failure and atrial fibrillation has an order for digoxin (Lanoxin). The client's pulse is 112 and irregular. The nurse should take which action? A) Give the dose as ordered. B) Give the dose and monitor vital signs every 15 minutes. C) Call the physician immediately. D) Hold the dose and call the physician.

A Explanation: Atrial fibrillation is accompanied by an irregular rhythm. The heart rate can be slow, within normal limits, or fast. The action of digoxin (Lanoxin) is to increase the force of contraction (positive inotropic) and decrease the heart rate (negative chronotropic). These actions will help in both congestive heart failure and atrial fibrillation. The data indicates that the client needs the medication for therapeutic effect. There is no need to monitor the vital signs every 15 minutes while on a telemetry monitor and in this situation.

Renin converts angiotensin I to angiotensin II (a potent vasoconstrictor) in order to increase the systemic blood pressure. This explains the effectiveness of which group of antihypertensives? A) ACE inhibitors B) Beta blockers C) Sympatholytics D) Diuretics

A Explanation: Beta blockers block the sympathetic nervous system. Sympatholytics block the sympathetic nervous system. Diuretics affect the absorption of sodium and water. ACE inhibitors block the conversion of angiotensin I to angiotensin II or inhibit the effect of angiotensin II; therefore, the potent vasoconstrictor is not able to increase the blood pressure.

A client is due to receive a calcium channel blocker and a beta blocker for angina. Vital signs are BP 100/68, pulse 52 bpm, respirations 20. Which of the following is an appropriate action by the nurse? A) Call the physician first. B) Give the medicine and check vital signs in 30 minutes. C) Give the medicine as usual. D) Withhold the medicine until the physician makes rounds.

A Explanation: Both the beta blocker and the calcium channel blocker have the potential of lowering the BP and pulse (sometimes significantly). Most textbooks still list 60 bpm as the baseline pulse. Giving the medicine as usual could lower the vital signs even further. Even if vital signs are monitored, the drugs will be in the client's system and could result in harm. Withholding the medicine until rounds is not usually an acceptable practice. Unless specific parameters are established on a unit, the nurse should obtain a written order for parameters.

Which statement made by the client with posttraumatic stress disorder (PTSD) would indicate the most improvement? A) "I enjoy being back at work with my friends." B) "I can't relax. I stay alert all the time." C) "I am responsible for what happened to me." D) "I like to stay awake all night."

A Explanation: Clients are likely to feel victimized by the traumatic event. People with PTSD often avoid interactions and develop an isolated lifestyle that prevents them from working and socializing with others. Staying awake all night reflects symptoms of PTSD, indicating the client is not yet showing improvement. The inability to relax and being hyper-alert reflects symptoms of PTSD, indicating the client is not yet showing improvement.

For a client with deep vein thrombosis receiving heparin sodium, the nurse evaluates the partial thromboplastin time (PTT) as therapeutic when which results are noted? A) Control = 25 seconds, PTT = 50 seconds B) Control = 20 seconds, PTT = 25 seconds C) Control = 30 seconds, PTT = 90 seconds D) Control = 25 seconds, PTT = 20 seconds

A Explanation: During heparin therapy, the therapeutic PTT equals 1.5-2.0 times the control value. This result does not reflect this ratio. During heparin therapy, the therapeutic PTT equals 1.5-2.0 times the control value.

In teaching a hypertensive client about the side effects of propranolol (Inderal), the nurse plans to include which side effect of this medication therapy? A) Heart failure B) Tachycardia C) Constipation D) Hypokalemia

A Explanation: Hypokalemia occurs from loop and thiazide diuretics, not propranolol (Inderal). Constipation is a side effect of therapy with some of the calcium channel blockers. Beta adrenergic blocking agents, such as propranolol, cause a decrease in heart rate and decreased contractility, which can result in bradycardia or heart failure.

The client is admitted to the coronary care unit with a diagnosis of left-sided heart failure. When listening to the lung sounds, the nurse hears crackles bilaterally. The nurse anticipates this because left ventricular failure leads to which complication? A) Pulmonary congestion B) Increased coronary artery perfusion C) Increased peripheral resistance D) Pulmonary emboli

A Explanation: Left ventricular failure leads to pulmonary congestion. When the left side cannot pump the blood out adequately, congestion occurs in the lungs where the blood backs up from the left ventricle.

A client has obsessive-compulsive disorder (OCD). Which statement made by the client to the nurse would be the best indicator of improvement? A) "I have more control over my thoughts and behaviors." B) "I only do my ritual to reward myself when I have been good." C) "I know that my thoughts and behaviors are not normal." D) "My friends don't know about my disorder."

A Explanation: Loss of control is a major concern for clients who have OCD. Goals related to control of unwanted thoughts and behaviors are appropriate for these clients. Clients with OCD are aware that their compulsive behaviors are not normal. Knowing this does not mediate or change their ability to manage or control the unwanted thoughts and behaviors. This statement only reflects the client's awareness of his or her disorder; it does not indicate control over the behaviors and thoughts. The compulsive behaviors are utilized to reduce anxiety, not to reward oneself for good behavior. Keeping the diagnosis of OCD from friends does not indicate control over behavior.

When educating the client with primary hypertension, the nurse instructs the client to take which action? A) Have regular eye exams. B) Monitor blood pressure annually. C) Avoid foods with concentrated sugars. D) Take anti-hypertensive medications when blood pressure is elevated.

A Explanation: Medications should be taken daily or more often as ordered, not just when blood pressure is high. Annual blood pressure monitoring is insufficient for a client who already has hypertension. Avoiding concentrated sugars may help keep blood glucose normalized in a client with diabetes mellitus. A common complication of hypertensive disease is target organ disease, including retinal damage to the eye. The appearance of the retina can provide important information about the severity of the hypertensive process.

The nurse is conducting a screening clinic for primary hypertension in the community. For which client should the nurse pay particular attention to blood pressure? A) African-American adult male B) Latino/Hispanic adult male C) Caucasian adult female D) Asian adult male

A Explanation: Primary hypertension is a prevalent problem, but it is less prevalent in Caucasians than in African-Americans. Primary hypertension is a prevalent problem, but it is less prevalent in Latino-Hispanics than in African-Americans. Primary hypertension is a prevalent problem, but it is less prevalent in men from Asian countries than in African-Americans. Primary hypertension is more common in African-Americans than in people of other ethnic backgrounds. For this reason, this client should be evaluated carefully.

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client is developing pulmonary edema after observing which change in the client? A) Cough with pink, frothy sputum B) Bradycardia C) Increased sleepiness D) Increased urination

A Explanation: Pulmonary edema in a client with heart failure is the accumulation of fluid in the alveoli characterized by increased rales; tachypnea; tachycardia; pink, frothy sputum; as well as decreased SO2 and PO2. The client presents with acute restlessness and anxiety. Urine output generally is decreased in heart failure clients; increased urinary output usually is caused by diuretic therapy.

he nurse should assess the client's pulse and blood pressure as part of the administration of which drugs? A) Propranolol (Inderal) and clonidine (Catapres) B) Glucagon (GlucaGen) and pyridostigmine bromide (Regonol) C) Sulfinpyrazone (Anturane) and calcitonin (Calcimar) D) Hydroxyzine (Vistaril) and prazosin hydrochloride (Minipress)

A Explanation: Sulfinpyrazone (Anturane) is a medication used to manage long-term gout, while calcitonin (Calcimar) is used in the treatment of Paget's disease by decreasing the rate of bone destruction. When administering propranolol (Inderal), the client's apical pulse and blood pressure must be assessed. Propranolol is a beta blocker used to treat hypertension and tachycardia. The drug should not be given if the apical pulse is below 60 beats per minute (bpm), if there has been a significant drop in the blood pressure, or if the systolic pressure is below 100 mm Hg. Side effects include bradycardia, congestive heart failure, pulmonary edema, hypotension and edema, depression, memory loss, insomnia, drowsiness, and dizziness. Glucagon (GlucaGen) is a specific medication for the management of hypoglycemia when glucose is not appropriate. Pyridostigmine may be used to treat myasthenia gravis. Hydroxyzine (Vistaril) is used in the treatment of anxiety, pruritus caused by allergies, psychiatric and emotional emergencies, nausea and vomiting (excluding the nausea and vomiting of pregnancy), as a preoperative and postoperative sedation, and as a prepartum and postpartum adjunct therapy. Prazocin is an antihypertensive that requires blood pressure measurement but not pulse.

A client with angina pectoris is given nitroglycerin (NTG) 1/150 sublingual for complaint of chest pain. Prior to the NTG, his blood pressure was 110/78. After 5 minutes, he says the chest pain is better but not gone. What action should the nurse take next? A) Check the blood pressure (BP). B) Give another NTG. C) Check the pulse rate. D) Give morphine sulfate instead of NTG.

A Explanation: The client does need another NTG if the chest pain is still present; however, a BP should be assessed first. If the systolic is greater than 100, another NTG can be given. If the systolic is less than 100, the physician should be consulted. A blood pressure measurement is more important than checking the client's pulse at this time. Morphine sulfate is often given for pain unrelieved by NTG.

A client's angiogram demonstrates the final stage of atherosclerosis. The nurse concludes that this client's pathophysiology includes which late developing element? A) The presence of atheromas. B) Lipoprotein accumulation in the intima. C) Fatty deposits in the intima. D) Inflammation of the arterial wall.

A Explanation: The final stage of the atherosclerotic process is the development of atheromas which are complex lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular waste, and capillaries. The calcified lesions may rupture or ulcerate, stimulating thrombosis. Earlier changes in development of atherosclerosis include fatty deposits in the intima layer of the arterial wall. Earlier changes in development of atherosclerosis include lipoprotein accumulation along the intima layer of the arterial wall. Earlier changes in development of atherosclerosis include inflammation of the arterial wall.

In planning care for a client receiving warfarin sodium (Coumadin), the nurse instructs the client to take which action as part of therapeutic drug management? A) Avoid aspirin and aspirin-containing products. B) Observe for signs and symptoms of infection. C) Monitor blood pressure weekly. D) Get up slowly from the chair or bed.

A Explanation: The medication does not alter blood pressure. The medication does not place the client at risk for infection. The medication does not cause orthostatic hypotension. Aspirin is an antiplatelet agent, and its properties will increase the risk of bleeding while the client is taking anticoagulant therapy.

A client scheduled for discharge after coronary artery bypass grafting (CABG) reports new onset of anorexia and nausea. The client's new medications include digoxin, metoprolol, and furosemide. The nurse plans to report this finding to the healthcare provider after checking the result of which laboratory test drawn earlier in the morning ? A) Digoxin level B) Potassium level C) Sodium level D) Creatinine kinase level

A Explanation: The potassium level would not explain the client's symptoms and therefore is not a priority to assess before notifying the healthcare provider. The sodium level would not explain the client's symptoms and therefore is not a priority to assess before notifying the healthcare provider. The creatinine kinase level would not explain the client's symptoms and therefore is not a priority to assess before notifying the healthcare provider. Nausea and anorexia are signs of digitalis toxicity, making the digoxin level high priority for assessment.

Which laboratory tests are usually ordered to aid in the assessment of the client with hypertension (HTN)? A) Serum cholesterol, complete blood count, and serum creatinine B) Serum sodium, serum potassium, and a bone density scan C) Hemoglobin, hematocrit, and a glucose tolerance test D) Stress test, prothrombin time, and urine analysis

A Explanation: These laboratory studies would be the most helpful and give an estimate of the degree of vascular involvement as well as the degree of damage. An elevated cholesterol level would suggest HTN related to atherosclerosis. Creatinine is the most specific test of kidney function (a cause of HTN) and is not affected by foods as is the blood urea nitrogen (BUN). A hematocrit will be helpful in determining fluid problems, which could account for HTN also. Bone scan (option 1), glucose tolerance (option 2), and prothrombin time (option 3) are not essential tests for diagnosing HTN.

What should the nurse include in the assessment of persistent severe hypertension? A) Level of consciousness B) Breath sounds C) Temperature D) Presence of headache

A Explanation: When assessing a client with severe hypertension, the client may be demonstrating hypertensive encephalopathy. If this occurs, the client will have a change in the level of consciousness ranging from confusion to coma and possible seizures. The client experiencing severe hypertension may or may not demonstrate a headache (option 2). Unless pulmonary edema is present, the breath sounds will be clear bilaterally (option 3). Temperature is less critical than pulse (option 4).

The client is admitted to the hospital with a diagnosis of left-sided heart failure. The nurse differentiates between left and right heart failure because the client would do which of the following? A) Present with dyspnea and crackles bilaterally with left heart failure. B) Have peripheral edema associated with left heart failure. C) Present with crackles in his lung fields with right heart failure. D) Demonstrate distended neck veins in left heart failure.

A Explanation:Shortness of breath, dyspnea on exertion, and crackles are classic signs and symptoms of left-sided heart failure. The fluid backs up into the lungs from the left side. Right-sided heart failure leads to backflow of blood to the peripheral circulation causing edema in the extremities, jugular vein distention, and possible ascites. Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse is educating a nursing student on essential hypertension. Which statement by the student demonstrates an understanding of the disorder? A) An overactive Renin-angiotensin system leads to vasoconstriction and water retention B) There is a rise in cardiac output as the disorder progresses C) There is a 90% increase of the arterial pressure. D) There is a decrease in the resistance of blood flow through the kidneys.

A Explanation:The mean arterial pressure rises between 40 and 60% in essential hypertension. Blood flow resistance rises between two- and four-fold in essential hypertension. The client with essential hypertension may have an early rise in cardiac output which stabilizes to normal levels. An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension. Prev Next Reset Notes Answer Review Save Exam Grade Exam

A nurse is teaching a client about aspirin for peripheral vascular disease​ (PVD). Which client statement indicates that teaching has been​ successful? A) ​"This medication will prevent me from developing a blood​ clot." B) "This medication will thin out my blood so it flows​ easier." C) "This medication will help decrease the plaque in my​ arteries." D) "This medication will open my arteries and increase blood flow to my​ legs."

A Rationale: Aspirin, an​ antiplatelet, is prescribed in PVD to prevent clot formation. Aspirin does not​ vasodilate, decrease​ viscosity, or help decrease plaque in the arteries. Pentoxifylline​ (Trental) decreases blood viscosity and Cilostazol​ (Pletal) decreases blood viscosity in addition to preventing further clots.

A client diagnosed with atherosclerosis asks the​ nurse, "What can I do to improve my​ condition?" Which response by the nurse is best​? A) "You should exercise five or six times a week for 30​ minutes." B) ​"You should eat a diet with a minimum of​ 40% fat." C) ​"You should take statins as prescribed by your healthcare​ provider." D) "You should decrease your smoking by one pack per​ day."

A Rationale: Conservative treatment would include regular physical exercise such as walking at a brisk pace. Fat should be no more than​ 35% of the daily diet. The Pritikin diet has a beneficial effect on coronary heart disease and recommends less than​ 10% fat. Smoking should be totally​ eliminated, usually through a cessation program or the use of assistive drugs such as nicotine patches. By controlling​ cholesterol, the client can help control coronary artery disease​ (CAD), but this will begin with lifestyle changes before medication such as statins are added.

The nurse is conducting a health screening within the Hispanic community. Which client is most likely to be at risk for​ hypertension? A) The client who has a body mass index of 30 B) The client who is 30 years old C) The client who eats salads each day for lunch D) The client who exercises daily

A Rationale: High body mass index​ (BMI) is a risk factor for hypertension.​ Middle-aged and older adults are at a greater risk for hypertension. Daily exercise reduces the risk of hypertension. A diet that is high in fruits and vegetables reduces the risk for hypertension. Next Question

A client is prescribed​ prazosin, an antihypertensive​ medication, for the pharmacologic treatment of posttraumatic stress disorder​ (PTSD). The client asks how a blood pressure medication will help with symptoms. Which response by the nurse is the most​ appropriate? A) "The medication has been found quite useful to reduce the nightmares associated with​ PTSD." B) "The medication reduces your blood​ pressure, which decreases the symptoms of​ PTSD." C) "Your medical record indicates elevated blood pressure during the last two​ visits." D) "I am not sure why this medication has been​ prescribed, so I will follow up with your healthcare​ provider."

A Rationale: Prazosin is an antiadrenergic agent that has been used to treat hypertension for many years. Recent research has found that this medication is useful in the treatment of the nightmares associated with PTSD through its action of inhibiting the​ brain's response to norepinephrine. While the medication will reduce blood​ pressure, this is not the reason it is used for PTSD. It is inappropriate for the nurse to avoid answering the question and to instead promise to follow up with the healthcare provider.

The nurse is teaching a client about lifestyle modifications to promote vasodilation in a client with peripheral vascular disease​ (PVD). Which intervention should the nurse​ suggest? A) Stop smoking. B) Take an aspirin daily. C) Wash extremities in cool water. D) Walk daily.

A Rationale: Smoking causes​ vasoconstriction, so stopping smoking will improve vasodilation. Increasing activity such as walking may lead to collateral circulation but does not cause vasodilation. The use of aspirin may impede platelet clumping but does not cause vasodilation. Cool water may cause vasoconstriction to occur.

