unit 2

The nurse is providing teaching to the parents of a preschool-age client who is prescribed iron supplements for iron-deficiency anemia. Which parental statements indicate the need for further education? Select all that apply. 1 "We will mix the iron with milk to enhance absorption." 2 "We will mix the iron with black tea to enhance absorption." 3 "We will mix the iron with orange juice to enhance absorption." 4 "We will avoid giving our child green tea because it can decrease absorption." 5 "We will avoid feeding our child tomatoes because it can decrease absorption."

1 "We will mix the iron with milk to enhance absorption." 2 "We will mix the iron with black tea to enhance absorption." 5 "We will avoid feeding our child tomatoes because it can decrease absorption." Milk contains phosphorus and black tea contains tannins, both which decrease the absorption of iron. Orange juice increases the acidity of the stomach, which enhances absorption. Green tea and tomatoes (an oxalate) are avoided as both will decrease the absorption of iron.

Which clinical finding does the nurse anticipate regarding the alveoli in the lungs of a 28-week-gestation neonate? 1 They have a tendency to collapse with each breath. 2 There usually is a sufficient supply of pulmonary surfactant. 3 Although apparently mature they cannot absorb adequate oxygen. 4 Oxygen is not released into the circulation because they overinflate.

1 They have a tendency to collapse with each breath. Alveolar collapse occurs because of a lack of pulmonary surfactant to overcome surface tension in the alveoli. Surfactant is present in sufficient amounts when the birth is closer to term. Fetal alveoli mature closer to term, around 35 to 36 weeks. Rather than overinflating, the alveoli tend to collapse and may stay collapsed, resulting in atelectasis.

A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. What does the nurse conclude is the probable cause of the severe dyspnea? 1 Abdominal distention or pressure 2 Bronchial obstruction or pleural effusion 3 Fluid retention as a result of renal failure 4 Anxiety associated with pain on inspiration

2 Bronchial obstruction or pleural effusion Proliferation of malignant cells may obstruct the bronchial tree or foster development of exudate in the pleural space, decreasing the availability of oxygen and increasing retention of carbon dioxide. A tumor of the lung does not cause abdominal distention or pressure. Fluid retention as a result of renal failure is not associated with cancer of the lung. Although anxiety associated with pain may increase the respiratory rate, it will not cause difficulty with breathing.

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain? 1 Polycythemia 2 Cor pulmonale 3 Compensated acidosis 4 Left ventricular failure

2 Cor pulmonale A sudden weight gain is an initial sign of right ventricular failure caused by COPD. Polycythemia is associated with polycythemia vera, not COPD. A sudden weight gain is not associated with compensated acidosis. Right, not left, ventricular failure [1] [2] occurs with COPD.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1 Fatigue related to weight loss secondary to COPD 2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation

2 Imbalanced nutrition: less than body requirements, related to fatigue The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

pH

7.35-7.45

PaO2

80-100 mmHg

SaO2

93-100

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that a. all patients with elevated BP require medication. b. obese persons must achieve a normal weight to lower BP. c. it is not necessary to limit salt in the diet if taking a diuretic. d. lifestyle modifications are indicated for all persons with elevated BP.

d. lifestyle modifications are indicated for all persons with elevated BP.

A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d. sudden onset of severe headache.

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively to bring secretions to the mouth.

d. teach the patient how to cough effectively to bring secretions to the mouth.

A priority consideration in the management of the older adult with hypertension is to a. prevent primary hypertension from converting to secondary hypertension. b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear? 1 Snorting sounds during the inspiratory phase 2 Moist rumbling sounds that clear after coughing 3 Musical sounds more pronounced during expiration 4 Crackling inspiratory sounds unchanged with coughing

2 Moist rumbling sounds that clear after coughing Coarse rhonchi [1] [2], particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD and usually clear with coughing. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished? 1 Neutral pressure in the pleural space 2 Negative pressure in the pleural space 3 Atmospheric pressure in the thoracic cavity 4 Intrapulmonic pressure in the thoracic cavity

2 Negative pressure in the pleural space Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

How does the nurse explain physiologic anemia to a pregnant client? 1 Erythropoiesis decreases. 2 Plasma volume increases. 3 Utilization of iron decreases. 4 Detoxification by the liver increases.

2 Plasma volume increases. There is a 30% to 50% increase in maternal plasma volume at the end of the first trimester, leading to hemodilution and a decrease in the concentrations of hemoglobin and erythrocytes. Erythropoiesis increases after the first trimester. Iron utilization is unrelated to the development of physiologic anemia of pregnancy. Detoxification demands are unchanged during pregnancy.

