ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 25 : Caring for Clients With Disorders of Coronary and Peripheral Blood Vessels Questions
Question 1 of 5
A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regimen?
Correct Answer: D
Rationale: The major goal in management of venous insufficiency is to promote venous circulation. Arterial flow improvement is not the goal of treatment for this disorder. Venous valves that are incompetent cannot be strengthened. Venous congestion is a complication of venous insufficiency.
Question 2 of 5
Which of the following factors would the nurse identify as a modifiable risk factor for the development of varicose veins?
Correct Answer: B
Rationale: Over-the-road truckers sit for long periods of time, and because prolonged sitting should be avoided, employment change could modify the risk associated with varicose vein aggravation. Varicose veins have a familial tendency, but this cannot be modified. Weight gained during previous pregnancies and history of thrombophlebitis cannot be changed.
Question 3 of 5
Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?
Correct Answer: C
Rationale: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive.
Question 4 of 5
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?
Correct Answer: A
Rationale: Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.
Question 5 of 5
Which nursing assessment finding(s) suggests increased risk for coronary artery disease? Select all that apply.
Correct Answer: A,D
Rationale: Arcus senilis is the opaque ring seen around the cornea that results from deposit of fat granules, and xanthelasma is raised yellow plaque on the eyelids. Both of these findings are suggestive of lipid accumulation that can increase the risk of CAD. An apple-shaped body carries a higher risk. Diagonal creases in the earlobe have been suggestive of CAD. Sensory and motor changes are more associated with CVA than CAD.