A​ 68-year-old client is admitted to the coronary care unit with complaints of dyspnea at​ rest, orthopnea, weight​ gain, and inability to perform chores in the home due to severe weakness. According to the American Heart​ Association, what stage of heart failure does the nurse​ suspect? A) IV B) II C) III D) I

A Rationale: Stage I​ (mild) heart failure is when the client has no limitations of physical activity and no shortness of breath with normal physical activity. A client with stage II​ (mild) heart failure has some physical limitations due to​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. In Stage III​ (moderate), a client has increased physical limitations with less than normal physical activity resulting in​ fatigue, shortness of​ breath, or​ palpitations; the client is comfortable at rest. Stage IV​ (severe) is the most debilitating and the client experiences symptoms of cardiac insufficiency at rest.

A client with chronic peripheral vascular disease​ (PVD) reports continuous pain in the bilateral lower extremities at rest and has pregangrenous lesions on his left foot. The nurse should expect to prepare the client for which collaborative​ intervention? A) Revascularization surgery B) Smoking cessation classes C) Semirigid boots D) Intense pulsed light​ (IPL)

A Rationale: When PVD is severe enough to cause pain with rest and pregangrenous or gangrenous​ lesions, revascularization therapy is likely necessary. IPL and semirigid boots are used to treat stasis pigmentation. Although smoking cessation is vital in the treatment of​ PVD, there is no information in this scenario that the client smokes.​ Additionally, smoking cessation alone will not treat severe PVD.

The nurse is teaching a client about​ angiotensin-converting enzyme​ (ACE) inhibitors. Which client statement requires​ follow-up? A) "I will use salt substitutes to help me decrease my sodium​ intake." B) "I will sit on the edge of the bed before getting up in the​ morning." C) ​"If I develop a persistent​ cough, I will call my healthcare​ provider." D) "I will take my medication 1 hour before​ eating."

A ​Rationale: Clients taking ACE inhibitors should not use salt substitutes due to the risk of hyperkalemia. ACE inhibitors should be taken about 1 hour before meals. A persistent cough should be reported to the healthcare provider. Antihypertensive medications can cause orthostatic hypotension. Sitting on the end of the bed before getting up will help prevent falls and keep the client safe.

A teenage client with obsessive-compulsive disorder​ (OCD) washes his hands 15 times every hour. Which intervention should the nurse include in the plan of​ care? A) Teaching to lubricate hands frequently. B) Removing all soap and hand gels from the home environment. C) Teaching to use hand gels instead of soap. D) Explaining that the behavior is unnecessary and is​ self-harm.

A ​Rationale: Clients who perform excessive washing rituals are at a high risk of impaired tissue​ integrity, especially on the hands. Excessive hand washing with soaps and antibacterial gels can dry the skin and leave it susceptible to cracking and bleeding. Teach the client about the consequences of excessive hand washing and techniques to help maintain skin integrity by including the regular use of lotions. Removing all soap and criticizing the behavior will not stop the ritual and may create more fear and anxiety

The nurse is performing an assessment on a client with peripheral vascular disease​ (PVD). Which finding should the nurse​ expect? A) Delayed capillary refill in the lower extremities B) Decreased sensation of the upper extremities C) Wheezing upon auscultation of the lungs D) Dilated blood vessels in the eye

A ​Rationale: Delayed capillary refill in the lower extremities may be present in the client with PVD. The other clinical manifestations are not present in the client with PVD. Next Question

A nurse is teaching a client diagnosed with peripheral arterial disease about proper positioning of the lower extremities. Which client statement indicates a need for further​ teaching? A) ​"I will elevate my legs and feet on pillows when I lie​ down." B) "I can sit in a chair while I watch​ television." C) "I will avoid crossing my​ legs." D) "I should hang my legs off the bed while I am​ resting."

A ​Rationale: Elevation of the affected limb can slow arterial blood flow to the​ feet, so this position should be avoided. The client may sleep with the extremities hanging or positioned upright in a chair. The client is also instructed to avoid crossing the legs because this interferes with blood flow.

The nurse is teaching a client diagnosed with prehypertension. Which instruction should be included in the​ teaching? (Select all that​ apply.) A) Maintaining a healthy weight B) Avoiding baths that are extremely hot C) Increasing the daily intake of saturated fats D) Following the treatment regimen E) Engaging in regular physical activity

A, B, D, E ​Rationale: To avoid progressing to​ hypertension, clients with prehypertension should follow their treatment​ regimen, maintain a healthy weight and​ diet, reduce salt​ intake, reduce saturated and total fat​ intake, engage in regular physical​ activity, use​ stress-management techniques, and avoid baths that are too hot.

A nurse receives a triage call from a client with newly diagnosed heart failure. Which statement indicates a worsening of the​ client's condition? A) "I've gained 3 pounds in 24​ hours." B) "I've had two episodes of diarrhea this past​ week." C) "I'm most comfortable sleeping with 2​ pillows." D) "I'm eating 6 small meals a day​ now."

A ​Rationale: Heart failure is a condition where the heart is unable to pump enough blood into circulation to meet the​ body's demands. When the heart is unable to eliminate extra fluid and wastes from the​ body, those fluids accumulate in the​ body, making the heart work harder. A weight gain of 3 pounds in 24 hours is approximately 1.3 liters of fluid and an indication of fluid volume retention. A client with heart failure would be expected to sleep with pillows to facilitate breathing. Two episodes of diarrhea in a week is not related to heart failure and not an indication of a worsening condition. Six small meals per day are encouraged to facilitate nutrition and consume energy.

Which clinical manifestation would the nurse expect to observe in a client with a compulsion to continually order and arrange​ objects? A) Places all spices in alphabetical order. B) Continually asks others for assurance. C) Checks several times that appliances are off. D) Repeatedly washes hands.

A ​Rationale: Rearranging spices is considered a compulsion to have objects in a fixed and symmetrical order.​ Similarly, repeatedly washing​ hands, going in and out of a​ doorway, or other repeated behaviors is a​ "repeating" compulsion. Repeatedly checking that doors are locked or appliances are turned off is considered an obsession with​ "checking." Asking others for continual assurance is also a​ "checking" compulsion.

A client diagnosed with primary aldosteronism has​ polyuria, weakness,​ paresthesia, and an elevated blood pressure. Which condition should the nurse expect as the most likely cause for the elevated blood​ pressure? A) Secondary hypertension B) Hypertensive crisis C) Primary hypertension D) Stroke

A ​Rationale: Secondary hypertension is an elevated blood pressure as a result of an underlying disease process. Primary aldosteronism can cause secondary hypertension with symptoms of​ hypertension, weakness,​ paresthesia, polyuria, and nocturia. Primary hypertension is a persistently elevated systemic blood pressure without an underlying disease process as the cause. Hypertensive crisis is a​ rapid, significant elevation in blood pressure. The​ client's symptoms were not those of a strok

The nurse is caring for a client with a history of atherosclerosis. The client has chest pain that occurs with physical exertion or stress and is relieved with sublingual nitroglycerin. Which disorder should the nurse recognize the client is most likely​ experiencing? A) Stable angina B) Acute coronary syndrome C) Myocardial infarction D) Prinzmetal angina

A ​Rationale: Stable angina is a predictable form of​ angina, which usually occurs when the work of the heart is increased by physical​ exertion, exposure to​ cold, or stress. Prinzmetal​ (variant) angina occurs unpredictably and often at night. The client is currently experiencing a predictable form of angina. Clinical manifestations of myocardial infarction include pain that is less​ predictable, more​ prolonged, and unrelieved by sublingual nitroglycerin. Clinical manifestations of acute coronary syndrome include pain that is more severe and longer than previously experienced. The pain is not predictable and is unrelieved by sublingual nitroglycerin.

A client recently diagnosed with hypertension has a family history of hyperaldosteronism. Which diagnostic test should the nurse expect to be​ ordered? A) Serum potassium B) Creatinine clearance C) Serum creatinine D) Renal function panel

A ​Rationale: The serum potassium level will be decreased with hyperaldosteronism. Serum creatinine is elevated and creatinine clearance is reduced if there is an underlying renal cause to the hypertension. A renal function panel is used to detect alterations in kidney function that may be causing the hypertension.

A nurse is on orientation in the coronary care unit​ (CCU) and learning about the​ Frank-Starling mechanism. Which statement by the nurse is​ correct? A) "The more the heart fills with​ blood, the stronger the force of cardiac​ contraction." B) "The less the heart fills with​ blood, the stronger the force of cardiac​ contraction." C) "The more the heart fills with​ blood, the weaker the force of cardiac​ contraction." D) ​"The Frank-Starling mechanism has no effect on the​ heart, only on the cardiac​ vessels."

A ​Rationale: The​ Frank-Starling mechanism occurs as the result of​ the heart muscle being​ stretched; active tension is created by altering the overlap of thick and thin filaments. This increase in contractile force leads to increased cardiac output. It is important to note that overstretching the muscle fibers beyond their physiologic limits results in ineffective contractions.

The nurse is creating a plan of care for a client with hypertension. Which instruction should the nurse​ include? (Select all that​ apply.) A) Using alcohol in moderation B) Beginning aerobic exercises C) Ensuring that the diet includes at least 2 servings of milk products daily D) Following a​ low-fat, no-sodium diet E) Reducing smoking

A, B, C Rationale: Smoking should be​ eliminated, not reduced. A​ low-fat diet is​ recommended, but sodium should be reduced and not eliminated from the diet. Alcohol should be used in​ moderation, if at all. At least 2 servings of milk products daily are recommended. Aerobic exercises are recommended.

A nurse is examining a client diagnosed with peripheral vascular disease​ (PVD) who has an ulcer on the great right toe. Which additional assessment finding should the nurse​ expect? (Select all that​ apply). A) The extremity is cool to touch. B) There is an absence of hair on the legs. C) The toenails are thickened. D) There is pitting edema in the lower extremity. E) There is brown pigmentation of the lower extremity.

A, B, C ​Rationale: Wounds on the​ toes, absence of hair on the​ legs, cool​ extremities, and thick toenails are all features of arterial problems. Venous problems are characterized by brown pigmentation of the skin of the lower extremity and edema

A client with hypertension is being treated with metoprolol, hydrochlorothiazide, and captopril. Other scheduled medications include docusate and a multivitamin. The client's current blood pressure is 124/86 mmHg and pulse rate is 48. Which scheduled medication doses should the nurse administer?Select all that apply. A) Docusate B) Multivitamin C) Hydrochlorothiazide D) Captopril E) Metoprolol

A, B, C, D Explanation: The client's heart rate is bradycardic, and metoprolol, a beta-blocker, decreases the heart rate. The dose of this medication should be withheld. The captopril does not lower the heart rate and may be safely administered to maintain control of the hypertension. The hydrochlorothiazide does not lower the heart rate and may be safely administered to maintain control of the hypertension. Docusate is a stool softener and may be safely administered to the client. Straining at stool could cause the client to use the Valsalva maneuver, which could temporarily lower the heart rate further. A multivitamin would not adversely affect the client's pulse rate and may be safely administered.

The nurse is planning care for a client with a deep venous thrombosis of the right calf. Which should the nurse include in this​ client's plan of​ care? (Select all that​ apply.) A) Applying​ warm, moist heat to the affected area every 6 hours B) Measuring the calf and thigh diameter of the right leg every shift C) Encouraging​ range-of-motion exercises every 2-4 hours D) Coaching to perform deep breathing and coughing every 2 hours E) Assisting to a sitting position with the legs dependent every 4 hours

A, B, C, D ationale: Interventions that may be appropriate for inclusion in the plan of care for the client with DVT include measuring the calf and thigh diameter of the affected leg every​ shift; applying​ warm, moist heat to the affected extremity at least 4 times a​ day; encouraging​ range-of-motion exercises; and assisting with deep breathing and coughing. The legs should be​ elevated, not dependent.

Which factor places older adults at an increased risk for deep venous​ thrombosis? (Select all that​ apply.) A) Limited mobility B) Multiple comorbidities C) False positive​ D-dimers D) Use of​ estrogen-containing drugs E) Decreased venous stasis

A, B, C, D Rationale: Older adults are at an increased risk for deep venous thrombosis due to limited​ mobility, multiple​ comorbidities, false positive​ D-dimers, increased venous​ stasis, and use of​ estrogen-containing drugs. Next Question

The nurse should assess which client for possible deep venous​ thrombosis? (Select all that​ apply.) A) The client with capillary refill less than 3 seconds in one lower extremity and 4 seconds in the other B) The client with bilateral lower extremity edema but slightly greater in the left lower extremity C) The client with cyanosis of the right lower extremity D) The client with​ sharp, stabbing pain in the right lower extremity only when walking E) The client who recently had surgery but has no reports of pain or swelling in the lower extremities

A, B, C, E ​Rationale: Signs and symptoms of DVT include​ cyanosis, dull aching pain when​ walking, edema greater in one​ leg, and capillary refill greater in one leg. DVT is often asymptomatic. The client who has had surgery is at risk for DVT and should be assessed.

A nurse is evaluating teaching for a client who recently experienced a hypertensive crisis. Which statement by the client indicates an understanding of the​ instructions? (Select all that​ apply.) A) ​"I will increase fruits and vegetables in my​ diet." B) ​"I will set a schedule to remind me to take my medications each​ day." C) "I need to restrict my alcohol intake to no more than 20 oz of beer a​ day." D) "I will exercise 3 days a​ week." E) ​"I must stop​ smoking."

A, B, C, E ​Rationale: Smoking is closely associated with cardiovascular​ disease, which is a complication of hypertension. In​ addition, smoking interferes with some antihypertensive medications. Clients with hypertension should drink only in moderation. The recommended alcohol intake is one alcoholic beverage per day. A diet that is high in fruits and vegetables will help maintain a normal weight and lower blood pressure. The client will also benefit from a diet that is low in fat. This client has experienced a hypertensive crisis. Failure to take medications as prescribed can cause hypertensive crisis. A routine that includes taking medications at a set time each day will help the client remember to take medications as prescribed. Exercise 5 days a week lasting 30-45 minutes per day is recommended. Exercise helps with stress​ reduction, weight​ loss, and general feelings of​ well-being.

The nurse is providing care for a client diagnosed with posttraumatic stress disorder​ (PTSD). The​ client's family has asked about nonpharmacologic therapies that may be appropriate. Which therapy should the nurse mention when responding to this​ family? (Select all that​ apply.) A) Cognitive-behavioral therapy B) Eye movement desensitization and reprocessing therapy C) Atypical antipsychotic therapy D) Selective serotonin reuptake inhibitor therapy E) Acupuncture therapy

A, B, E ​Rationale: Acupuncture therapy is a​ complementary, nonpharmacologic therapy that has been useful in the treatment of PTSD.​ Cognitive-behavioral therapy​ (CBT) and eye movement desensitization and reprocessing therapy​ (EMDR) are nonpharmacologic therapies used by interdisciplinary teams to treat posttraumatic stress disorder. Selective serotonin reuptake inhibitor​ (SSRI) and atypical antipsychotic therapy are both pharmacologic therapies that may be used to treat PTS

A client who exercises for 30 minutes every day and maintains a normal body weight develops primary hypertension. The client asks how this could have happened. Which finding in the​ client's health history should the nurse include in the response to the​ client? (Select all that​ apply.) A) Insulin resistance B) Age: 62 years C) Family history of hypertension D) High magnesium intake E) Working as an air traffic controller

A, B, C, E ​Rationale: The role of stress in primary hypertension is not clear. Frequent or continued stress may cause vascular smooth muscle hypertrophy or affect central integrative pathways of the brain. Insulin resistance has been found in people of normal weight and is linked with hypertension by its effects on the sympathetic nervous​ system, vascular smooth​ muscle, renal regulation of sodium and​ water, and changes in ion transport across cell membrane. Low magnesium intake contributes to hypertension by unknown mechanisms. Hypertension primarily affects​ middle-aged and older​ adults: More than​ 50% of people aged 60-74 and about​ 75% of those 75 and older are hypertensive. Studies show a genetic link in up to​ 40% of people with primary hypertension.

The nurse is reviewing the personal and medical history of several clients. Which finding indicates that a client is at risk for the development of a deep venous​ thrombosis? (Select all that​ apply.) A) Hormone therapy B) 28​ weeks' gestation C) Hypercholesterolemia D) Lung cancer E) Diabetes mellitus

A, B, D Rationale: Hormone​ therapy, lung​ cancer, and pregnancy are all risk factors for the development of DVT. Hypercholesterolemia and diabetes mellitus are risk factors for peripheral vascular​ disease, not DVT.

The nurse is caring for a client who is recovering from a myocardial infarction​ (MI) who expresses fear. Which response by the nurse is​ appropriate? (Select all that​ apply.) A) "Tell me more about what you are worried​ about." B) What specific questions can I answer about your​ recovery?" C) It's normal to feel anxious after what you have been​ through." D) ​"Your body language is telling me something is​ wrong." E) ​"If you let your wife help you​ more, it will decrease your​ stress."

