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
After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?
Correct Answer: B
Rationale: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels do not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
Question 2 of 5
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) immediately following confirmed diagnosis of acute myocardial infarction. The client is overtly anxious and crying. Which response by the nurse is most appropriate?
Correct Answer: D
Rationale: Allowing the client to share feelings tends to relieve or reduce emotional distress. Telling a client that everything is fine negates the feelings they are expressing. Telling a client not to cry can be viewed as insensitive to the feelings being expressed. Providing a prescribed sedative may be helpful but does not address the fears and concerns of the client.
Question 3 of 5
The nurse provides care for a client following a percutaneous transluminal coronary angioplasty (PTCA). Which is the priority action by the nurse?
Correct Answer: D
Rationale: The PTCA is an invasive nonsurgical procedure in which a balloon-tipped catheter is inserted and threaded through a peripheral artery. The nurse monitors the client for bleeding postprocedure in addition to palpating distal, bilateral pulses in the appropriate extremity. Fluid volume deficit is not a primary concern. This procedure does not require general anesthesia; therefore, monitoring for an impaired gag reflex is not a priority nursing action. Signs of infection should be monitored post-PTCA, but this is not an immediate concern.
Question 4 of 5
Which nursing problem statement is most significant in planning the care for a client with Raynaud syndrome?
Correct Answer: A
Rationale: The hallmark symptom of Raynaud syndrome is acute pain related to the arterial insufficiency. ADL Deficit, Coping Impairment, and Activity Intolerance can occur but are less significant than Acute Pain.
Question 5 of 5
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?
Correct Answer: A
Rationale: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.