<P>

<Q>The
<TYPE>single</TYPE>
nurse is performing an assessment on a 50-year-old male who is a cashier
at a local store, and who often stands 6 to 8 hours at a time. The nurse should
inspect the client
<MC1>Delayed
<MC2>Buerger's
<MC3>Varicose
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Aneurysms.</MC4>
capillary
Aveins.</MC3>
disease.</MC2>
major
for:</Q>
risk
refill.</MC1>
factor for varicose veins is standing in one place fo
r long periods of time (option 3). Delayed capillary refill (option 1) and aneur
ysms (option 4) both reflect the arterial system and are unrelated to standing i
n one position. Buerger's disease (option 2) affects arteries and veins, but smo
king is the major risk factor for this disorder, which tends to affect young adu
lt malesNeed:
Cognitive
Client
Integrated
Content
Strategy: Area:
toEliminate
Level:
Process:
aHealth
greater
Adult
Application
Promotion
Nursing
Health:
distracters
extentCardiovascular
Process:
than
andthat
others.
Maintenance
Assessment
are arterial in nature as this is a high-pr
essure system. This question is related to the man standing for extended periods
Reference:
of time andLeMone,
thereforeP., &isBurke,
about K.the(2008).
low-pressure
<i>Medical-surgical
venous system.nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1195-1196.</F>
is conducting a screening clinic for hypertension in the community.
For which of the following clients should the nurse pay particular attention to
<MC1>Caucasian,
<MC2>Latino/Hispanic
<MC3>Asian
<MC4>African
<F>Rationale:
<CORRECT>4</CORRECT>
the blood adult
pressure?</Q>
American
Primary
adult
male</MC3>
adult
female</MC1>
adult
or essential
male</MC2>
male</MC4>
hypertension is more common in African Americ
ans (option 4) than in people of other ethnic backgrounds (options 1, 2, and 3).
Cognitive
Client
Integrated
Content
Strategy:
For this
Need:
Area:
reason,
Level:
This
Process:
Health
Adult
question
Application
this
Promotion
Nursing
Health:
client
is asking
Process:
Cardiovascular
should
and Maintenance
for beidentification
Assessment
carefully evaluated.
of the population at highes
t risk for hypertension. Specific knowledge is needed to make a selection, so re
view this information
Reference: LeMone, P.,now & Burke,
if youK.have
(2008).
the need.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1156.</F>
<Q>When
<TYPE>single</TYPE>
<P>
</P> assessing an older adult client, the nurse determines the capillary refi
ll time to be 6 seconds. The nurse determines the client may be experiencing:</Q
><MC1>Normal signs
<MC2>Impending
<MC3>Decreased
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Hypokalemia.</MC4>
Blanching
stroke.</MC2>
cardiac
of aging.</MC1>
output.</MC3>
of the nails for more than 3 seconds after release of pr
essure may indicate reduced arterial capillary perfusion, which may be an indica
tion of decreased cardiac output (option 3). Changes in capillary refill time ar
e not associated with normal changes of aging (option 1). Hypokalemia may cause
prolongation of the cardiac cycle but does not affect capillary refill (option 4
). A client with an impending stroke would be more likely to experience central
nervousNeed:
Cognitive
Client
Integrated
Content
Strategy:system
Area:
Level:
This
Process:
Health
Adult
alterations
item
Analysis
Promotion
Nursing
Health:
requires than
Process:
Cardiovascular
knowledge
andcardiovascular
Maintenance
Assessment
of what capillary
symptoms (option
refill time
2). represents
and a normal finding. Memorize the number 3 as the time limit for capillary refi
Reference: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). <i>Fundamentals
ll.
of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurseEducation,
is caring for p. 626.</F>
a client who has just returned from the cardiac cathe
terization laboratory following a percutaneous transluminal coronary angioplasty
(PTCA). Which of the following problems is a priority during the <i>immediate</
i> postprocedure
<MC1>Impaired coronary
care oftissue
this perfusion
client?</Q>related to presence of atherosclerotic p
<MC2>Potential for internal hemorrhage related to sodium warfarin (Coumadin) the
laque</MC1>
<MC3>AlterationAfter
rapy</MC2>
<MC4>Potential
<F>Rationale:
<CORRECT>4</CORRECT>
for
in chest
INR
PTCA,
related
pain
thererelated
toisaspirin
a risk
to coronary
therapy</MC3>
for the blood
arteryvessel
spasm/reocclusion</MC4>
to go into spasm
and/or to reocclude. If this happens, the client will experience chest pain and
would be the priority for treatment (option 4). The atherosclerotic plaque is co
mpressed against the intimal surface of the coronary artery during the PTCA (opt
ion 1) and is therefore less likely to be directly responsible for decreased per
fusion postprocedure. However, because of the continued risk for reocclusion, th
is problem could be considered to be second in importance. The client is on hepa
rin immediately after the procedure (option 2), not sodium warfarin (Coumadin).