A, B, D Rationale: It is important for the nurse to encourage​ self-care; the​ client's confidence increases as his dependence on others decreases. Encouraging questions helps provide information and relieve fears when the client may have been reluctant to ask. Telling the client how that his feelings are normal is dismissing how he feels. Acknowledge the​ client's feelings and encourage expression of those feelings and fears. It is imperative the nurse be able to identify the​ client's fear using both verbal and nonverbal clue

The nurse is caring for a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which outcome should the nurse include in the​ client's plan of​ care? (Select all that​ apply.) A) The client will remain free of harm or injury to self or others. B) The client will report fewer or no nightmares. C) The client will demonstrate avoidance of situations related to the trauma or general social contacts. D) The client will talk about emotions that are associated with traumatic experiences with at least one counseling professional. E) The client will demonstrate comorbidity that may include​ depression, substance​ abuse, or other anxiety disorders.

A, B, D ​Rationale: General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with PTSD​ include: The client will remain free of harm or injury to self or others. The client will articulate decreased feelings of anxiety. The client will talk about emotions that are associated with traumatic experiences with at least one counseling professional or other mental health care provider. The client will report fewer or no nightmares. The client will articulate awareness of stress reduction techniques that are not pharmacologic. Demonstrating comorbidity or avoidance are clinical manifestations of the​ disorder, and not client goals and outcomes. Next Question

The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a deep venous thrombosis​ (DVT)? (Select all that​ apply.) A) Pale skin color of the left lower leg B) Swelling of the left lower leg C) Muscle twitching of the left thigh D) Aching of the left calf E) Area of redness along a left lower leg vein

A, B, D, E Rationale: Manifestations of DVT include calf​ pain/tightness or​ dull, aching pain in the affected extremity that gets worse with​ walking; possible​ tenderness, swelling,​ warmth, and erythema along the affected​ vein; and edema and cyanosis of the affected extremity. Muscle twitching is not a manifestation of DVT.

The nurse is caring for a client with peripheral vascular disease​ (PVD). Which nursing intervention should the nurse​ implement? (Select all that​ apply.) A) Encourage frequent position change. B) Encourage exercise. C) Keep legs in dependent position during sleep. D) Assess peripheral pulses. E) Keep lower extremities warm.

A, B, D, E Rationale: To evaluate and promote tissue perfusion in the client with​ PVD, the nurse should assess peripheral pulses to ensure adequate​ perfusion, keep lower extremities warm to prevent vasoconstriction associated with cold​ temperatures, encourage exercise to increase circulation to lower​ extremities, and encourage frequent position changes to avoid a decrease in circulation to the lower extremities. The nurse should elevate the legs during sleep and rest. Elevation promotes venous return from the​ extremity, increasing circulation and relieving pain.

The nurse is caring for a client admitted with new onset atrial fibrillation. Which intervention should be included in the plan of​ care? (Select all that​ apply.) A) Monitor for bilateral edema. B) Assess extremities for cyanosis. C) Teach the client to report​ sharp, stabbing pain in calf. D) Elevate the foot of the bed with knees slightly flexed. E) Monitor for tenderness and warmth of bilateral lower extremities.

A, B, D, E ationale: Atrial fibrillation is a risk factor for deep venous thrombosis​ (DVT). Elevating the feet and keeping the knees slightly flexed will prevent venous stasis and decrease the risk for DVT.​ Edema, aching​ pain, warmth,​ cyanosis, and​ tenderness, especially in one lower​ extremity, are signs of DVT.

The nurse is providing discharge teaching about a cardiac diet to a client following a myocardial infarction. Which client statement indicates that the​ nurse's teaching has been​ successful? (Select all that apply.​) A) "I don't like vegetable oil​ spread, so I will seek a different healthy butter​ alternative." B) "I am going to have a roast beef sandwich for​ lunch." C) ​"As soon as I get out of​ here, I'm going to my favorite steakhouse to​ celebrate!" D) "I will continue cooking my food in coconut oil because of its many health​ benefits." E) "I am happy that I​ won't have to give up my almond butter​ sandwiches!"

A, B, E ​Rationale: Clients with coronary artery disease​ (CAD) should reduce their consumption of saturated fats and cholesterol and should increase fiber intake. The goal is to lower the​ client's low-density lipoprotein​ (LDL). Roast beef is a lean cut of meat and therefore is appropriate in moderation. Almonds are high in​ fiber, and almond butter and peanut butter are full of monounsaturated​ fats, which are recommended to be a​ client's source of fat. Coconut oil and red​ meat, like​ steak, are high in saturated fat and should be avoided. Clients should be encouraged to find alternatives to their favorite foods that work with their prescribed diet.

While conducting an​ assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. Which assessment finding led the nurse to this​ conclusion? (Select all that​ apply.) A) A history of atrial fibrillation B) A myocardial infarction 2 years ago C) Controlling type 2 diabetes mellitus with diet and exercise D) Taking​ over-the-counter medication for arthritis E) Treatment for bladder cancer

A, B, E ​Rationale: Risk factors for the development of a DVT include​ cancer, atrial​ fibrillation, and myocardial infarction. Use of​ over-the-counter medication for arthritis and having controlled type 2 diabetes mellitus are not risk factors for the development of this health problem.

The nurse is preparing a bulletin board regarding lifestyle changes to prevent coronary artery disease. Which information should the nurse​ include? (Select all that apply.​) A) Walk for 30 minutes five or six times a week to lower LDL and triglycerides and to raise HDL levels. B) Family history of CAD is a strong indicator for the development of​ heart-related problems. C) Stopping smoking will increase​ high-density lipoprotein​ (HDL) levels and help prevent the development of coronary artery disease​ (CAD). D) During​ menopause, women see a decrease in HDL levels and an increase in​ low-density lipoprotein​ (LDL) levels. E) Diabetes affects the tissue that lines the blood​ vessels, making way for diseases like atherosclerosis.

A, C Rationale: Stopping smoking and walking for 30 minutes several times a week represents modifiable risk factors for CAD. Clients can make lifestyle changes in these areas to decrease their risk for developing CAD. Smoking cessation improves HDL levels and lowers LDL levels and also improves the viscosity of​ blood, so clients should be encouraged to quit smoking. Regular physical exercise lowers very​ low-density lipoprotein​ (VLDL), LDL, and triglyceride​ levels, and it raises HDL levels. Clients are encouraged to participate in 30 minutes of exercise five or six times a week. While understanding about menopause and its associated symptoms is​ important, it is not information that can be used to effectively change the risk of CAD. Family history is not modifiable and cannot help with needed lifestyle changes. Although understanding the effects of diabetes is also​ important, it is not an effect of lifestyle change to decrease the risk of CAD.

When working with a client with peripheral arterial disease (PAD), the nurse assesses for which signs and symptoms that would be consistent with tissue ischemia?Select all that apply. A) Leg pain while walking B) Brownish discoloration to the skin on the leg C) Thickened toenails D) Cooler skin temperature on affected extremity E) Peripheral edema

A, C, D Explanation: Peripheral edema on the affected leg would be consistent with venous disease. Trophic changes from hypoxia and tissue malnutrition in PAD consist of thickened toenails, hair loss on the extremity, and thin shiny skin. Leg pain (also called intermittent claudication) is a primary manifestation of peripheral arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, resulting in tissue hypoxia. Brownish discoloration to the skin on the leg would be consistent with venous disease, while pale colored skin is consistent with arterial disease. Because of insufficient blood supply, expected temperature of the skin of the affected extremity would be cooler than normal.

The nurse is providing care to the victim of a kidnapping that occurred over 1 year ago. Which clinical manifestation supports the diagnosis of posttraumatic stress disorder​ (PTSD) in this​ client? (Select all that​ apply.) A) Flashbacks B) Tremors C) Hypervigilance D) Agitation E) Depression

A, C, D, E Rationale: Agitation,​ flashbacks, depression, and hypervigilance are all clinical manifestations of PTSD that usually emerge within 3 months but may become evident years after the experience. Tremors are not a clinical manifestation of PTSD

The nurse is caring for a client with obsessive-compulsive disorder​ (OCD). Which clinical manifestation would the nurse expect to see in this​ client? (Select all that​ apply.) A) Fear of contamination from touching others B) Happy and overly excited affect C) Signs of fear and increased anxiety D) Thoughts that may be considered taboo E) Repetitive actions or motions

A, C, D, E Rationale: The most frequently reported obsessions in OCD are repeated thoughts about contamination from shaking hands. Repetitive behaviors are a hallmark sign of OCD. Signs of distress or increased anxiety can be seen in clients when they feel compelled to complete rituals. The ritual is the​ client's way of resolving the anxiety. Common themes of the associated​ intrusive, repetitive thoughts include those that are considered by the individual to be forbidden or taboo. A happy and overly excited affect is not a clinical manifestation associated with OCD.

The nurse is planning to teach a client about coronary angiography. Which information should the nurse​ include? (Select all that​ apply.) A) Pressure will be applied to the insertion site after the procedure. B) You will not be able to eat or drink for several hours after the procedure. C) There will be a flushing sensation while the dye is injected during the procedure. D) Pulses on your feet will need to be checked frequently after the procedure. E) You will need to remain in bed with your leg straight after the procedure.

A, C, D, E ​Rationale: A coronary​ angiogram, obtained through a procedure known as cardiac​ catheterization, is a radiographic study of the circulation of the coronary arteries. The client will be on bedrest for up to 8 hours after the procedure with his leg​ straight, and pedal pulses will be checked every 15 minutes following the procedure. There will be a flushing sensation while the dye is injected during the procedure. After the​ procedure, the client will have pressure applied to the insertion site when the sheath is removed. Food and drink are allowed as tolerated.

A client newly diagnosed with heart failure is prescribed​ digitalis, a positive inotropic drug. Which sign and symptom would the nurse instruct the client to report to the healthcare​ provider? (Select all that​ apply.) A) Confusion B) Weight gain C) Vision changes D) Nausea E) Weight loss

A, C, D, E ​Rationale: Digitalis increases the strength of myocardial contraction by increasing intracellular calcium concentrations. It also increases ventricular filling time by decreasing SA node automaticity and slowing the conduction time through the AV node. Since digitalis has a narrow therapeutic​ index, therapeutic levels are very close to toxic levels. Signs of digitalis toxicity include poor​ appetite, anorexia, nausea and​ vomiting, headache, altered​ vision, and confusion. Clients should be instructed to contact their healthcare provider if they experience any of these symptoms. Older adults are at a greater risk for digitalis toxicity than younger clients.

The nurse is performing a nursing assessment for a client with peripheral vascular disease​ (PVD). Which data should the nurse collect during the health​ history? (Select all that​ apply.) A) Current medications B) Presence of skin discoloration C) History of coronary artery disease D) Current diet E) Presence of pain

A, C, D, E ​Rationale: During the health history portion of the nursing assessment for the client with​ PVD, the nurse will assess client history of coronary artery disease​ (CAD), current medications and​ diet, and any complaints of pain. Presence of skin discoloration would be assessed during the physical exam portion of the nursing assessment

The nurse is following up with a client after a diagnosis of prehypertension. Which statement by the client indicates healthy​ coping? (Select all that​ apply.) A) ​"I have reduced my grain intake to​ 6-8 servings per​ week." B) ​"I eat about 3 servings per day of fats and​ oils." C) ​"I get 4-5 servings of fruit every​ day." D) "I take brisk walks with my dog 6 days a​ week." E) ​"I have stopped​ smoking."

A, C, D, E ​Rationale: Lifestyle modifications can stop the progression of prehypertension into primary hypertension. Good modifications include stopping smoking and getting regular exercise at least 5 days a week.​ Also, dietary modifications are​ recommended, such as following the DASH​ diet, which includes 4-5 servings of fruit a​ day, limiting fats and oils to 2-3 servings per​ day, including grain intake of 6-8 servings per day.

The nurse is preparing to encounter a client who has experienced multiple violent assaults during the last month. Which priority should the nurse consider when assessing this client with possible posttraumatic stress disorder​ (PTSD)? (Select all that​ apply.) A) Determine alcohol or drug use. B) Assess for indirect nonprofessional exposure. C) Establish trust. D) Lower client anxiety levels. E) Ensure the safety of the client and others.

A, C, D, E ​Rationale: When assessing a client diagnosed with​ PTSD, the nurse will ensure the safety of the client and​ others, lower the​ client's anxiety​ levels, determine the use of alcohol or​ drugs, and establish trust. Indirect nonprofessional​ exposure, such as observing a terrorist event through electronic​ media, television,​ movies, or​ photographs, is not a factor in the development of PTSD.

A psychotherapist is attempting to increase social interaction for a client with obsessive-compulsive disorder​ (OCD) who performs so many rituals that they are unable to attend any function with friends. Which strategy should the nurse suggest to the client to support the​ effort? (Select all that​ apply.) A) Encourage the client to discuss their anxiety with friends and family. B) Inform the client to take medication doses early to avoid the need for the ritual. C) Suggest inviting friends to a therapy session. D) Teach the client to skip the rituals so that social interaction can occur. E) Devise a time schedule that allows for the ritual to be completed prior to a social event.

A, C, E ​Rationale: As clients progress through​ treatment, nurses can promote social interaction of the client by teaching time management techniques so the client can plan to arrive at social events on time. Encouraging the client to be open with friends about the disorder is another strategy. The nurse may also encourage the client to invite close friends and family to a counseling session so they can be a part of the healing process. Skipping the ritual and altering medication dosages are not acceptable suggestions and may cause harm.

A nurse working in a community health center is developing an educational program for clients who are at risk for heart failure. Which modifiable risk factor should be included in this​ program? (Select all that​ apply.) A) Cigarette smoking B) Age C) Stress D) Race E) Gender F) Obesity

A, C, F ​Rationale: In prevention of​ disease, there are modifiable and nonmodifiable risk factors. Modifiable risk factors are those the client can change or has control​ over, such as​ obesity, stress, and cigarette smoking. These can be achieved by lifestyle changes. Nonmodifiable risk factors are those that the client cannot​ change, such as​ age, gender, or ethnicity.

The nurse is teaching a client about behavioral changes that can affect development of atherosclerosis. The nurse should discuss which risk factors for atherosclerosis that are modifiable?Select all that apply. A) Hyperlipidemia B) Family history C) Female over 55 years of age D) Sedentary lifestyle E) Cigarette smoking

A, D, E Explanation: Age and gender are nonmodifiable risk factors. Hyperlipidemia can be changed by modifying behaviors. This risk factor should be stressed and plans made for how to reduce this risk. Cigarette smoking can be changed by modifying behaviors. This risk factor should be stressed and plans made for how to reduce this risk. Sedentary lifestyle can be changed by modifying behaviors. This risk factor should be stressed and plans made for how to reduce this risk. Family history is a nonmodifiable risk factor.

The nurse is providing care to a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which factor could interfere with the nurse establishing trust during a therapeutic encounter with this​ client? (Select all that​ apply.) A) Depersonalization B) Ineffective coping C) Nightmares D) Hypervigilance E) Aggressiveness

A, D, E Rationale: Clients with PTSD have experienced traumatization and may be physically and emotionally isolated. They may be​ irritable, aggressive, emotionally​ numb, frightened, experiencing​ flashbacks, and on high physical and emotional alert during an appointment with the nurse. They may be reluctant to share their thoughts and feelings and should not be pressured to until they feel ready. These clinical manifestations of PTSD make establishing trust with the client a challenge for the nurse. Nightmares are a clinical manifestation of PTSD that do not take place during therapeutic encounters between the client and nurse. Ineffective coping is a problem that may be included in the nursing plan of care for a client with PTSD.

A​ client's daughter asks how to prevent peripheral vascular disease. Which information should the nurse include as a preventative​ measure? (Select all that​ apply.) A) Quitting smoking B) Starting​ cholesterol-lowering medications C) Starting blood pressure medications D) Maintaining a healthy weight E) Exercising regularly

A, D, E Rationale: Preventative measures for PVD include maintaining a healthy lifestyle​ (ideal weight,​ exercising), smoking​ cessation, and following treatment for chronic illnesses. It is outside of the scope of the nurse to prescribe blood pressure or​ cholesterol-lowering medications. It is also unknown whether this client requires those medications.​ However, blood pressure and​ cholesterol-lowering medications can help slow or reverse the progress of PVD if taken as ordered by a provider.

A client with a diagnosis of deep venous thrombosis is being discharged on warfarin therapy. Which statement should the nurse include in discharge​ teaching? (Select all that​ apply). A) "Use a​ soft-bristle toothbrush." B) ​"If bleeding​ occurs, take your scheduled dose of warfarin and call your healthcare​ provider." C) "You will need to begin taking the warfarin 4 days after stopping the​ heparin." D) ​"Avoid garlic, green​ tea, or gingko supplements while taking​ warfarin." E) ​"Regular follow-up and blood tests will be​ necessary."