A 30-month-old toddler is brought to the emergency department in acute respiratory distress, and a diagnosis of laryngotracheobronchitis (viral croup) is made. What is the most important equipment for the nurse to have available when the child is admitted to the pediatric unit? 1. Intravenous set 2. Tracheotomy set 3. Nasal cannula for oxygen 4. Crib with padded side rails

2. Tracheotomy set A patent airway is the priority. A tracheotomy set should be kept immediately available in case of complete obstruction of the airway. An intravenous setup may be needed later if the child does not respond to treatment. Humidified mist, not oxygen, is the treatment of choice unless the child does not respond to the treatment. Padded side rails are appropriate for seizures, which are not associated with croup.

HCO3

22-26 mEq/L

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? 1 "Lately I can only breathe well if I sit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up larger amounts of thicker mucus for the last several days."

3 "I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.

A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? 1 Change in level of consciousness 2 Increased pain 3 Increased respiration 4 Decreased heart rate

3 Increased respiration Naloxone is given for decreased respirations caused by opioid overdose. The amount given is determined by the respiratory status, not the level of consciousness. Undesirable side effects of naloxone are pain and rapid heart rate with dysrhythmias.

What is the priority nursing management for a client in myasthenic crisis? 1 Performing plasmapheresis 2 Administering intravenous atropine 3 Maintaining adequate respiratory function 4 Administering intravenous immunoglobulins

3 Maintaining adequate respiratory function The priority nursing management of a client with myasthenic crisis is maintaining adequate respiratory function to promote gas exchange. Plasmapheresis is used as a short-term management of an exacerbation, but it is not the priority nursing intervention. Atropine is administered after maintaining adequate respiratory function. Intravenous immunoglobulins are administered as a long-term option for disease refractory to other treatment.

A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to do what? 1 Hold the breath while spraying the medication into the mouth. 2 Position the lips loosely around the mouthpiece and take rapid, shallow breaths. 3 Seal the lips around the mouthpiece and breathe in and out, taking slow, deep breaths. 4 Inhale the medication from the nebulizer, remove the mouthpiece from the mouth, and then exhale.

3 Seal the lips around the mouthpiece and breathe in and out, taking slow, deep breaths. Sealing the lips around the mouthpiece ensures that medication is delivered on inspiration; slow, deep breaths promote better deposition and efficacy of medication deep into the lungs. The breath should not be held; a nebulizer treatment delivers medication by inhaling it into the mouth through a mouthpiece. Positioning the lips loosely around the mouthpiece may allow room air to be inhaled, which will dilute the aerosolized medication; rapid, shallow breaths mainly will deposit medication in the oral cavity and will not effectively deliver medication deep into the lung. Inhaling the medication from the nebulizer, removing the mouthpiece from the mouth, and then exhaling allows valuable aerosolized medication to be deposited into the air when the client removes the mouthpiece from the mouth to exhale; the client will not receive the full dose of aerosolized medication.

PaCO2

35-45 mmHg

A nurse teaches a client about Coumadin and concludes that the teaching is effective when the client agrees not to drink which juice? 1 Apple juice 2 Grape juice 3 Orange juice 4 Cranberry juice

4 Cranberry juice Antioxidants in cranberry juice may inhibit the mechanism that metabolizes warfarin, causing elevations in the international normalized ratio, resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

The nurse is caring for a child with spasmodic croup. The nurse knows that which symptom requires immediate nursing intervention? 1 Irritability 2 Hoarseness 3 Barking cough 4 Rapid respiration

4 Rapid respiration Rapid respiration may be a sign of impending airway obstruction. Unless irritability is accompanied by severe restlessness, symptomatic care should be given. Unless accompanied by signs of respiratory embarrassment, hoarseness needs no immediate intervention. A barking cough may sound ominous, but it is not a sign of respiratory compromise, as is rapid respiration.

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern does the assessment include? 1 Value-belief pattern 2 Role-relationship pattern 3 Cognitive-perceptual pattern 4 Self-perception-Self-tolerance pattern

4 Self-perception-Self-tolerance pattern The nurse is applying Gordon's Self-perception-Self-tolerance pattern to assess the client. This functional pattern describes the client's self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client's choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.

When caring for a patient with acute bronchitis, the nurse will prioritize a. auscultating lung sounds. b. encouraging fluid restriction. c. administering antibiotic therapy. d. teaching the patient to avoid cough suppressants.

a. auscultating lung sounds.

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

a. depression. d. sleep disturbances. e. denial of severity of stroke.

In a severely anemic patient, the nurse would expect to find a. dyspnea and tachycardia. b. cyanosis and pulmonary edema. c. cardiomegaly and pulmonary fibrosis. d. ventricular dysrhythmias and wheezing.

a. dyspnea and tachycardia.