Sodium warfarin would prolong the INR rather than therapy aspirin therapy (optio
n 3). Need:
Cognitive
Client
Integrated
Content
Strategy:Area:
Level:
Note
Process:
Physiological
Adult
theAnalysis
critical
NursingIntegrity:
Health: Process:
Cardiovascular
word <i>immediate</i>
Planning
Reduction ofinRisk
thePotential
stem of the question. T
his question is related to the timing of specific complications and selected int
erventions. Eliminate distracters that are likely prior to the procedure or wher
e the pharmacologic
Reference: LeMone, P., intervention
& Burke, K.is(2008).
not appropriate.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 977-978.</F>
is caring for a client with a diagnosis of hypertension. The nurse
concludes that which of the following outcomes indicates successful treatment fo
r this client?
<MC1>End
<MC2>Return
<MC3>No
<MC4>Compliance
<MC5>Stable
<F>Rationale:
<CORRECT>[1,2,4]</CORRECT>
further
organ
ofWhether
systolic
Select
damage
blood
increase
with pressure
medication
blood
allclient
ahas innot
that
pressure
blood
developed</MC1>
to
apply.</Q>
ismanagement</MC4>
within
pressure</MC3>
managed
of 140
normal
with
mmHg</MC5>
range</MC2>modification or pharmac
lifestyle
otherapy, successful treatment is the achievement of a normal blood pressure, co
mpliance with medications, and prevention of end organ damage. Both the systolic
and diastolic blood pressures are relevant to the diagnosis and treatment of hy
pertension, with acceptable values being lower than 130/88. As long as the BP is
elevated, the client is at risk for end organ damage such as renal failure or v
entricular
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Review
hypertrophy.
Process:
Physiological
Adult
Application
the Nursing
Health:
complications
Integrity:
Process:that
Cardiovascular
Evaluation
Physiological
occur with unmanaged
Adaptationhypertension. Selec
t distracters
Reference: LeMone,
that P.,
can &prevent
Burke,them.
K. (2008). <i>Medical-surgical nursing: Critical
 thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
</P>p.hypertensive
n,
<Q>A
<TYPE>single</TYPE>
<P> 1166-1167.</F>client taking spironolactone (Aldactone) reports onset of diar
rhea and stomach cramping. The cardiac monitor shows tall, tented T waves. The n
urse suspects Spironolactone
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Hypernatremia</MC4>
<MC3>Hyperkalemia</MC3>
<MC2>Hypercalcemia</MC2>
<MC1>Hyponatremia</MC1>
which of the following
is a potassium-sparing
drug-related electrolyte
diuretic. Hyperkalemia
imbalances?</Q>
(pota
ssium greater than 5.5 mEq/L) is a possible side effect (option 3) and could lea
d to the manifestations that the client in the question is experiencing. Hyponat
remia (option 1) can result from excessive use of high ceiling diuretics. Hyperc
alcemia may occur with the use of thiazide diuretics (option 2). Hypernatremia i
s more Need:
Cognitive
Client
Integrated
Content
Strategy:
likely
Area:
Level:
There
Process:
Physiological
toare
Pharmacology
occur
Analysis
Nursing
two incontent
dehydration
Integrity:
Process:
areasAnalysis
than must
Pharmacological
that diuretic
be known
useand(option
toParenteral
correctly
4). Therapies
answer thi
s item: the mechanism of action for spironolactone and manifestations of hyperka
References: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). <i>Fundamental
lemia.
s of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
<Q>The
<TYPE>single</TYPE>
<P>
</P>
NJ: Pearson
nurse explains
Education,topp. a client
1438-1440,
that the
1448.</F>
goal of anticoagulant therapy in a cl
ient with aimmediate
<MC1>Prevent
<MC2>Dissolve
<MC3>Allow
<MC4>Prevent
<F>Rationale:
<CORRECT>1</CORRECT>
deep
additional
infection.</MC4>
thevein
Anticoagulant
clot.</MC2>
ambulation.</MC3>
thrombosis
thrombus
therapy is is
formation.</MC1>
to:</Q>
used for deep vein thrombosis to prevent
development of new clots or the enlargement of the existing clot (option 1). Hep
arin does not dissolve the clot; a thrombolytic must be given to achieve that ef
fect (option 2). Even with anticoagu-lation, the client is maintained on bedrest
to prevent embolization of a portion of the clot to the lungs (option 3). Hepar
in has no effect on infection because it is an anticoagulant rather than an anti
infective
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
(option
Level:
This
Process:
Physiological
Pharmacology
question
Application
4).Nursing
is actually
Integrity:
Process:asking
Implementation
Pharmacologic
the mechanism
and Parenteral
of action for
Therapies
heparin.