A, D, E Rationale: Use of a​ soft-bristle toothbrush will reduce bleeding risk. Regular​ follow-up and blood tests are necessary to ensure the warfarin therapy remains in therapeutic range.​ Garlic, green​ tea, and gingko can increase the risk of bleeding while taking warfarin. Warfarin takes 4-5 days to become effective and should be started before heparin is discontinued. If bleeding​ occurs, the dose of warfarin should be skipped and the healthcare provider notified immediately.

The nurse is teaching a client diagnosed with obsessive-compulsive disorder​ (OCD) on the different therapies that are available for the disorder. Which therapy is appropriate for the nurse to​ include? (Select all that​ apply.) A) Antipsychotic medication B) Hypoglycemic agents C) Herbal​ supplements, such as St.​ John's wort D) Antihypertensive agents E) Cognitive-behavioral therapy

A, E ​Rationale: Cognitive-behavioral therapy is a recommended treatment for OCD to assist the client with learning new coping skills. While not a​ first-line treatment,​ antipsychotics, such as​ risperidone, may be used in the treatment of OCD when the client has not responded to selective serotonin reuptake inhibitors​ (SSRIs). No information is available on the effectiveness of herbal supplements in the treatment of OCD. Antihypertensive agents are not indicated in the treatment of OCD.

The client wants to try complementary health methods to reduce stress. Which therapy should the nurse​ recommend? (Select all that​ apply.) A) Memory games B) Angiotensin II receptor blockers​ (ARBs) C) Physical exercise D) Yoga E) Tai chi

C, D, E ​Rationale: Complementary behavioral and mind-body therapies used to reduce blood pressure in clients with hypertension include​ yoga, tai​ chi, and physical exercise. Memory games are not used to help clients with hypertension reduce blood pressure. ARBs are a type of​ medication, not a complementary behavioral or mind-body ​therapy, used to treat clients with hypertension.

Which laboratory value is most important for the nurse to assess when monitoring therapeutic levels of heparin? A) Clotting time B) Partial thromboplastin time (PTT) C) Prothrombin time (PT) D) Bleeding time

B Explanation: A PT helps to monitor effectiveness of sodium warfarin (Coumadin). A clotting time is not specific enough to be helpful in monitoring heparin therapy. Heparin dose concentration and number of units per milliliter per hour are ordered to maintain a therapeutic PTT. Bleeding time is not specific enough to monitor effectiveness of heparin therapy.

The client presents to the emergency department with substernal crushing chest pain. The doctor orders nitroglycerin (NTG) sublingual to be given. The client asks the nurse what the NTG is for. What is the best explanation? A) An opioid for pain relief B) A vasodilator that works by providing more oxygenated blood flow to the heart C) A neuromuscular blocking agent to reduce the pain D) An antidysrhythmic to treat supraventricular tachycardia

B Explanation: A neuromuscular blocking agent will cause paralysis. Morphine sulfate would be an example of an opioid analgesic for pain of cardiac origin. Nitroglycerin is a vasodilator that dilates the coronary arteries and increases the blood flow to the myocardium, therefore relieving the pain. Antidysrhythmics are used to control cardiac dysrhythmias.

Which medication is likely to be administered on a daily basis to a client newly admitted to the clinical nursing unit who has a history of peripheral arterial disease? A) Heparin B) Aspirin C) Acetaminophen (Tylenol) D) Ibuprofen (Motrin)

B Explanation: Because of the risk for inflammation or a blood clot, low doses of aspirin are recommended for all clients with peripheral vascular disease. Aspirin has antiplatelet activity; without platelet aggregation, a clot cannot form.

A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. What response from the client indicates that the client understands this medication? A) "I will carry my nitroglycerine tablets in the inside pocket of my jacket, so they are always close." B) "I have a small, labeled case for a few nitroglycerine tablets that I carry with me when I go out." C) "Will the physician give me a year's supply of nitroglycerine tablets?" D) "I usually take three of my nitroglycerine tablets at the same time. I find that they work better that way."

B Explanation: Clients should get a new bottle of NTG every six months. Nitroglycerine loses potency over time when exposed to light and heat. The tablets should be kept cool, dry place, and in a dark container. Tablets should be taken five minutes apart; taking more that one tablet at a time can actually decrease the effectiveness of the drug, and can cause severe hypotension. Nitroglycerine loses potency over time when exposed to light and heat. The tablets should be kept cool, dry place, and in a dark container.

The nurse has finished reviewing the shift report on a cardiac unit. The nurse should plan to see which assigned client first? A) A client who is recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 38.3°C (101° F) B) A client taking antibiotics for endocarditis who has sudden dyspnea and anxiety C) A client with hypertrophic cardiomyopathy who is reporting dyspnea D) A client who had a cardiac catheterization and will be ambulating for the first time

B Explanation: Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment but is not the highest priority. However, the client who needs to be assessed for PE is the most emergent. A client who is ambulating for the first time needs to be assessed by the nurse before activity, but this is not the highest priority. However, the client who needs to be assessed for PE is the most emergent. A client with endocarditis is at risk for thrombus formation, and dyspnea and anxiety are signs of pulmonary embolism (PE), which is a life-threatening complication requiring immediate attention. A temperature of 38.3°C (101°F) requires additional assessment but is not the highest priority at this time. However, the client who needs to be assessed for PE is the most emergent.

Early in the development of hypertension, there may be few, if any, pathological changes except intermittent elevations of the systemic blood pressure. This is called which of the following? A) Secondary hypertension B) Labile hypertension C) Essential hypertension D) Normotension

B Explanation: Essential hypertension is an elevated systemic arterial pressure. The disease of hypertension progresses slowly into the vessels, heart, kidneys, and brain. Normotension is a client with a normal blood pressure. Secondary hypertension is an elevated blood pressure associated with several primary diseases.

The nurse devises a teaching plan with the client about management of hypertension. What is the highest priority outcome of this teaching plan? A) Actively monitor the blood pressure (BP). B) Manage medication therapy. C) Identify unawareness of noncompliance. D) Prevent poor compliance.

B Explanation: If the drugs are properly administered, compliance is also maintained, so this is not the most inclusive outcome. If the drugs are properly self-administered, compliance is maintained and so this is not the most comprehensive outcome of the teaching plan. Monitoring BP monthly is an important assessment, but not the highest priority outcome of the teaching plan. Teaching about the antihypertensive drug management will include informing the client about situations that might cause lightheadedness and fainting. These situations would be standing motionless for a prolonged period of time, rising suddenly from a sitting position, or soaking in a hot bath.

The homecare nurse is visiting a client with heart failure. The client denies any changes in the way she feels. The nurse notes that the client has gained 3 pounds in the last week, and the client is concerned about the weight gain. Which would be the nurse's best response? A) "I can't even tell that you gained the weight. Three pounds isn't really a problem." B) "Tell me what medications you took this week." C) "Let's go over your diet for the last week and see if we can plan menus for next week that are lower in fat." D) "What did you eat differently this week?"

B Explanation: In a client with heart failure, a weight gain of 3-5 pounds over a week is a significant indicator of an increase in retained fluid. It is not appropriate to provide false reassurance to a client. The fluid increase indicates that the therapeutic regime is not adequate for this client. It is important for the nurse to ascertain if the client has been taking her prescribed diuretics, and to consult with the primary care provider before the client's fluid overload becomes excessive. Diet alone is not adequate to treat this increase in fluids.

What is the priority intervention the nurse should include when caring for a client with deep vein thrombosis? A) Monitor the client for the degree of discomfort B) Monitor the anticoagulant therapy C) Assess lung sounds D) Elevate the legs to at least a 45-degree angle

B Explanation: Interventions when caring for a client with thrombi include monitoring for pain, elevating the affected leg, assessing for lung sounds to monitor for embolism. The priority intervention is monitoring the anticoagulant therapy. Anticoagulant medications have a narrow therapeutic index and a therapeutic level must be maintained.

The pathophysiology of hypertension is related to which monitoring system? A) Baroreceptors only B) Regulation of the amount of body fluid volume C) Endocrine system D) Underproduction of sodium-retaining substances

B Explanation: One of the factors that regulates blood pressure is the amount of fluid volume within the body system. Excess concentration of sodium and water increases the blood pressure and the pressure in the kidney filtration, resulting in diuresis. The baroreceptors respond to the activity of the receptors as well as pressure and chemical composition within the vascular system. Arterial receptors are also involved (option 1). The endocrine system is usually not involved (option 3). Hypertension causes an increased production of sodium and water releasing hormone (option 4).

A compensatory mechanism in a client with essential hypertension is the development of hypertrophy to increase the work capacity of the left ventricle. Over a long period, however, what can this hypertrophy cause? A) Cardiac tamponade B) Congestive heart failure (CHF) C) Pulmonary embolus D) Myocardial infarction

B Explanation: Pulmonary emboli formation is not a compensatory mechanism. Cardiac tamponade is not a compensatory mechanism. Myocardial infarction is not a compensatory mechanism. As the muscle hypertrophies in order to contract forcefully enough to overcome the high pressure and peripheral vascular resistance, this mechanism eventually requires more oxygenated blood to the heart. The increased workload will cause the heart to "tire out" and congestive heart failure can occur. What was a compensatory mechanism of the heart becomes a complication. The stiffened muscle cannot produce the necessary cardiac output and becomes congested.

Which finding made by the nurse should conclude that an important outcome of care for a client with hypertension has been met? A) Return to usual activities of daily living (ADLs) B) Implements actions to counteract two modifiable risk factors C) Discontinue temporary lifestyle modifications D) Maintain a blood pressure lowered by 10%

B Explanation: Returning to ADLs is not likely to be an issue. An important outcome in care of the hypertensive client is the ability to identify and counteract personal risk factors that the client has the ability to change. Modifiable risk factors for hypertension include smoking, hypercholesterolemia, diabetes mellitus, sedentary lifestyle, obesity, stress, and alcohol use. Lowering BP by 10% may or may not be sufficient. Discontinuing lifestyle modifications is contraindicated because the blood pressure could rise again.

The client reports the foot feels cold after a fall from the bed. Which assessment should the nurse perform after inspection of the foot? A) Palpate for sensation of touch. B) Palpate the pedal pulses. C) Palpate for any bony deformities. D) Percuss the bony prominence.

B Explanation: The assessment of the circulation or potential disruption of the circulation would be a priority in assessment of this client. Palpation to assess disruption of sensorimotor or bone integrity would follow assessment of circulation. Bony prominences are not percussed.

The first priority in assessing a client with thrombophlebitis is: A) Palpation of a pulse. B) Inspection of the lower extremities for swelling. C) Homan's sign because it is reliable. D) Color change and tenderness.

B Explanation: The nurse will assess the lower extremities for swelling. Frequently, measurement of the mid-calf is obtained every eight hours. Homan's sign is considered somewhat unreliable. It is reported that approximately 35% of clients with deep venous thrombosis will have a positive Homan's sign (option 1). The extremity may be reddened in the area of the thrombosis if a superficial vein is involved. The client may or may not report calf tenderness (option 3). A pulse is usually palpable or audible by doppler unless an arterial clot is present (option 4).

The client with intermittent claudication is at risk for activity intolerance and possible tissue breakdown. If tissue breakdown occurs, the plan of care would consist of: A) Walking in comfortable light slippers B) Bed rest C) Range of motion exercises D) Limited exercise

B Explanation: Whenever there is tissue breakdown associated with intermittent claudication, the client will be confined to bed in order to be able to meet the oxygen requirements for the damaged tissues. Activity (options 1, 3, and 4) raises the amount of oxygen required to sustain both healthy and diseased tissues to a point where deficits will occur and healing will be stalled. At the time the client is to be ambulated, the shoe of choice is a supportive, comfortable shoe.

The client reports chest pain after mowing the lawn. This pain is most likely the result of which cause? A) Pericardial effusion of fluid B) Myocardial ischemia C) Pulmonary edema D) Pulmonary emboli

B Explanation:Angina pectoris is the term for chest pain related to myocardial ischemia (not enough oxygen supply to the tissue for the demand). Any activity that increases the need for oxygen without an adequate available supply can cause angina. Pain from a pulmonary embolus would be abrupt in onset and not necessarily related to activity. Prev Next Reset Notes Answer Review Save Exam Grade Exam

Which food selection made by the client with hypertension indicates an understanding of appropriate food choices? A) Nuts B) Milk and oranges C) Carbonated beverages D) Processed foods

B Explanation:The diet of the client with hypertension needs to include the essential amounts of calcium found in milk for neuromuscular irritability, transmission of nerve impulses, skeletal muscle contraction, and clotting. Magnesium in the form of oranges is needed as an important intracellular enzyme system. Also, neither of these foods is high in sodium. Processed foods are generally high in sodium and should be avoided by the hypertensive client (option 1). Carbonated beverages contain either high levels of sodium or potassium (option 2). Nuts are high in phosphorus and sodium. Phosphorus and calcium are in an inverse relationship to each other (option 4). Prev Next Reset Notes Answer Review Save Exam Grade Exam

The nurse is monitoring a client who is undergoing an exercise stress test on a treadmill. Which assessment finding requires the most rapid action by the​ nurse? A) Pulse change from 80 to 92 beats per minute B) ST segment elevation on the electrocardiogram​ (ECG) monitor C) Client complaint of feeling tired D) Blood pressure increase from​ 134/68 to​ 150/80 mmHg

B Rationale: ECG changes such as ST segment elevation are associated with a myocardial infarction​ (MI), indicating that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately. Increases in both blood pressure and heart rate are normal responses to aerobic exercise. Tiredness is also normal.

A nurse is assessing a client and notices pitting edema in the lower legs. The client has a history of mild congestive heart failure​ (CHF), which is controlled with​ medication, and reports that the swelling has become worse lately. Which could the increased edema​ indicate? A) The client has not been compliant with medications. B) The client has a possible progression of CHF. C) The client has been under stress. D) The client has increased physical activity.

B Rationale: Increased edema in a client with known congestive heart failure is common and can indicate a progression of the​ disease, as perfusion is further compromised. A client with increased edema may need medications adjusted or may need to have further lifestyle management. The nurse should encourage compliance and should stress the importance of avoiding foods and activities that could contribute to edema and decreased tissue perfusion.

The client with posttraumatic stress disorder​ (PTSD) states they are experiencing undesirable adverse effects from sertraline​ (Zoloft). Which is the most appropriate response by the​ nurse? A) "Divide the doses in half to decrease the side​ effects." B) "These effects are​ expected, but they should not stop you from continuing your​ medication." C) ​"It is OK to stop any medication that does not agree with​ you." D) You may be overdosing on your​ medication."

B Rationale: Selective serotonin reuptake inhibitors​ (SSRIs) like sertraline have known adverse effects that should be discussed with the client to improve adherence to prescribed pharmacologic treatment. Overdosing is not the cause of adverse effects. Decreasing or stopping medication should not be done without the order from the healthcare provider.​ However, since SSRIs carry a black box warning for increased​ suicidality, the nurse should question the client about experiencing any increase in suicidal ideation and follow up appropriately.

A client is learning about a​ low-sodium diet due to heart failure. Which food does the client select for lunch to demonstrate understanding of a​ low-sodium diet? A) Ham B) Turkey breast C) Shrimp D) Hot dog

B Rationale: The best selection for the client is 3.5 ounces of​ turkey, as it contains between 63 and 76 mg of sodium. A client who has heart failure should not consume more than​ 2,000 mg of sodium per day. A​ 3.5-ounce piece of roasted ham contains approximately​ 1,400 mg of sodium. A hot dog contains approximately 585 mg of sodium. Three ounces of shrimp contains 190 mg of sodium.

The nurse is planning care for the older veteran with posttraumatic stress disorder​ (PTSD). Which understanding should the nurse apply to the care of this​ client? A) The older veteran with PTSD will have significant depression. B) The older veteran with PTSD is at an increased risk of suicide. C) The older veteran with PTSD is likely to be hostile. D) The older veteran with PTSD will report emotional symptoms.

B Rationale: The older veteran with PTSD is at increased risk of suicide compared to a​ middle-aged veteran. The older veteran with PTSD is less likely to be​ hostile, has less​ depression, and complains of somatic issues instead of emotional issues when compared to the younger veteran

The nurse suspects that a client is having a myocardial infarction​ (MI). Which diagnostic test should the nurse anticipate will be​ ordered? A) Brain natriuretic peptide​ (BNP) B) Troponin C) Complete blood count​ (CBC) D) Ankle-brachial blood pressure index​ (ABI)

B Rationale: When the healthcare provider believes that a client has experienced a myocardial infarction​ (MI), diagnostic tests will include cardiac​ markers, including a troponin​ test, which measures the levels of troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged. Additional tests would include a CPK and​ CK-MB and an electrocardiogram​ (ECG). A CBC and BNP will not be useful to confirm the diagnosis of an MI. An ABI tests for peripheral vascular disease that may predict coronary artery disease​ (CAD), so it is not relevant to the diagnosis of an MI.