When assessing activity-exercise patterns related to respiratory health, the nurse inquires about a. dyspnea during rest or exercise. b. recent weight loss or weight gain. c. ability to sleep through the entire night. d. willingness to wear O2 equipment in public.

a. dyspnea during rest or exercise.

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism

a. Alveolar macrophages

A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategy(ies) would be most appropriate for this patient (select all that apply)? a. Measuring hourly urine output b. Decreasing the MAP by 50% within the first hour c. Continuous BP monitoring with an arterial line d. Maintaining bed rest and providing tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

a. Measuring hourly urine output c. Continuous BP monitoring with an arterial line e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Medication will be required because the BP is still not at goal. b. BP monitoring should continue for another 3 months to confirm a diagnosis of hypertension. c. Lifestyle changes are less important, since they were not effective, and medications will be started. d. More vigorous changes in the patient's lifestyle are needed for a longer time before starting medications.

a. Medication will be required because the BP is still not at goal.

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding

a. Patient with seizures b. Patient with head injury e. Patient who is receiving nasogastric tube feeding

Which BP-regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)? a. Release of norepinephrine b. Secretion of prostaglandins c. Stimulation of the sympathetic nervous system d. Stimulation of the parasympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

a. Release of norepinephrine c. Stimulation of the sympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

a. Thoracentesis Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier.

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood. e. overall balance of electrolytes in arterial blood.

a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply) a. instructions for high-iron diet. b. taking vital signs every 8 hours. c. monitoring stools for occult blood. d. teaching self-injection of erythropoietin. e. administration of cobalamin (vitamin B12) injections.

a. instructions for high-iron diet. c. monitoring stools for occult blood.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis. e. administration of IV iron and diet high in iron content.

a. monitoring CBC. b. optimal pain management and O2 therapy. c. blood transfusions if required and iron chelation. d. rest as needed and deep vein thrombosis prophylaxis.

To promote the release of surfactant, the nurse encourages the patient to a. take deep breaths. b. cough five times per hour to prevent alveolar collapse. c. decrease fluid intake to reduce fluid accumulation in the alveoli. d. sit with head of bed elevated to promote air movement through the pores of Kohn.

a. take deep breaths.

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply. a. Weight loss b. Extreme fatigue c. Coughing at night d. Excessive urination e. Difficulty breathing

b. Extreme fatigue c. Coughing at night e. Difficulty breathing Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur. Auscultation reveals crackles and rhonchi. Dyspnea is associated with pulmonary edema that occurs as cardiac output decreases and pulmonary congestion increases. Weight gain, not loss, occurs as fluid is retained by the kidneys. Fluid retention, not diuresis, occurs because of decreased circulation to the kidneys, resulting from decreased cardiac output.

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.

b. apprehension and restlessness.

When auscultating the chest of an older patient in respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.

b. begin listening at the lung bases.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about a. folic acid intake. b. dietary intake of iron. c. a history of gastric surgery. d. a history of sickle cell anemia.

b. dietary intake of iron.

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. a low-calcium diet. b. excessive alcohol intake. c. a family history of hypertension. d. consumption of a high-protein diet.

b. excessive alcohol intake.

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared.

A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. increased CO2 and decreased O2 in the blood. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. decrease in intrathoracic pressure relative to pressure at the airway.

d. decrease in intrathoracic pressure relative to pressure at the airway.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? a. Cyanosis b. Bradycardia c. Mental confusion d. Distended neck veins

c. Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

c. Weak, irregular pulse and poor muscle tone

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

c. arterial oxygen partial pressure.

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c. assisting the patient to stand to void.

Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet. b. increase in retrograde venous blood flow in the legs. c. decrease in arterial blood flow to the nerves of the feet. d. constriction in arterial blood flow to the leg muscles during exercise.

c. decrease in arterial blood flow to the nerves of the feet.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. O2 content of the blood. c. degree of collateral circulation. d. level of CO2 in the blood.

c. degree of collateral circulation.

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

c. increased residual volume. d. diminished lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c. left middle cerebral artery.

A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the HCP of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.

c. notify the HCP of the change in peripheral perfusion.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c. patency of the cerebral blood vessels.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.

A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that must be modified are a. weight and diet. b. activity level and salt intake. c. tobacco use and high blood pressure. d. sedentary lifestyle and exercise training.

c. tobacco use and high blood pressure.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-yr-old Native American. b. 35-yr-old Asian American woman who smokes. c. 32-yr-old white woman taking oral contraceptives. d. 65-yr-old African American man with hypertension.

d. 65-yr-old African American man with hypertension.

Which assessment finding of the respiratory system does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields

d. Bronchial breath sounds in the lower lung fields