<Q>The nurse is performing an assessment on a 50-year-old male who is a cashier <TYPE>single</TYPE> <P> at a local store, and

who often stands 6 to 8 hours at a time. The nurse should <F>Rationale: major <CORRECT>3</CORRECT> <MC4>Aneurysms.</MC4> refill.</MC1> <MC3>Varicose Adisease.</MC2> <MC2>Buerger'sveins.</MC3> <MC1>Delayed capillaryrisk inspect the client for:</Q>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 Strategy: Content Eliminate Health: IntegratedLevel: Application and Maintenance Client Need:a greater extentCardiovascular CognitivetoProcess: Nursing Process: Assessment lt malesArea:Health Promotionthan others.arterial in nature as this is a high-pr Adult distracters that are essure system. This question is related to the man standing for extended periods Reference: LeMone, P., isBurke, the(2008). <i>Medical-surgical nursing: Critical of time and therefore & about K. low-pressure venous system. thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>The <TYPE>single</TYPE> <P> </P> nurse is conducting a screening clinic for hypertension in the community. n, pp. 1195-1196.</F> For which of the following clients should the nurse pay particular attention to <F>Rationale: Primary <CORRECT>4</CORRECT> or <MC4>African American adult male</MC4> <MC3>Asian pressure?</Q> essential <MC2>Latino/Hispanic female</MC1> hypertension is more common in African Americ <MC1>Caucasian, adultadult male</MC2> the blood adult male</MC3> ans (option 4) than in people of other ethnic backgrounds (options 1, 2, and 3). Strategy: This question is Cardiovascular Content Area: Adult Nursingasking for identification of the IntegratedLevel: this client and Maintenance Client Need: Health Promotion should Assessment Cognitive reason,ApplicationProcess: be carefully evaluated.population at highes For this Process: Health: t risk for hypertension. Specific knowledge is needed to make a selection, so re Reference: LeMone, P., & if you have the <i>Medical-surgical nursing: Critical view this information nowBurke, K. (2008).need. thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>When assessing <TYPE>single</TYPE> <P> </P> n, p. 1156.</F> 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 <F>Rationale: cardiac <CORRECT>3</CORRECT> <MC4>Hypokalemia.</MC4> of the <MC3>Decreased stroke.</MC2> nails <MC2>ImpendingBlanchingoutput.</MC3> for more than 3 seconds after release of pr >MC1>Normal signs of aging.</MC1> < 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 Strategy: Process: requires Content Area: item Health: and Maintenance IntegratedThis alterations Cardiovascular Client systemAdult Nursing Process: Assessment Cognitive Level: Analysis than cardiovascular capillary refill time nervousNeed: Health Promotionknowledge of what symptoms (option 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, <Q>The <TYPE>single</TYPE> <P> </P> nurse is caring for a client NJ: Pearson Education, p. 626.</F> 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</ <MC1>Impaired coronary tissue perfusion related to presence of atherosclerotic p i> postprocedure care of this client?</Q> <MC2>Potential for internal hemorrhage related to sodium warfarin (Coumadin) the laque</MC1> <F>Rationale: in <CORRECT>4</CORRECT>PTCA, there is a to for the blood <MC4>PotentialAfterchest pain to aspirin therapy</MC3> spasm/reocclusion</MC4> <MC3>Alterationfor INR relatedrelatedriskcoronary arteryvessel to go into spasm rapy</MC2> 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 Strategy: Process: Health: Content IntegratedNote the Nursing word <i>immediate</i> Risk stem of Client Area: Adultcritical Cardiovascular Cognitive Level: Analysis Process: Reduction n 3). Need: Physiological Integrity:Planning ofin thePotentialthe 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 Reference: LeMone, intervention is not appropriate. e the pharmacologicP., & Burke, K. (2008). <i>Medical-surgical nursing: Critical thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>The <TYPE>multi</TYPE> <P> </P> nurse is caring for a client with a diagnosis of hypertension. The nurse n, pp. 977-978.</F> concludes that which of the following outcomes indicates successful treatment fo <F>Rationale: with a <CORRECT>[1,2,4]</CORRECT> blood pressure</MC3> <MC5>Stable systolic has not <MC4>Compliance increaseclient iswithin normal <MC3>No organ blood allinpressure of 140 mmHg</MC5> <MC2>Return of damagebloodthattomanagement</MC4> <MC1>EndfurtherSelectmedicationapply.</Q> with lifestyle modification or pharmac r this client?Whetherpressure developed</MC1> range</MC2> managed 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 Strategy: Process: complications that occur with Adaptation Content Area: Adult Health: Integrated hypertrophy. Client Need: Physiological Cardiovascular Cognitive Review theNursingIntegrity: Physiologicalunmanaged hypertension. Selec entricularLevel: ApplicationProcess: Evaluation Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical t distracters that can prevent them.

thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>A <TYPE>single</TYPE> <P> </P> 1166-1167.</F> n, p.hypertensive client taking spironolactone (Aldactone) reports onset of diar rhea and stomach cramping. The cardiac monitor shows tall, tented T waves. The n <F>Rationale: Spironolactone is a potassium-sparing diuretic. Hyperkalemia (pota <CORRECT>3</CORRECT> <MC4>Hypernatremia</MC4> <MC3>Hyperkalemia</MC3> <MC2>Hypercalcemia</MC2> <MC1>Hyponatremia</MC1> urse suspects which of the following drug-related electrolyte imbalances?</Q> 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 Strategy: Process: two content areas that must Content Area: Pharmacology IntegratedThere Analysis Client Need: to occur in Process: Pharmacological and Parenteral Cognitive Level:are NursingIntegrity: than diuretic use to correctly answer thi s more likelyPhysiologicaldehydrationAnalysis be known(option 4). Therapies 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 nurse explains <TYPE>single</TYPE> to a 1438-1440, the goal <P> </P> Pearson Education, pp.client that 1448.</F>of anticoagulant therapy in a cl NJ: <F>Rationale: Anticoagulant therapy is <CORRECT>1</CORRECT> <MC4>Prevent the clot.</MC2> <MC3>Allow infection.</MC4> <MC2>Dissolveadditional thrombus formation.</MC1> <MC1>Preventdeep vein thrombosis is to:</Q> ient with aimmediate ambulation.</MC3> 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 Strategy: Process: Nursing Content Area: question IntegratedThisPharmacology Client Need: Physiological actually Pharmacologic Cognitive Level: 4). is Integrity:Implementation and of action for heparin. infective (optionApplicationProcess:asking the mechanismParenteral Therapies The presence of a DVT provides a context but is additional but unnecessary data. Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical Recall what heparin does in the body to make the correct selection. thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>A <TYPE>single</TYPE> <P> </P> client reports leg n, pp. 1188-1189.</F> pain and cramping after short periods of walking that st op when he rests. The nurse immediately concludes that this client's manifestati <F>Rationale: phenomenon</MC4> <CORRECT>3</CORRECT> <MC4>Raynaud'sIntermittent claudication caused by muscle ischemia is a primary s <MC3>Intermittent with which of the <MC2>Phlebitis</MC2> <MC1>Arterial-venous shunting</MC1> ons are consistentclaudication</MC3> following?</Q> 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 Strategy: Process: any distracters Content Area: joining of IntegratedEliminate Health: Cardiovascular Client Need: Physiologicalarterial andPhysiological Adaptation Cognitive Level: ApplicationProcess:that imply venous disease. Among those that 1) describes aAdult NursingIntegrity:Analysis circulation. venous Reference: LeMone, contrast the meaning of the distracter with the question. remain, compare andP., & Burke, K. (2008). <i>Medical-surgical nursing: Critical thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio <Q>The <TYPE>single</TYPE> <P> </P> nurse anticipates that which medication is likely to be ordered on a dail n, pp. 1176-1177.</F> y basis to a newly hospitalized client who has a history of peripheral arterial <F>Rationale: <CORRECT>3</CORRECT> <MC4>Heparin</MC4> <MC3>Aspirin</MC3> <MC2>Ibuprofen (Motrin)</MC2> <MC1>Acetaminophen (Tylenol)</MC1> disease?</Q> Aspirin 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 Strategy: Process: Nursing Content Area: Pharmacology IntegratedRecall first the Process: of the Client a Level: Analysis categories Pharmacologic drugs listed Therapies Cognitive nonsteroidal anti-inflammatory agent (NSAID). ofen isNeed: Physiological Integrity:Analysisvariousand Parenteralin the options . Eliminate all distracters that are unrelated to arterial circulation. Then exa References: LeMone, P., & determine the severity of the disease. mine the question again toBurke, K. (2008). <i>Medical-surgical nursing: Critica l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati <Q>Which of the <TYPE>single</TYPE> <P> </P> on, p. 1177.</F>following statements would indicate a positive outcome for a cli <MC1>"I chronic my feet elevated disease?</Q> ent withwill keeparterial occlusiveabove the level of my heart when I sleep."</M <MC3>"I <MC2>"I will wear my compression stockings when awake."</MC2> increase circulati C1> keep walking even when I feel pain in my legs to <MC4>"I will on."</MC3> check the temperature of my bathwater with my hands before getting <F>Rationale: Sensation <CORRECT>4</CORRECT> into the water."</MC4> 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 Strategy: Process: Health: Content Area: critical disease the Evaluation IntegratedThe Adult Nursing and prevent Client Need: Health Promotionin toMaintenance Cognitive Level: Analysis Cardiovascular or decrease venous stasis. l treatments for venouswordsProcess:question are <i>arterial occlusive disease</ i>. Since the question is about arterial blood flow, eliminate any distracters t Reference: LeMone, P., & Burke, or are related to venous disease. hat may compromise arterial flowK. (2008). <i>Medical-surgical nursing: Critical thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio </P> n, pp. 1179-1180.</F>