A client who has been diagnosed with obsessive-compulsive disorder​ (OCD) asks the​ nurse, "What is causing me to be this​ way?" Which response from the nurse is​ accurate? A) "It is caused by ingestion of food preservatives throughout your​ lifetime." B) "The exact cause is unknown but it is thought to be a problem with the way impulses are transmitted in your​ brain." C) The onset of OCD has been linked to childhood​ immunizations." D) "OCD is thought to be caused by damage to your brain during your​ mother's delivery."

B ​Rationale: A malfunction in the​ cortico-striato-thalamo-cortical (CSTC) circuit in the brain is the possible cause for OCD. The neurotransmitters​ serotonin, dopamine, and glutamate are all involved in​ OCD; however, an exact cause is still unknown. There is no association between brain damage during labor and​ delivery, preservatives, or immunizations and OCD.

he nurse is admitting a client to the coronary care unit​ (CCU) and is assessing risk factors for heart failure. What is the most concerning risk​ factor? A) Body mass index​ (BMI) of 18.0 B) Blood pressure of​ 188/122 mm/Hg C) Total cholesterol of 184​ mg/dL D) Influenza

B ​Rationale: Although there are multiple risk factors for heart​ failure, hypertension is a major risk factor because the heart must work harder for effective blood circulation. The BMI and cholesterol labs are within normal limits. Influenza is not a risk factor.

A nurse is evaluating lab results on a​ 70-year-old client. The nurse notices an increased level of brain natriuretic peptide​ (BNP). What does this​ indicate? A) Decreased vascular congestion B) Increased left ventricular pressure C) Decreased gas exchange in lungs D) Reduced cardiac workload

B ​Rationale: Brain natriuretic peptide​ (BNP) is a hormone released by the heart muscle in response to changes in heart muscle and has been shown to correlate with pressures in the left ventricle and the pulmonary vascular system. As heart failure​ worsens, BNP levels​ rise, and as the heart​ stabilizes, BNP levels decrease. Noting the trend of BNP levels provides information about cardiac output and the​ heart's pumping ability. BNP does not measure cardiac workload or gas exchange in the lungs.

The nurse is preparing to administer an initial dose of heparin. Which should be included in the​ client's plan of​ care? A) Assess INR levels daily to ensure therapeutic range is maintained. B) Give a test dose if the client has a history of asthma. C) Keep vitamin K available to reverse the effects of the heparin in case excessive bleeding occurs. D) Administer in conjunction with aspirin therapy.

B ​Rationale: Clients with a history of multiple allergies or asthma should be given a test dose of heparin. It is not appropriate to administer heparin in conjunction with aspirin. INR levels are checked for warfarin. Vitamin K reverses the effects of warfarin.

The nurse is teaching a client about coronary artery disease​ (CAD). Which response by the client indicates the need for further​ teaching? A) ​"Damage to the linings of my arteries can cause clots and​ blockage." B) "It decreases quality of life but does not increase a​ person's risk of​ death." C) "It is a leading cause of death for men and women in the United​ States." D) "The increased levels of​ high-density lipoproteins decrease the risk of​ atherosclerosis."

B ​Rationale: Coronary artery disease is a leading cause of death for men and women in the United States. A lack of oxygenated blood to the coronary arteries will decrease a​ client's ability to function and increase their risk of death.​ High-density lipoproteins attract​ cholesterol, returning it from peripheral tissues to the liver. Endothelial damage causes the body to send platelets to seal the area and leukocytes to fight inflammation. These protective mechanisms also contribute to the formation of fibrous plaque. Fibrous plaque protrudes into the arterial lumen and invades the muscular media layer of the vessel as well as the inner wall of the intima. This results in a decreased ability of the vessel to dilate.

A client is undergoing exposure and response prevention​ (ERP) therapy for obsessive-compulsive disorder​ (OCD). Which would be appropriate as part of this​ therapy? A) Allowing verbalization of feelings in a group setting B) Playing with a dog for 5 minutes a day and increasing exposure each week C) Removing and hiding any objects that may trigger anxiety D) Stopping a ritual when in progress

B ​Rationale: ERP has proven to be most effective for clients with OCD. Using​ ERP, the client is gradually exposed to the object of the​ individual's obsession or fear and is taught healthy methods of coping with the associated anxiety. Stopping a ritual in progress is not a form of ERP and will likely cause more anxiety. Although verbalization of feelings may help a client with​ OCD, this is also not a form of​ ERP, nor is hiding trigger objects.

The nurse is caring for a client who had a total hip replacement 8 hours ago. The nurse should question which​ order? A) Begin early mobilization and leg exercises. B) Keep foot of bed flat and knees straight. C) Begin prophylactic anticoagulant therapy per protocol. D) Apply an intermittent pneumatic compression device.

B ​Rationale: Elevating the foot of the bed and keeping the knees slightly flexed will promote venous return and decrease the risk of DVT. Early​ mobilization, prophylactic anticoagulant​ therapy, compression​ stockings, and pneumatic compression devices are used to prevent DVT.

The nurse taught a client who is diagnosed with hypertension. Which outcome requires an intervention by the​ nurse? A) The client demonstrates the ability to select foods that are low in sodium. B) The client describes when to stop taking prescribed antihypertensive medications. C) The client describes strategies for quitting smoking. D) The client accurately performs blood pressure monitoring and maintains a log.

B ​Rationale: Medications should be taken as prescribed. Hypertension often has no signs or symptoms. The client should be able to verbalize how to quit smoking and how to select foods low in sodium. The client should demonstrate how to take blood pressure and maintain a log.

The mother of a child with posttraumatic stress disorder​ (PTSD) expresses concern that the child is now wetting the bed at night. Which response by the nurse is​ accurate? A) ​"The traumatic event may have damaged the​ child's kidneys." B) "This is an expected manifestation of PTSD that will get resolved with​ treatment." C) ​"Drinking too much before bedtime is likely causing this​ problem." D) "The child should be tested for a urinary tract​ infection."

B ​Rationale: PTSD in children can lead to nocturnal​ enuresis, wetting the bed at​ night, in a​ toilet-trained child.​ Infection, kidney​ damage, and excessive fluid intake are not the primary causes of bedwetting in the child with PTSD.

The nurse is teaching a client about the signs and symptoms of a stroke. Which client statement indicates a need for further​ teaching? A) "One-sided paralysis may be a​ stroke." B) "Increased urge to urinate at night may be a​ stroke." C) ​"Sudden loss of taste or smell may be a​ stroke." D) ​"Sudden loss of vision may be a​ stroke."

B ​Rationale: Polyuria and nocturia are most likely not due to a stroke. Signs and symptoms of a stroke include sudden onset of loss of sensation or movement. This may manifest as​ hemiplegia, hemiparesis,​ flaccidity, spasticity, or loss of the sense of​ vision, hearing,​ taste, touch,​ proprioception, or smell.

The student nurse caring for a client with hypertension is listing interventions related to fluid volume. Which intervention should alert the nurse to​ intervene? A) Weighing the client daily B) Assisting the client set​ short-term goals to reach a realistic target weight C) Assessing intake and output D) Referring the client to a dietician for restricting sodium intake

B ​Rationale: Setting a target weight and​ short-term goals to reach are effective for promoting balanced nutrition but not for maintaining fluid volume. Assessing intake and output is a good implementation for maintaining fluid volume. Bedridden clients can develop sacral edema if the​ client's fluid volume is not balanced. Reducing sodium intake will help the client to maintain fluid volume.

The nurse is discussing treatment options with a client with posttraumatic stress disorder​ (PTSD). The client asks the nurse how the PTSD will be cured. How should the nurse​ respond? A) We will try the therapies that your insurance company covers. B) Treatment and therapies are done with and without medication. C) PTSD will reoccur if you skip group counseling. D) There are medications that can cure PTSD.

B ​Rationale: The client with PTSD will be treated holistically with pharmacologic and nonpharmacologic therapies to obtain the best results. The​ nurse's response would not focus on medication​ alone, therapy​ alone, or concerns over insurance​ coverage, because it is better to avoid them as therapeutic responses.

The nurse is performing an assessment on a​ 57-year-old client with newly diagnosed heart failure. The product of which factors determine a​ client's cardiac​ output? A) Heart rate and urinary output B) Stroke volume and heart rate C) Heart rate and ejection fraction D) Stroke volume and urinary output

B ​Rationale: The correct formula for cardiac output​ (CO) is: CO​ = heart rate​ (HR) x stroke volume​ (SV). To increase blood circulation​ (CO), there needs to be an increased heart​ rate, increased stroke​ volume, or both. Stroke volume is the amount of blood exerted from the left ventricle per beat and can be altered by factors of​ preload, contractility, and afterload.

A client with obsessive-compulsive disorder​ (OCD) tells the nurses about checking the lock 10 times before leaving the house in the morning for work. The​ client's mother does not understand the reason for her​ son's behavior. Which statement from the nurse explains the rationale for this​ behavior? A) "This activity brings him​ pleasure." B.) He does this to help with​ anxiety." C) ​"He thinks this behavior pleases​ you." D) "He feels the need to check the safety of the​ home."

B ​Rationale: The nurse stating that the client behaves in such a way to reduce anxiety explains the rationale. Clients with OCD perform rituals to control intrusive​ thoughts, not to check the safety of the​ home, produce​ pleasure, or to please others.

Which client should the nurse consider to be at highest risk for developing obsessive-compulsive disorder​ (OCD)? A) A spouse with OCD B) A client with a history of sexual assault C) A student with poor school performance D) A client with a history of childhood obesity

B ​Rationale: Risk factors for OCD include having a​ first-degree relative with the disorder​ (so spouse would not​ qualify). A history of childhood sexual or physical abuse also increases the​ risk, as does exposure to other stressful or traumatic events during childhood. Obesity and school performance are not risk factors.

The nurse is assessing a client diagnosed with chronic vascular insufficiency​ (CVI). Which assessment finding should the nurse​ expect? (Select all that​ apply.) A) Excessive hair growth on the legs B) Lower extremity edema C) Cyanosis of lower legs D) Pale skin on lower legs E) Soft subcutaneous tissue on affected areas on leg

B, C Rationale: Manifestations of CVI include lower extremity edema that worsens with​ standing; itching, dull leg discomfort or pain that increases with​ standing; thin,​ shiny, atrophic​ skin; cyanosis and brown skin pigmentation of lower leg and​ foot; possible weeping​ dermatitis; thick, fibrous​ (hard) subcutaneous​ tissue; and recurrent ulcerations of medial or anterior ankles.

The nurse observes an adult client pacing the room and wringing their hands. The client checks the lock on the exam room door 12 times after the nurse enters the room. Which assessment question would be appropriate when evaluating this​ client? (Select all that​ apply.) A) ​"Does anyone in your family suffer from​ depression?" B) "Does this behavior interfere with your daily​ life?" C) ​"How old were you when you first started this​ behavior?" D) "Are you easily​ annoyed?" E) "What would happen if you were​ dead?"

B, C ​Rationale: Appropriate questions for the nurse to include in the assessment of this client includes asking the client when the behavior started and if it interferes with daily life. The other questions are not helpful in evaluating this clien

A home health nurse is caring for a client with peripheral vascular disease​ (PVD). When teaching the client regarding foot and leg​ care, which statement should the nurse​ include? (Select all that​ apply.) A) ​"When swimming, ensure the water is​ cool, not​ warm." B) ​"Apply moisturizing cream to feet and legs​ daily." C) "Dry between your toes after​ showering." D) "Avoid using powder on your​ feet." E) "Buy shoes in the​ morning, when feet are​ largest."

B, C ​Rationale: Foot and leg care for clients with PVD includes applying moisturizing cream to feet and legs daily as well as drying between the toes after showering. The client should use powder on the feet to keep feet dry. When​ swimming, water should be warm because cool water causes​ vasospasm, worsening the​ client's condition. The client should buy shoes in the​ afternoon, when feet are largest. OK

A client who has a strong family history of coronary artery disease asks the​ nurse, "How can I decrease my chances of developing problems with my​ arteries?" Which response by the nurse is​ appropriate? (Select all that​ apply.) A) "There is little you can do except take medication to prevent coronary artery​ disease." B) "A diet high in​ fruits, vegetables, and unsaturated fatty acids may help protect your​ arteries." C) "Keeping your blood pressure within normal levels will decrease the risk of injury to your​ arteries." D) "You can reduce your risk by making some changes in your​ lifestyle, such as moderate​ exercise." E) "As long as your cholesterol is​ normal, your arteries will remain​ clear."

B, C, D ​Rationale: The causes of atherosclerosis are not​ known, but research has shown a connection with modifiable risk factors such as​ cholesterol, triglycerides, lack of​ exercise, smoking,​ obesity, blood​ pressure, diet,​ stress, and diabetes. Elevated cholesterol is only one of the factors that can contribute to the development of plaque in the arteries. Excessive pressures within the arterial system can cause injury to the arterial endothelium. Endothelial damage promotes platelet adhesion and aggregation and attracts leukocytes to the area. Risk factors such as​ age, gender, and heredity cannot be modified. The exact cause is​ unclear, but it is believed that​ fruits, vegetables, whole​ grains, and unsaturated fatty acids have nutrients that help protect the arteries from injury.

The nurse is planning care for client families who are refugees from​ war-torn countries. Which client outcome would be the most appropriate for inclusion in a plan of care for a client with posttraumatic stress disorder​ (PTSD)? (Select all that​ apply.) A) The client will report no change in the occurrence of nightmares. B) The client will articulate decreased feelings of anxiety. C) The client will demonstrate stress reduction techniques. D) The client will remain free of harm or injury to self or others. E) The client will talk about emotions that are associated with traumatic experiences.

B, C, D, E Rationale: Client goals and outcomes should be measurable. In​ addition, client goals and outcomes should be​ client-specific and tailored to meet the​ client's needs. General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with PTSD​ include: The client will remain free from harm. The client will be able to talk about emotions associated with the traumatic experiences. The client will demonstrate stress reduction techniques. The client will verbalize a decrease in anxious feelings. The goal for no change in the occurrence of nightmares is inappropriate. An appropriate goal would be for the client to report a decrease in the occurrence of nightmares.

A client has recently been diagnosed with hypertension. Which intervention should the nurse include in the plan of​ care? (Select all that​ apply.) A) Encouraging the client to reduce smoking B) Assisting the client to set a goal for a healthy weight C) Teaching the client how to adhere to the DASH diet D) Encouraging the client to perform stress reduction techniques E) Teaching the client about the health benefits of regular exercise

B, C, D, E Rationale: The client should be taught to​ stop, not​ reduce, smoking. The client should learn the DASH diet and benefits of regular exercise. The nurse should assist the client to set a realistic​ short-term goal for healthy weight. The client should learn stress reduction techniques.

The nurse is assessing a client who has a possible myocardial infarction​ (MI). Which finding is consistent with this​ diagnosis? (Select all that​ apply.) A) ST segment depression B) Vomiting C) Q wave changes D) Tachypnea E) Anxiety

B, C, D, E ​Rationale: Clinical manifestations of a myocardial infarction ​ (MI) include​ tachypnea, anxiety,​ vomiting, and electrocardiogram​ (ECG) changes in the Q wave. A client experiencing an MI would experience ST segment​ elevation, not depression.

A female client is undergoing diagnostic testing for coronary heart disease. The nurse should assess for which symptoms that are indicative of heart​ disease? (Select all that​ apply.) A) Insomnia B) Chronic fatigue C) Abdominal fullness D) Headache E) Indigestion

B, C, E Rationale: Women may not have chest pain but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal​ fullness, feeling of chronic fatigue despite adequate​ rest, and feeling unable to catch their breath. Insomnia and headache are not indicative of heart disease.

A client presents with​ tenderness, edema, and erythema of a lower extremity. Which diagnostic test should the nurse anticipate being ordered for this​ client? (Select all that​ apply.) A) Magnetic resonance angiography B) Magnetic resonance imaging C) Duplex venous ultrasonography D) Color-flow Doppler ultrasound E) Plethysmography

B, C, E ​Rationale: Duplex venous​ ultrasonography, magnetic resonance​ imaging, and plethysmography are used to diagnose a deep venous thrombosis.​ Color-flow Doppler ultrasound and magnetic resonance angiography are used to diagnose peripheral vascular disease.

The nurse is teaching about how to recognize those at risk for posttraumatic stress disorder​ (PTSD) to begin early intervention. Which scenario should the nurse include as an example to look for in the general​ population? (Select all that​ apply.) A) Clients who have looked at photographs of a war zone B) Clients who have engaged in military combat C) Clients who have been taken hostage and tortured D) Clients who watched a documentary about the terror attack of September 11 E) Clients who have been to prison

B, C, E ​Rationale: To be at risk for​ PTSD, the client must have experienced direct exposure to the traumatic stressor and witnessed it in person. The client can also have had indirect exposure​ (for example, by learning that a close friend or relative was exposed to trauma such as a violent or accidental​ death), or have had repeated or extreme exposure to aversive details of the traumatic event​ (usually through professional​ duties, such as being a first​ responder). Nonprofessional exposure through electronic​ media, television,​ movies, or photographs does not qualify for a diagnosis of PTSD.