The presence of a DVT provides a context but is additional but unnecessary data.
Reference:
Recall whatLeMone,
heparinP.,does
& Burke,
in theK.body (2008).
to make
<i>Medical-surgical
the correct selection.
nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 1188-1189.</F>
reports leg pain and cramping after short periods of walking that st
op when he rests. The nurse immediately concludes that this client's manifestati
ons are consistent
<MC1>Arterial-venous
<MC3>Intermittent
<MC2>Phlebitis</MC2>
<MC4>Raynaud's
<F>Rationale:
<CORRECT>3</CORRECT>
Intermittent
phenomenon</MC4>
claudication</MC3>
with
shunting</MC1>
which
claudication
of the following?</Q>
caused by muscle ischemia is a primary s
ymptom of peripheral arterial disease (option 3). Pain occurs with activity but
is relieved with rest. Raynaud's phenomenon is associated with vasospasm (option
4), a functional disorder rather than a structural one. Phlebitis (option 2) ma
y cause pain, but it is unrelated to activity. Arterial venous shunting (option
1) describes
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Eliminate
Process:
aAdult
Physiological
joining
Application
Nursing
Health:
any ofdistracters
arterial
Integrity:
Process:and
Cardiovascular
that
Analysis
Physiological
venous
implycirculation.
venousAdaptation
disease. Among those that
remain, compare
Reference: LeMone,
andP.,
contrast
& Burke,theK.meaning
(2008).of<i>Medical-surgical
the distracter withnursing:
the question.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1176-1177.</F>
anticipates that which medication is likely to be ordered on a dail
y basis to a newly hospitalized client who has a history of peripheral arterial
<MC1>Acetaminophen
disease?</Q>
<MC2>Ibuprofen
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Heparin</MC4>
<MC3>Aspirin</MC3>
Aspirin
(Motrin)</MC2>
(Tylenol)</MC1>
prevents platelet aggregation, which is the first step in
clot formation (option 3). Heparin (option 4) is an anticoagulant that would be
used following an angioplasty or while awaiting surgery in a client with advance
d disease. Acetaminophen (option 1) and ibuprofen (option 2) have no therapeutic
benefit in arterial disease, although they are helpful as analgesics, and ibupr
ofen isNeed:
Cognitive
Client
Integrated
Content
Strategy:a Recall
Area:
nonsteroidal
Level:
Process:
Physiological
Pharmacology
Analysis
first
Nursing
anti-inflammatory
the Integrity:
categories
Process: Analysis
Pharmacologic
of agentvarious
the (NSAID).
and
drugsParenteral
listed inTherapies
the options
. Eliminate all distracters that are unrelated to arterial circulation. Then exa
mine the question
References: LeMone,again
P., &toBurke,
determineK. (2008).
the severity
<i>Medical-surgical
of the disease.nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, p. 1177.</F>
<Q>Which
<TYPE>single</TYPE>
<P>
</P> of the following statements would indicate a positive outcome for a cli
ent withwill
<MC1>"I chronic
keeparterial
my feet elevated
occlusiveabovedisease?</Q>
the level of my heart when I sleep."</M
<MC2>"I will keep
C1>
<MC3>"I wear walking
my compression
even when stockings
I feel pain
when in
awake."</MC2>
my legs to increase circulati
<MC4>"I will check the temperature of my bathwater with my hands before getting
on."</MC3>
into the water."</MC4>
<F>Rationale:
<CORRECT>4</CORRECT>
Sensation in the feet may be diminished in clients with arterial o
cclusive disease. Teach the client to check the bathwater with the hands to prev
ent the risk of a burn injury (option 4). The client should stop and rest when p
ain is experienced to relieve the ischemia (option 3). Options 1 and 2 are usefu
l treatments
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
for
Health
Adult
critical
venous
Analysis
Promotion
Nursing
Health:
words
disease
Process:
Cardiovascular
inandthe
toMaintenance
prevent
question
Evaluation
orare
decrease
<i>arterial
venousocclusive
stasis. disease</
i>. Since the question is about arterial blood flow, eliminate any distracters t
hat may compromise
Reference: LeMone, P.,
arterial
& Burke,
flowK.or(2008).
are related
<i>Medical-surgical
to venous disease. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 1179-1180.</F>
</P>