ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 23 : Caring for Clients With Infectious and Inflammatory Disorders of the Heart
and Blood Vessels Questions
Question 1 of 5
The nurse is completing a nursing problem statement of chronic pain for a client with thromboangiitis obliterans. Which of the following nursing instruction(s) will help relieve the client's pain? Select all that apply.
Correct Answer: C,D,E
Rationale: Thromboangiitis obliterans is an inflammation of the blood vessels associated with clot formation and fibrosis of the blood vessel wall. It affects primarily the small arteries and veins of the legs. The client should not elevate the extremity or apply ice. This causes an increase in ischemia.
Tobacco products and caffeine cause vasoconstriction, which is contraindicated. Proper fitting shoes are important to avoid any foot irritation or problems.
Question 2 of 5
The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which finding(s) confirms a positive outcome? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Evaluation of the expected outcome of thrombolytic therapy includes restoring blood flow to the extremity. Findings include no pain from impaired circulation, a pink extremity of comparable size, and no bleeding from complications of the thrombolytic medication. A thready pulse would indicate impaired circulation, and a positive Homan's sign would indicate a continuing thrombus.
Question 3 of 5
The nurse is performing client teaching with a client who has just been diagnosed with cardiomyopathy. What instructions should the nurse provide a client with cardiomyopathy to avoid pulmonary complications that may compromise cardiopulmonary function?
Correct Answer: B
Rationale: The nurse should instruct the client to receive the pneumonia vaccine and yearly influenza vaccinations to avoid pulmonary complications that may compromise cardiopulmonary function. Staying within the level of exercise tolerance does not help to avoid pulmonary complications. Eating a diet high in sodium causes water retention and therefore makes the client at risk for pulmonary edema, pneumonia, etc. The client should keep appointments for medical follow-up to evaluate the status of the disease and symptom control.
Question 4 of 5
The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main characteristic of pericarditis. What should be the student's answer?
Correct Answer: A
Rationale: Precordial pain is the main characteristic of pericarditis. Dyspnea, fever, and respiratory symptoms are not the main characteristics of pericarditis.
Question 5 of 5
The nurse is instructing a new graduate nurse. Together, they are caring for a client with infective endocarditis. What is a sign of infective endocarditis?
Correct Answer: B
Rationale: Splinter hemorrhage, black longitudinal lines, can be seen in the nails of the clients with endocarditis. Polyarthritis, inflammation of more than one joint, is a potential manifestation of rheumatic carditis. A heart murmur is the first abnormal sign detected in clients with cardiomyopathy. Precordial pain is the main characteristic of pericarditis.