A client with venous stasis ulcers is being treated with an Unna boot. Which additional intervention should be in this client's plan of care? Select all that apply. A) Wet to dry dressings to ulcer twice a day B) Assess peripheral pulses C) Encourage standing out of bed as much as possible D) Elevate the legs E) Keep legs dependent

B, D Explanation: Pulses are assessed to ensure adequate circulation with the rigid compression of the Unna boot. Elevating the legs helps promote venous return and is a generally helpful circulatory measure. Dependent position is not necessary to provide comfort. The Unna boot is a rigid dressing that is changed every 1-2 weeks. Excessive standing uses gravity to impede blood return and is not effective.

In providing community education on prevention of peripheral arterial disease (PAD), the nurse should include which major risk factors?Select all that apply. A) Dysrhythmias B) Cigarette smoking C) Exposure to cool weather D) Hypertension E) Low-protein intake

B, D Explanation: The presence of dysrhythmias is not a risk factor for PAD. Intake of a low protein diet is not a risk factor for PAD, although hyperlipidemia from high fat intake or familial tendency is a risk factor. Cool weather is not a risk factor for PAD, although cool weather could worsen symptoms when disease is already present. Cigarette smoking promotes vasoconstriction. The three most significant risk factors for development of PAD are smoking, hyperlipidemia, and hypertension. Hypertension is a major risk factors for development of PAD (others are smoking and hyperlipidemia).

The nurse receives a report on a client with severe obsessive-compulsive disorder​ (OCD) who is triggered by fear of germs. Which teaching should the nurse include in this​ client's plan of​ care? (Select all that​ apply.) A) Validating​ client's concern by providing statistics on secondary inpatient infections B) Explaining the strategies that are implemented in the hospital setting to decrease germ exposure C) Implementing full protective personal equipment for all who enter the room to decrease fear D) Sharing​ client's concern with all involved team members E) Allowing client to view healthcare workers performing hand hygiene prior to entering room

B, D, E Rationale: The nurse should include any measures that would help minimize the​ client's fears and would allow the client to have less anxiety. Explaining the precautions that are implemented for all​ clients, allowing the client to see these​ implemented, and ensuring that all team members are aware of the strategies may all help to reduce anxiety and fear. Providing statistics that validate the​ client's concerns would likely add to the anxiety. Full protective personal equipment would be unnecessary and costly.

The nurse is planning care for the combat veteran with posttraumatic stress disorder​ (PTSD). Which nursing intervention should the nurse​ include? (Select all that​ apply.) A) Limit contact with the client to reduce the occurrence of compassion fatigue. B) Improve client coping through nonpharmacologic and pharmacologic therapies. C) Remove the family from therapy so the client can focus on health. D) Reduce client​ harm, anxiety, and fear. E) Connect clients with resources for​ social, occupational, and interpersonal support

B, D, E ​Rationale: Appropriate nursing interventions for clients with PTSD aim to reduce and eliminate client​ harm, anxiety, and​ fear, and improve client​ coping, using nonpharmacologic and pharmacologic therapies. Nursing interventions also aim to connect clients and families with organizations and community resources that can provide longer term​ social, occupational, and interpersonal support. The family should be involved and included in resources for support. Compassion fatigue should be recognized but not avoided through decreasing contact with clients.

The nurse is working with a child suspected of having posttraumatic stress disorder who has been removed from the home because of neglect. Which manifestation may the nurse observe with the young child that conveys a message about the traumatic​ event? (Select all that​ apply.) A) Crying B) Drawing C) Jumping D) Dreaming E) Playing

B, E ​Rationale: Young children with posttraumatic stress disorder often recreate a traumatic event by playing and drawing.​ Jumping, dreaming, and crying do not give a coherent message.

The client presenting with angina pain in the emergency department states, "I thought I was having a heart attack." Which response by the nurse would provide the client with the most accurate information about the difference between the pain of angina and that of myocardial infarction? A) "The intensity of pain with a heart attack indicates the amount of muscle damage." B) "The pain associated with angina is much more intense than that of a heart attack." C) "The pain of angina is usually relieved by resting or lying down." D) "The pain associated with a heart attack radiates up the jaw and that of angina radiates down the arm."

C Explanation: Angina pectoris is pain related to insufficient oxygen supply to meet the workload demands of the heart. If the workload demand is decreased (as in rest), the pain goes away. Option 1 may be correct but is not usually the case; option 2 is incorrect. In option 3, a CPK-MB level indicates the amount of muscle damage.

The nurse is caring for a client who just had a cardiac catheterization. The client insists on getting up to go to the bathroom to urinate immediately when he is brought back to his room. What would be the nurse's best response? A) "The doctor has ordered that you stay on bedrest for the next six hours. It is important that you follow these orders." B) "You can't walk yet. You might be too weak after the procedure, and may fall." C) "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications." D) "If you get out of bed, you could have an arrhythmia from the catheterization. Your heart has to rest after this procedure."

C Explanation: Although weakness could be a risk for a fall, this does not assist the client to understand the basis for care restrictions. Bedrest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. Explaining the rationale to the client is the best way to facilitate the client's cooperation. Although dysrhythmias are possible after the procedure, this does not assist the client to understand the basis for care restrictions. Repeating an order does not assist the client to understand the basis for care restrictions.

Which is the first priority of care in the management of a client with thrombophlebitis? A) Elevation of the client's legs which are supported by elastic bandages from toes to groin. B) The use of warm packs and a sedative. C) Using anticoagulant therapy with heparin (Liquaemin). D) Monitoring effect of anticoagulant therapy every 36 hours by using the partial thromboplastin time (PTT).

C Explanation: Anticoagulant therapy is started early to prevent the extension of the thrombus or the possible embolization of the thrombus. All options are correct but anticoagulant therapy is the highest priority. Elevation of the client's legs is a comfort measure, and the elastic bandages will provide support to the extremity. The client's heel must be included in the wrap. These bandages are to be applied snuggly and rewrapped every 4 to 8 hours. They must be inspected frequently as they may become dislodged. The use of warm packs and a sedative is not beneficial for the client. The monitoring of the PTT will be done every 6 hours.

Frequently, the client with chronic, untreated hypertension will have an ophthalmoscopic examination. The findings will be reported as: A) Microaneurysms. B) Cupping of the optic disc. C) Ocular changes in the fundi. D) No red reflex.

C Explanation: As hypertension progresses untreated, the fundi of the eye will demonstrate changes. These include a) minimal vascular changes in the early stage; b) irregular appearance of arterioles; c) changes progressing to attenuation of retinal vessels with retinal hemorrhage; and d) attenuation of retinal vessels with disc swelling in the late stage. Microaneurysms are seen in clients with diabetes mellitus (option 2). No red reflex is seen in clients with a completely opaque lens (option 3). Cupping of the optic disc is seen in a client with glaucoma (option 4).

The client is in the clinic for a follow-up visit following new onset of stable angina. The nurse should teach the client precipitating causes of angina, such as exercise and stress. How should the nurse instruct the client to handle these precipitating causes? A) Perform such activities anyway. B) Avoid these activities. C) Use a nitroglycerin (NTG) tablet before the activity. D) Lead a sedentary lifestyle.

C Explanation: NTG can be taken as a preventive measure prior to activities that trigger angina. This is especially helpful with sexual activity or work-related activities that may need to be continued. Modifying such activities may be necessary, but cardiac clients should not become restricted by their condition and lead sedentary lifestyles.

The nurse is caring for a client who recently was admitted to the intermediate care unit with a myocardial infarction (MI). The nurse is most concerned about achieving which client outcome? A) The client will maintain a balanced intake and output. B) The client will have a normal sinus rhythm. C) The client will be pain-free. D) The client will ambulate in the room without fatigue.

C Explanation: Pain usually is the first presenting sign of new or extended MI, which is a very serious complication for this client. Activity orders for a client immediately post-MI usually is bedrest or commode privileges. Although an important client outcome is to be free from life-threatening dysrhythmias, clients frequently have benign dysrhythmias after an MI, and many are not in normal sinus rhythm. Maintaining a balanced intake and output is important, but not as critical as remaining pain-free.

The nursing management for a client with thrombophlebitis would include: A) Using low molecular weight heparin (LMWH) once a confirmed diagnosis exists. B) Elevating the head of the bed 6 inches on wooden blocks. C) The use of anticoagulant therapy to inhibit the clotting factors. D) Keeping the client's legs in a position of comfort.

C Explanation: Part of the medical regime will include anticoagulant therapy. The rationale for this is to prevent the development or extension of thrombi by inhibiting the synthesis of the clotting factors or through deactivation of the mechanism. The client's legs need to remain in an elevated position for comfort and to facilitate venous circulation to prevent the development of emboli and thrombi in the lower extremities (option 2). Low molecular weight heparin (LMWH) is usually used as a preventative agent in clients prone to thrombophlebitis, not as a treatment with a confirmed diagnosis (option 3). The treatment is usually to raise the foot of the bed 6 inches off the floor (Trendelenburg's position). The knee level needs to remain in this position 24 hours per day until the healthcare team considers the need for elevation of the legs no longer exists (option 4). The head of the bed may be elevated for activities such as eating and bathing.

The client was admitted with a diagnosis of right ventricular failure. If the client's condition were to worsen and go into biventricular failure, which symptoms would the nurse expect to find? A) 3+ pitting edema in the legs B) Jugular neck vein distention C) Rales and rhonchi D) Decreased urine output

C Explanation: Rales and rhonchi are not characteristic of right heart failure (RHF). All the others are classic signs and symptoms. If the client entered with RHF and develops left heart failure (LHF), pulmonary complications would develop.

The client has a follow-up visit after discharge from the hospital for an acute myocardial infarction. The client explains that when he walks, he sometimes notes that his pulse is slightly irregular. The monitor confirms a slightly irregular rhythm with no ectopic beats and all the characteristics of a normal sinus rhythm. The nurse explains this to the client as which of the following? A) A condition that must be treated with medication. B) A very serious condition that must be addressed by the physician. C) A normal variation that occurs in some people and is frequently associated with deep breathing. D) A condition that reflects a decreased oxygen supply to the myocardium.

C Explanation: Sinus arrhythmia is a normal variant related to increased intrathoracic pressure (vagus stimulation) as seen with deep inspiration and expiration. It is a benign arrhythmia that requires no treatment.

Which method should the nurse use to obtain data from an adult client with a possible diagnosis of hypertension? A) Blood pressure from both arms taken 5 minutes apart B) Blood pressure from one arm only C) Orthostatic blood pressure with 2 minutes between each reading D) Cuff and doppler blood pressure in both arms

C Explanation: This data will not provide enough data to determine if a problem exists. Blood pressure readings from three different positions are helpful in ruling out the presence of hypertension. The difference between each of these readings should be less than 5 mmHg. If the reading difference is higher, repeat readings should be within the follow-up plan for this client.

The nurse is planning to teach a client how to lower her cholesterol level. Which instruction should the nurse​ include? A) Practicing smoking cessation B) Participating in stress reduction C) Eating a diet low in saturated fat D) Exercising occasionally

C Rationale: Elevated cholesterol is closely related to cardiovascular disease. The body manufactures​ 85% of the cholesterol found in the body. The other​ 15% comes from the diet. The American Heart Association recommends eating a diet low in fat to maintain normal cholesterol levels. The client can lower cholesterol and the risk of cardiovascular complications by eating a diet that is low in saturated fats. Aerobic exercise 5 days a week is recommended to lower blood pressure and cholesterol. Smoking is not directly linked to hypertension.​ However, smoking is closely linked to cardiovascular disease. In​ addition, smoking can interfere with some antihypertensive medications. Smoking cessation does not lower cholesterol. Stress is known to cause vasoconstriction because of the release of hormones.​ However, stress reduction alone will not reduce cholesterol levels.

The nurse is caring for a client with hypertension who has been noncompliant with the treatment plan and has gained weight. Which response should the nurse say to the​ client? A) "Why are you not following the treatment​ plan?" B) "Let me share with you the importance of following the treatment​ plan." C) ​"You have gained weight since the last​ follow-up." D) ​"Because you have been unable to lose​ weight, we will need to add more medications to your treatment​ plan."

C Rationale: Stating facts without judgment will open the client up to discussion. Asking why the client is not following the treatment plan is confrontational. The client probably already knows the importance of following the treatment plan. It is more important to determine why the client has gained weight. This is also more important than simply adding medications.

The nurse is teaching a client about best practices in managing symptoms of coronary artery disease. Which client statement suggests that the​ nurse's teaching has been​ successful? A) "Ibuprofen will help to increase blood flow to my​ heart." B) ​"I will stop taking Lipitor every day in order to decrease my​ cholesterol." C) "I will take salicylic acid every day to increase blood flow to my​ heart." D) ​"I should take a pain reliever every day for my chest​ pain."

C Rationale: To increase the​ client's blood​ flow, one goal is to prevent the aggregation of platelets in the arteries. Salicylic acid​ (aspirin) is a pharmacologic measure to control the aggregation. Statins such as atorvastatin​ (Lipitor) are used to decrease cholesterol and would be a part of the​ client's protocol unless the client experienced side effects. Analgesics are not given for chest pain since they do not increase blood flow. Nitrates for angina would increase blood flow. Ibuprofen is not recommended to increase blood flow to the coronary arteries.

The nurse explains to a high risk client that which is the most common cause of a thrombus? A) Arterial stasis, hypocoagulability, and arterial wall injury B) Motor vehicle accident and prolonged bed rest C) Venous stasis, hypercoagulability, and venous wall injury D) Myocardial infarction, stroke, and prolonged sitting

C xplanation: These are known as Virchow's triad and are the most commonly associated reasons for a blood clot. A thrombus usually involves the venous, not arterial, system. Situations that contribute to venous stasis are myocardial infarction and prolonged sitting; however, a stroke is not classified in this manner. These are known as Virchow's triad and are the most commonly associated reasons for a blood clot. Injury may or may not cause thrombi, while continued bed rest can contribute.

A client diagnosed with obsessive-compulsive disorder​ (OCD) tells the nurse about having feelings of apprehension that are alleviated through frequent hand washing. The​ client's hands are red and​ swollen, and the nurse notes several areas of excoriation. Which nursing diagnosis is the priority for this​ client? A) Sleep​ Pattern, Disturbed B) Anxiety C) Skin​ Integrity, Impaired D) Coping, Ineffective

C ​Rationale: Based on the assessment​ findings, diagnosis of Skin​ Integrity, Impaired is a priority for the nurse. Sleep​ Pattern, Disturbed;​ Anxiety; and Coping​, Ineffective are appropriate nursing diagnoses for a client with​ OCD, but they are not a priority for this client.​ (NANDA-I © ​2014)

The nurse is talking to a client with peripheral vascular disease​ (PVD) who reports using biofeedback as a complementary therapy. The nurse knows this serves which purpose for​ PVD? A) Decreasing arterial plaque buildup B) Reducing stress C) Improving peripheral circulation D) Lowering overall cholesterol

C ​Rationale: Biofeedback is used to improve peripheral​ circulation; biofeedback does not reduce plaque buildup. Exercise and a change in diet can reduce overall cholesterol and slow the progress of PVD. Many alternative therapies are used to reduce​ stress, but that is not a main function of biofeedback.

The nurse is evaluating the goal established for a client with peripheral vascular​ disease, "The client will learn appropriate foot and wound​ care." Which outcome demonstrates goal​ achievement? A) The​ client's leg ulcer is showing signs of healing. B) The client informs the nurse that the wound is improving C) The client demonstrates proper wound care techniques to the nurse. D) The​ client's leg wound shows no signs of infection.

C ​Rationale: Client goals are​ measurable, specific,​ realistic, and achievable. The client verbalizing proper wound care demonstrates goal achievement. The ulcer showing signs of healing and​ improvement, and no signs of infection are medical outcomes.

The nurse is teaching a client with coronary artery disease about the therapeutic lifestyle changes​ (TLC) diet. Which client statement indicates that more teaching is​ needed? A) ​"I will switch from whole milk to​ 2% milk." B) "I will be able to have a glass of red wine with​ dinner." C) ​"I will miss having avocado slices on toast for​ breakfast." D) ​"I will use olive oil to cook with instead of​ butter."

C ​Rationale: Even though 25-​35% of a​ person's daily calorie consumption should come from​ fat, the TLC diet recommends monounsaturated fats as a​ person's source of fat. These are found in​ nuts, olive​ oil, avocado, and canola oil. Avocados are high in monounsaturated​ fat, so the client does not have to give up avocados. Switching to​ lower-fat milk is indicated for this​ client, as is using olive oil to cook instead of butter. There is research that indicates a benefit to consuming moderate alcohol on the TLC diet.

A client at 27​ weeks' gestation is diagnosed with deep venous thrombosis. Which collaborative therapy should the nurse​ anticipate? A) Prescription for warfarin therapy B) Immediate emergency cesarean section C) Prescription for heparin therapy D) Increased risk of hemorrhage after delivery

C ​Rationale: Heparin therapy is considered safe during pregnancy because heparin does not cross the placenta. Warfarin does cross the placenta and may cause congenital​ malformations; therefore, it is contraindicated during pregnancy. An emergency cesarean section is not indicated with the information provided. Even if the client is on heparin​ therapy, there is not an increased risk of hemorrhage after deliver

A nurse is teaching a client with suspected peripheral vascular disease​ (PVD) about segmental pressure measurements. Which statement should the nurse include in the​ teaching? A) ​"We need to do this before surgery to locate and evaluate the blood​ clot." B) "If you have​ PVD, the BP in your legs will drop further during​ exercise." C) "If you have​ PVD, your BP may be lower in your legs than your​ arms." D) ​"This uses sound waves reflected off red blood cells to look at blood​ flow."

C ​Rationale: Segmental pressure measurements use a Doppler and sphygmomanometer to compare BPs in the upper and lower extremities. In​ PVD, the BP in the legs will be lower than in the arms. A Doppler uses sound waves that reflect off of RBCs to evaluate blood flow. Angiography is done before revascularization surgery to locate and evaluate the extent of the arterial obstruction. A stress test measures pressures in the lower extremities during exercise

The nurse is assessing an adolescent foster child diagnosed with posttraumatic stress disorder​ (PTSD). Which question is most beneficial for the nurse to ask the adolescent with​ PTSD? A) ​"Are you napping during the​ day?" B) "Are you wetting the bed at​ night?" C) "Have you had thoughts of hurting​ yourself?" D) ​"Do you know what year it​ is?"

C ​Rationale: The adolescent with PTSD is at an increased risk for​ suicide, and reduction of harm is a priority for the client with PTSD. Mental orientation should be performed with the older adult client. A​ follow-up question about napping may be asked to assess​ sleep, but it does not take precedence over suicide and​ self-harm. Bedwetting should be assessed in a child with PTSD.

The nurse is teaching a client who is diagnosed with obsessive-compulsive disorder​ (OCD) about medication therapy. Which statement should the nurse​ include? A.) You will definitely need to take these medications for the rest of your​ life." B) "The medications have no side​ effects, so you​ don't have to worry about that." C) "The medication will be continued for 1-2 years before we check to see if the OCD is​ resolved." D) "If you take these​ medications, you will not have to meet with a​ psychologist."

C ​Rationale: The medication should be continued for 1-2 years before gradually tapering while observing for symptom exacerbation. Although SSRIs are generally prescribed and have fewer side effects than some other​ medications, all drugs have side effects that the client needs to be aware of. Pharmacologic therapy is used in conjunction with psychotherapy. Next Question

Which client reaction should the nurse expect during a coronary artery​ spasm? A) Gradual increase in systolic blood pressure B) Acute reduction in level of consciousness C) Sudden onset of acute chest pain D) Gradual increase in peripheral edema

C ​Rationale: The nurse should expect a sudden onset of acute chest pain from a coronary artery​ spasm, which is characteristic of Prinzmetal​ angina, in which there is an acute reduction in coronary blood flow. An acute reduction in level of consciousness indicates neurologic involvement. A gradual increase in peripheral edema is a sign of heart failure. A gradual increase in systolic blood pressure can have multiple causes.

The nurse is caring for a client in law enforcement diagnosed with posttraumatic stress disorder​ (PTSD). Which finding in the​ client's health history places the client at risk for this​ disorder? (Select all that​ apply.) A) Experiencing difficulty sleeping B) Adult-onset diabetes mellitus C) Preexisting mental illness D) Losing a job after a traumatic event E) Witnessing the death of a friend

C, D, E Rationale: Risk factors for developing PTSD include preexisting mental​ illness, direct exposure to a traumatic event such as witnessing a​ death, and experiencing loss after a traumatic event. Difficulty sleeping is a clinical manifestation of​ PTSD, not a risk factor. A concurrent diagnosis of diabetes mellitus is not a risk factor for PTSD.

The nurse is describing obsessive-compulsive disorder​ (OCD) and cultural differences to a community support group. Which statement should the nurse​ include? (Select all that​ apply.) A) "Religious differences do not play a role in development of​ OCD." B) Members of minority groups are more likely to receive treatment for​ OCD." C) "The prevalence rate and many manifestations of OCD in many populations are similar to those experienced by Caucasian​ Americans." D) "The majority of clinical studies on OCD show that the majority of studies focus on Caucasian​ Americans." E) "African Americans and Hispanics are underrepresented in many clinical studies on​ OCD."

C, D, E Rationale: Studies on differences among cultures are​ limited, and many groups are underrepresented in clinical studies on OCD. Prevalence rates and manifestations of OCD in non-Caucasian American populations are thought to be similar to those experienced by Caucasian Americans. Members of some groups are less likely to be treated due to socioeconomic factors as well as the stigma associated with a mental health condition. Individuals who adhere to religions that practice rituals may be more likely to develop OCD.

Which statement should the nurse expect to hear from a client with posttraumatic stress disorder​ (PTSD)? (Select all that​ apply.) A) "I'm a​ high-stress person. I feel content most of the​ time." B) "I feel very optimistic and positive about the future and what I can​ accomplish." C) ​"I can't remember the last time I enjoyed​ myself." D) "There is no one I can really talk to. I​ don't feel close to​ anyone." E) "I have trouble sleeping at night and​ don't feel rested in the​ morning

C, D, E ​Rationale: Clients with PTSD experience​ recurrent, involuntary, and intrusive​ memories, traumatic​ nightmares, and flashbacks. They have negative alterations in cognition and mood that began or worsened after the traumatic event. Examples are an inability to experience positive emotions and persistent blame of self or others for causing the trauma or its consequences. Clients may have trouble sleeping and may become emotionally numb or have trouble with​ affection, impairing their relationships. Clients with PTSD typically do not express feelings of optimism and contentment.

The nurse is caring for a client recently diagnosed with peripheral vascular disease​ (PVD). Which intervention should the nurse teach the​ client? (Select all that​ apply.) A) Encourage wearing​ knee-high compression stockings. B) Avoid walking or standing to allow the legs to rest. C) Elevate the legs when asleep or resting. D) Avoid crossing the legs when in a sitting position. E) Put on​ above-the-knee elastic hose with the legs elevated.

C, D, E ​Rationale: Nursing interventions for PVD include elevating the legs when resting or​ asleep, avoiding crossing the legs or putting pressure on the back of the​ knees, and putting on hose after the legs have been elevated. The client should be encouraged to walk as much as possible. Compression hose should be above the knee and tighter over the feet than the top of the leg.

A client has been diagnosed with secondary hypertension. Which condition should the nurse expect to find in the​ client's medical​ history? (Select all that​ apply.) A) Lupus B) Asthma C) Pregnancy D) Kidney disease E) Diabetes

C, D, E ​Rationale: The conditions that can cause secondary hypertension include pregnancy after 20 weeks of​ gestation, diabetes, and kidney disease. Asthma and lupus are not known to cause secondary hypertension.

A 6-month-old infant is receiving digoxin (Lanoxin) and furosemide (Lasix) for congestive heart failure. The nurse who is evaluating the effectiveness of furosemide would monitor which of the following?Select all that apply. A) Hemoglobin and hematocrit levels B) Partial pressure of oxygen C) Intake and output D) Daily weight E) Pulse rate

C,D Explanation: Furosemide is a diuretic, so measurements that most directly illustrate output and water loss would be evaluated. With this in mind, intake and output and daily weight would be key assessment parameters, as they typically and accurately reflect fluid balance. Hemoglobin level measures the iron content of red blood cells. The pulse can be influenced by many variables. Partial pressure of oxygen is measured via arterial blood gases and is unrelated to the question.

The early stage of left ventricular failure would most likely result in which client changes? A) Low pulmonary pressure B) Diminished left atrial pressures C) Right ventricular failure D) Higher pulmonary pressures

D Explanation: Left ventricular failure results in inability to empty the pulmonary vascular system leading to increased pulmonary pressures.

Adolescent and young adult women are at a greater risk for thrombosis. Which accurately explains one reason for the increased​ risk? A) Increased incidence of sepsis B) Prematurity at birth C) Increased blood volume and pressure in the bilateral lower extremities D) Use of contraceptives containing estrogen and progestin

D ​Rationale: Estrogen in contraceptives or in hormone replacement therapy increases the risk for thrombosis. Prematurity at​ birth, increased risk of​ sepsis, and increased blood volume and pressure do not explain why women have a greater risk for thrombosis.

The client admitted for an acute myocardial infarction (MI) is getting ready for discharge. The client is anxious to go home and states, "I have so much work to do around the house." The nurse instructs the client on the need for rest periods, especially if beginning to feel chest discomfort. What is the rationale for rest in treatment of acute myocardial infarction? A) Decrease the heart rate B) Negative tourniquet test C) Decrease the peripheral vascular resistance D) Reduce the workload of the heart

D Explanation: Although a slower heart rate can decrease workload and oxygen demand, rest does not necessarily lower the heart rate. Decreased workload of the myocardium leads to decreased oxygen demand. Rest periods allow the demand to equal the supply. This is indicated for hypertension. This is indicated for congestive heart failure.

Evidence that the outcome of "restore tissue integrity" has been met in a client with a venous stasis ulcer includes which finding? A) Absence of bleeding B) No reports of pain C) Increased activity tolerance D) No signs of inflammation or infection

D Explanation: A goal of venous ulcer care is for the client to experience no signs of inflammation or infection. This is the goal that is directly related to tissue integrity. The other options are good outcomes but do not relate directly to the question as stated.

The client is being discharged from the hospital and needs discharge teaching. An important measure the nurse should teach the client to prevent reinfarction following a myocardial infarction (MI) would include: A) Reduction in cigarette smoking B) Heavy exercise such as high-intensity aerobics C) Thrombolytic therapy D) Low-fat, low-sodium diet

D Explanation: A low-fat, low-sodium diet aids in the reduction of cholesterol and/or triglycerides that could have caused the MI. A client who has had an MI should not participate in heavy exercise; a moderate exercise program with daily walking would be sufficient. Anticoagulant therapy with aspirin, not thrombolytics, may be recommended, and clients with an MI should stop smoking completely.

A client is taking digoxin (Lanoxin) and furosemide (Lasix) for heart failure. Which menu choice made by the client would indicate an understanding of dietary restrictions? A) Pizza with pepperoni B) Grilled cheese sandwich and French fried potatoes C) Eggs and ham D) Chicken with baked potato and cantaloupe

D Explanation: A prudent diet would be high in potassium because digoxin and furosemide both can deplete potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart failure. Chicken, potato, and cantaloupe are all potassium-rich foods. A prudent diet would be high in potassium because digoxin and furosemide both can deplete potassium. The diet needs to be low in sodium to prevent additional fluid overload with heart failure. These items are higher in sodium.

The nurse would plan to do which intervention as the most effective measure to reduce the risk of developing deep vein thrombosis (DVT)? A) Active range of motion (ROM) B) Repositioning every two hours C) Passive ROM D) Ambulation as soon as possible

D Explanation: Active range of motion prevents joint contractures but is not the most effective way to reduce the risk for DVT. Passive range of motion prevents joint contractures but is not the most effective way to reduce the risk for DVT. Bedrest and immobility are risk factors for the development of deep vein thrombosis. Early ambulation assists venous return to the heart because of muscle movement against veins, and should be implemented as soon as possible in hospitalized clients. Repositioning is helpful in relieving pressure on skin, but may not be the most effective against developing DVT.

Which client would the nurse identify to be at high risk for thrombophlebitis? A) 72-year-old male with a history of arthritis and bypass surgery B) 25-year-old male who is a smoker with hypertension C) 22-year-old female with a history of Raynaud's disease in the family D) 67-year-old overweight female recovering from a hip replacement (1st day post-op)

D Explanation: An overweight client on bed rest from a hip surgery is at higher risk because of the two risk factors (obesity and immobility). Even though the client will be ambulated and progressively increase weight-bearing, the potential exists because of the immobility. HTN does not increase the risk, nor does smoking (option 1). Raynaud's is not a factor (option 3); option 4 is vague about the cardiac history and further information is needed.

Which client assigned to the nurse is most at risk for developing a deep vein thrombosis (DVT)? A) A 63-year old client post-CVA on anticoagulant therapy. B) A 30-year old client who is 1-week postpartum. C) A 41-year old female who underwent laparoscopic cholecystectomy. D) A 40-year old woman who smokes and uses oral contraceptives.

D Explanation: Being 1-week postpartum does not place a client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent development of thrombi. A major risk factor for DVT is oral contraceptive use in women who smoke. Laparoscopic surgical procedures are associated with more rapid recovery times with reduced immobility, keeping this client at lower risk for DVT.

Secondary hypertension (HTN) is an elevated blood pressure caused by a number of underlying physiological processes. Which statement about secondary HTN is correct? A) Hypertension with an endocrine disorder accounts for a large population of clients. B) A nonsystematic, short-term use of contraceptives containing estrogen can cause HTN. C) Coarctation of the aorta has little to no relationship with the renin-angiotension-aldosterone system of the kidney. D) Hypertension in pregnancy is a frequent cause for maternal and fetal morbidity and mortality.

D Explanation: By definition, secondary hypertension has some underlying cause. Approximately 10% of all pregnant women develop this condition. The criteria are that the systolic blood pressure rises 30 mmHg and the diastolic blood pressure rises 15 mmHg prior to the 20th week of gestation. Diagnostic tests are conducted to confirm the diagnosis and rule out polycythemia, hyperaldosteronism, and pheochromocytoma. The systematic long-term use of contraceptives containing estrogen may contribute to secondary hypertension (option 1). Coarctation of the aorta is rare; when it occurs, it interferes with the renal blood flow, which stimulates the renin-angiotension-aldosterone system of the kidney (option 2). Endocrine disorders and hypertension are rare and involve the adrenal medullary system (option 4).

After a pediatric client has a cardiac catheterization, which intervention would the nurse consider to be of highest priority during the immediate post-procedure period? A) Monitor the site for signs of infection. B) Teach the parents signs of congestive heart failure. C) Encourage intake of small amounts of food. D) Apply direct pressure to entry site for 15 minutes

D Explanation: Food intake is a lesser concern than maintaining hemostasis. Signs of congestive heart failure could relate to the original disease process but are not a priority at this time. Infection would not be apparent immediately following the procedure. Direct pressure on the wound site helps to form a clot and reduce bleeding. Hemorrhage can be life-threatening in the immediate post-procedure period.

The medical management of thrombophlebitis is through the use of anticoagulant therapy. The nurse will determine the effectiveness of heparin therapy by assessing which of the following? A) Prothrombin time (PT) B) Glutamate pyruvate transaminase (GPT) C) Fasting blood sugar (FBS) D) Partial thromboplastin time (PTT)

D Explanation: GPT is a liver enzyme and will not be affected by heparin. The PT is used to monitor Coumadin therapy. The PTT is used to monitor the level of heparin so that a therapeutic dose may be administered. The FBS is used to monitor the blood glucose levels.

The nurse is planning to instruct a client on the side effects of nifedipine (Procardia) for hypertension. Which side effect should the nurse include? A) Hypokalemia B) Tachycardia C) Bleeding D) Dizziness

D Explanation: Hypoaklemia is not a side effect of calcium channel blockers. Calcium channel blockers relax arterial smooth muscle, which lowers peripheral resistance through vasodilation. Dizziness is a common side effect due to orthostatic hypotension. Clients need to be taught to change position slowly to prevent falls. Bleeding is not a side effect of calcium channel blockers. Tachycardia is not a side effect of calcium channel blockers.

The nurse assessing a client with obsessive-compulsive personality disorder (OCD) anticipates that most of the client's cognitive content will be centered around which of the following? A) Relationships with others B) Global approaches to problem solving C) Preferred leisure activities D) The importance of rules and regulations

D Explanation: Individuals diagnosed with obsessive-compulsive personality disorder become overly involved in details such as rules and regulations related to a need to be perfect. Individuals diagnosed with obsessive-compulsive personality disorder do not have a global approach to problem-solving because they are excessively focused on details and often fail to see the "big picture." For those diagnosed with obsessive-compulsive personality disorder, relationships with others is less important than devotion to work and productivity. For those diagnosed with obsessive-compulsive personality disorder, participation in leisure activities is less important than devotion to work and productivity.

The client demonstrates significant Q waves on the electrocardiogram (ECG). The nurse should notify the physician because this is indicative of which of the following? A) Ischemia B) Infection C) Gangrene D) Infarction

D Explanation: Infarction (heart attack) is the term for tissue that has been deprived of oxygen leading to cellular death. Immediate attention should be given to the client who has just had a myocardial infarction (MI), which is noted by Q waves on an ECG.

The client is experiencing shortness of breath, productive cough, tachycardia, and orthopnea. Based on these symptoms, which disorder would the nurse expect to find in the client's medical record? A) Hypertension (HTN) B) Coronary artery disease (CAD) C) Peripheral vascular disease D) Left ventricular failure

D Explanation: Left ventricular failure causes pulmonary congestion and increased pressure in the lungs, which leads to tachycardia. Remember Left and Lung—the two Ls go together; two of the symptoms deal with respiratory symptoms and none of the other answers are related to a diagnosis affecting the lungs.

The client in the coronary care unit, status post-anterior myocardial infarction (MI), has been diagnosed with heart failure. A pulmonary artery (PA) catheter has been placed. The PA pressure is 30/15 mmHg and the client has mild crackles. The nurse concludes that the client is experiencing which of the following? A) Both right and left-sided failure B) Right-sided heart failure C) Pulmonary edema D) Left-sided heart failure

D Explanation: Left-sided heart failure produces increased pulmonary congestion and therefore elevated pulmonary artery pressures. A normal PA is 25/10 mmHg. Pink, frothy sputum and exaggerated symptoms would be present for pulmonary edema to be diagnosed. Right-sided heart failure includes signs of peripheral edema.

The client admitted with right-sided heart failure was treated with diuretics, with decreased edema on the second day. On day 3, the client has a relatively normal head-to-toe assessment at 8:00 A.M. when the nurse made rounds. Around 10:00 A.M., the nurse aide reports the client is having trouble breathing and the respirations are 42 and labored. The nurse assesses the client has marked crackles and rhonchi; an S3 heart sound; and frothy, pink sputum. What does the nurse suspect? A) Return of right-sided heart failure B) Development of mild left-sided heart failure C) Tamponade D) Pulmonary edema

D Explanation: Marked crackles, rhonchi, S3 heart sounds, and frothy sputum (frequently pink from being blood-tinged) are classic pulmonary edema characteristics.

Frequently, sodium consumption and substance abuse are linked to hypertension. How would the nurse describe these factors to a client when teaching about hypertension? A) Gender risk factors B) Personal choice risk factors C) Nonmodifiable risk factors D) Modifiable risk factors

D Explanation: Nonmodifiable risk factors are those that are not changeable, such as family history, gender, and ethnicity. Personal choice risk factors is not a commonly used phrase. Gender risk factors are a subgroup of the nonmodifiable risk factors. When reviewing the risk factors that are listed, both sodium consumption and the use of substances may be modified if the client desires to participate in a lifestyle change.

The nurse teaching a client how to manage risk factors in coronary artery disease would include which modifiable risk factor? A) Postmenopausal syndrome B) Gender C) Father died of acute myocardial infarction at age 63 D) Total Cholesterol level of 290 mg/dL

D Explanation: Postmenopausal syndrome (female gender and age) is nonmodifiable but is a risk factor nevertheless. Emphasis should always be placed on modifiable risks. Gender is nonmodifiable but is a risk factor nevertheless. Emphasis should always be placed on modifiable risks. Family history is nonmodifiable but is a risk factor nevertheless. Emphasis should always be placed on modifiable risks. Normal total cholesterol is less than 200 mg/dL. Emphasis should always be placed on modifiable risks.

The nurse provides discharge instructions to the client with severe hypertension. Which client statement indicates that teaching has been effective? A) "It means my blood pressure is 140/90 mm Hg." B) "There's no real way to treat it." C) "It is corrected by not taking my usual medication." D) "Signs and symptoms include blurred vision and headache."

D Explanation: Signs and symptoms of hypertensive crisis include headache and blurred vision. A crisis is a blood pressure greater than 180/120 mm Hg. It can be caused by abruptly stopping antihypertensive medication. Treatment includes vasodilator medications.

The priority intervention in the plan of care for a hypertensive client with excess fluid volume includes which intervention? A) Assessing the client for signs of dependent edema. B) Teaching the client the importance of following the treatment plan. C) Teaching the client about low-sodium diets. D) Monitoring the intake and output of fluids carefully for each shift.

D Explanation: Teaching the client about the treatment plan is important but is not the highest priority. When the client has a diagnosis of fluid volume excess, monitoring all fluids is important. Failure to monitor the client places him or her at risk for further complications, such as pulmonary edema and congestive heart failure. The client needs to know about a low-sodium diet and appropriate food selection. This is correct but is not the highest priority. Assessing the client for signs of dependent edema is important but intake and output of all fluids is higher.

The client with a diagnosis of anterior myocardial infarction (MI) begins to show dysrhythmias on the monitor. Which most likely predisposes the heart to dysrhythmia development with a myocardial infarction? A) Respiratory alkalosis B) Hypokalemia C) Digitalis toxicity D) Tissue ischemia

D Explanation: The ischemia that causes the MI can also cause the heart muscle to become irritable and irritated cells fire early, causing dysrhythmias. Although hypokalemia and digoxin toxicity are true, nothing in the stem indicates that these are specific to this client. Acidosis is usually the shift with MI, if one occurs.

A client is being treated for new-onset heart failure with a sodium-controlled diet, digoxin (Lanoxin), and furosemide (Lasix). The ECG monitor shows a new U wave. Based on this new finding, the nurse determines that it is important to check which laboratory test result? A) Calcium B) Sodium C) Magnesium D) Potassium

D Explanation: The sodium level is unrelated to this finding. A side effect of digoxin and furosemide is that they promote the excretion of potassium, and a U wave is a sign of hypokalemia. The calcium level is unrelated to this finding. The magnesium level is unrelated to this finding.

Which client has the greatest risk of developing a thromboembolism? A) A client with known kidney disease B) A female client who is Jewish C) A 20-year-old client D) A client with a cardiac disease

D Explanation: Thromboembolism generally occurs in clients over the age of 40. Cardiac diseases such as congestive heart failure, myocardial infarction, and cardiomyopathy are conditions that coexist with thromboembolism. Each condition creates the possibility of thromb occurring because of ineffective emptying of the heart during contraction. Gender usually does not play a role in embolism; a male who is Jewish and over the age of 40 is more prone to Buerger's disease. Kidney disease has not been identified as a cause of emboli.

What would the nurse notice in order to distinguish venous insufficiency from arterial insufficiency? A) Warmth to the calf B) Red skin appearance C) Severe pain D) Pulses

D Explanation: Warmth usually indicates inflammation and possible thrombophlebitis. The skin appearance is brown with a venous stasis and cyanotic when placed in a dependent position. The level of pain the client is reporting is usually a mild, achy pain with venous insufficiency. The pulses with a venous insufficiency are normal or decreased; however, the pulses for an arterial ulcer are diminished or absent.

The nurse is caring for a mildly obese older adult client with coronary artery disease. Which action should the nurse take to encourage additional physical activity in this​ client? A) Telling the client that older adults should exercise no more than 15 minutes at a time B) Telling the client that moderate exercise can lead to 2 pounds of weight loss per week C) Teaching the client to warm​ up, stretch, and cool down before and after all physical activities D) Asking the client what kind of exercise or activities she likes to do

D Rationale: Clients are more likely to be motivated to increase physical activities that they already like to​ do, so the nurse should ask about their preferences. The benefits of weight loss should be emphasized instead of how much weight will be​ lost, especially in an​ older, obese client. Older adults should get 30 minutes of moderate activity on most​ days, and they should always​ stretch, warm​ up, and cool down before and after activity.

A nurse is caring for a client with stage IV heart failure. Which nursing diagnosis would be a priority​? A) Knowledge, Deficient B) Cardiac​ Output, Decreased C) Activity Intolerance D) Fluid​ Volume: Excess

D Rationale: Compensatory mechanisms are activated in heart​ failure, specifically neuroendocrine responses. The cascade of decreased cardiac output and decreased renal perfusion stimulates the​ renin-angiotensin system, which stimulates the release of aldosterone from the adrenal cortex and ADH from the posterior pituitary. ANP and BNP are released and blood flow is redistributed to the heart and brain. As a​ result, there is salt and water retention by the kidneys and water excretion is​ inhibited, causing pulmonary​ congestion, renal vasoconstriction and decreased renal​ perfusion, and increased preload and afterload. According to​ Maslow's Hierarchy of​ Needs, oxygenation is the priority need for a client in stage IV heart​ failure, and therefore Fluid​ Volume: Excess is the priority​ diagnosis, since oxygenation is compromised with fluid overload in the lungs. The second one would be Cardiac​ Output, Decreased​, then Activity Intolerance and ​Knowledge, Deficient. ​(NANDA-I ©​ 2014)

The nurse is assessing a client who is ambulating after a myocardial infarction. Which finding indicates that the client is able to tolerate more​ activity? A) Oxygen saturation changes from​ 99% to​ 93%. B) Blood pressure changes from​ 120/60 to​ 218/68 mmHg. C) Respiratory rate changes from 14 to 26 breaths per minute. D) Heart rate is consistent at 77​ beats/min during exercise.

D Rationale: If the​ client's heart rate changes by more than 20 beats over the resting heart​ rate, this indicates that the client should stop and rest. Because the​ client's heart rate only increased moderately from the resting heart​ rate, there is no need to stop. After an acute myocardial infarction​ (AMI), a​ client's level of exercise should be increased as tolerated. The increases in the blood pressure and breathing​ rate, and the decrease in O2 saturation are normal during​ exercise, but excessive changes could mean that the client is not tolerating the activity.

The nurse is evaluating a client who has been treated for obsessive-compulsive disorder​ (OCD). Which outcome would indicate the treatment is​ successful? A) Performs the same ritual with the same frequency but states that it is not interfering with life. B) States that no coworkers suspect that the client has OCD. C) States that the client applies lotion frequently to hands to treat skin irritation. D) Demonstrates an ability to effectively perform expected family functions.

D Rationale: The ritualistic behaviors and shame associated with OCD often interfere with the ability of the client to perform normal​ roles, including​ family, home, and work responsibilities. The ability to function successfully in these roles suggests that treatment is successful. If the client is continuing to perform rituals and hide​ behaviors, more therapy is indicated. Next Question

An elementary school nurse is assessing a child for behaviors of obsessive-compulsive disorder​ (OCD). Which finding should alert the nurse to consider as a​ symptom? A) Sits alone at lunchtime. B) Has difficulty concentrating in class. C) Refuses to comply with uniform rules. D) Expresses extreme fear that his parents will die.

D Rationale: Young children are often not diagnosed with OCD until they reach prepubescence because they lack the ability to articulate their fears. A common fear is that of a natural disaster or of losing parents. Sitting alone at​ lunchtime, difficulty​ concentrating, and refusing to cooperate with rules are not characteristic behaviors of children with OCD.

The nurse teaches a client about medications used in the treatment of obsessive-compulsive disorder​ (OCD). Which client statement indicates appropriate understanding of the teaching​ session? A) ​"I will have to take medication for the rest of my​ life." B) "Medications are not effective in the treatment of​ OCD." C) "There are no side effects associated with this​ medication." D) "I may only have to take medication for 1-2 years and gradually be weaned​ off."

D ​Rationale: Clients with a successful medication regimen may be on therapy for 1-2 years and then be tapered off the medication while observing for symptom exacerbation. Client response will determine whether the client needs to be on medications for​ short-term or​ long-term use. All medications have side​ effects, and clients should be taught about the side effects. Medications are effective in the management of OCD.

A nurse is implementing comfort measures for a client with class IV heart failure. What position is best for client​ comfort? A) Supine B) Prone C) Left lateral D) ​High-Fowler

D ​Rationale: Clients with class IV heart failure are very dyspneic. The best placement would be the​ high-Fowler position to facilitate lung expansion and gas exchange. The other positions would not facilitate comfort.

A client with heart failure is being discharged home with his wife. What is the priority goal for this​ client? A) To walk 5 miles per day B) To lose 2 pounds every wee C) To consume a​ high-salt diet D) To not gain more than 5 pounds in a week

D ​Rationale: Clients with heart failure should be on a​ no-salt diet due to fluid retention. Walking 5 miles per day is not a safe or appropriate goal for a client with heart failure. Losing 2 pounds per week is not an appropriate​ goal, as the client could become fluid deficient. Gaining 2-3 pounds in 24 hours or 5 or more pounds in a week is not an appropriate goal for a client with heart failure and must be​ re-evaluated by a healthcare provider.

A client is admitted to a medical unit with a diagnosis of congestive heart failure. The​ client's wife requests no physical therapy for the client because it​ "makes him​ tired." What is the​ nurse's most appropriate​ response? A) ​"I'll make a note in the chart that he is refusing physical​ therapy." B) ​"That will only make him worse in the long​ run." C) "Don't worry—our physical therapists will be​ careful." D) ​"Moderate exercise is important to maintain his overall​ health."

D ​Rationale: Family members may worry if a client has activity intolerance. They may discourage any activity and try to do everything for the client. The nurse should provide information and support to families while encouraging as much activity for the client as tolerated. The family should be given encouraging information about optimizing heart function and​ perfusion, without being falsely reassured or have their concerns belittled. Assisting the client and family with activity tolerance optimizes perfusion and overall homeostasis.

The school nurse is a guest speaker in a high school health class talking about coronary artery disease​ (CAD). Which statement by the nurse is most beneficial to include in the​ presentation? A) "If you eat healthy foods you can keep the levels of fat in your bloodstream​ low, which will minimize your risk of​ CAD." B) "It is much better to learn to prevent​ CAD, rather than to pay for the related treatments and​ surgeries." C) ​"CAD is the leading cause of death in both men and​ women, which means that all of you are at​ risk." D) "Some of the things that you can do now to minimize your risk of CAD are avoid fatty​ food, be​ active, and do not​ smoke."

D ​Rationale: In this​ case, it is important for the nurse to highlight the changes that are most easily achievable by the high school audience. Although excess lipids in the bloodstream can contribute to the development of​ CAD, it is not enough to say that eating healthy foods will keep lipid levels low.​ Further, high school students are unlikely to be convinced by the cost of CAD care. Telling students that they are all at risk is also unlikely to motivate them to be proactive in avoiding CAD. By warning high school students about their predispositions to the disease and advising them of the modifications they can make to avoid​ it, the audience is much more likely to be receptive to the information.

The nurse working at a dementia unit is assessing an older adult client for obsessive-compulsive disorder​ (OCD). Which factor warrants further​ evaluation? A) Is demanding of healthcare assistants B) Recently lost a spouse C) Has several other medical conditions D) Constantly complains about general aches and pains

D ​Rationale: Older adults are more likely to report their physical complaints and avoid discussing their mental complaints. Preexisting medical​ conditions, grief, and demanding behavior are not suggestive of OCD.

The nurse is completing a physical assessment on a client with edema and pooling of blood in the veins of the lower extremities. The nurse suspects the diagnosis of chronic venous insufficiency. Which additional assessment finding should the nurse expect to​ observe? A) Cool feet and toes B) Gangrene C) Absent pedal pulses D) Skin hyperpigmentation

D ​Rationale: Symptoms of chronic venous insufficiency include edema of the lower extremities and hyperpigmentation of the skin of the feet and ankles. Absent​ pulses, cool skin on the feet and​ toes, and gangrene are signs of an arterial​ problem, not a venous problem.

The nurse is evaluating a client who​ states, "I usually walk 30 minutes every​ morning, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop​ walking, though." Which action should the nurse do first​? A) Ask the client about skin color changes. B) Notify the healthcare provider. C) Discuss benefits of daily exercise. D) Assess the posterior tibial and pedal pulses.

D ​Rationale: This client is describing symptoms of intermittent claudication. The nurse should assess the strength and equality of peripheral pulses to determine perfusion. Changes in skin color are important but not the priority. The nurse should complete the assessment before contacting the healthcare provider or discussing the benefits of daily exercise.

The nurse is giving a presentation regarding the pathologic factors that may lead to the formation of a thrombus. Which participant statement indicates a need for further​ teaching? A) "Hypercoagulability is a pathologic factor associated with a​ thrombus." B) "Circulatory stasis can lead to the formation of a​ thrombus." C) "Vascular damage is a pathologic factor associated with a​ thrombus." D) An active lifestyle can lead to the formation of a​ thrombus."

D ​Rationale: Virchow's triad is named for the three pathologic factors associated with the formation of a​ thrombus: circulatory​ stasis, vascular​ damage, and hypercoagulability. An inactive lifestyle​ (not an active​ lifestyle) can lead to circulatory stasis and thrombus formation

A nurse is teaching a client about digitalis and dietary considerations. Which food should the nurse​ recommend? A) Potato chips B) Low-fat milk C) Green leafy vegetables D) Bananas

D ​Rationale: When taking​ digitalis, low potassium levels​ (hypokalemia) increase the risk of digitalis toxicity. Bananas are high in​ potassium, while​ low-fat milk, green leafy​ vegetables, and potato chips are low in potassium. Clients should be given a list of​ high-potassium foods, scheduled to have their digitalis levels checked​ frequently, and instructed to call with any symptoms of digitalis toxicity.

The nurse is teaching a client who is newly diagnosed with hypertension. Which client statement requires an intervention by the​ nurse? A) ​"I will take my blood pressure every morning and write it in the​ log." B) ​"I will stop​ smoking." C) ​"I will decrease the sodium in my diet by adding herbs instead of salt to my​ food." D) "I will begin doing aerobic exercises for 60 minutes every​ day."

D ​Rationale: While aerobic exercises are recommended at least 5 days a​ week, the client should start slowly. Stopping​ smoking, taking blood pressure daily and​ recording, and decreasing the sodium in the diet are all good lifestyle modifications