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
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 2 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.
Question 3 of 5
The nurse is caring for a client who is post-varicose vein surgery. The nurse would include which teaching measure(s)? Select all that apply.
Correct Answer: A,C
Rationale: Movement/exercise and use of elastic stocking aid in venous return. Cool compresses can cause vasoconstriction, which can diminish arterial blood flow. Elevation of legs can be helpful in aiding venous return. Standing or sitting for prolonged periods of time should be avoided. Showers in the morning can dilate blood vessels and contribute to venous congestion and edema.
Question 4 of 5
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?
Correct Answer: C
Rationale: The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.
Question 5 of 5
The nurse is caring for a client with Raynaud syndrome. What is an important instruction for a client who is diagnosed with this disease to prevent an attack?
Correct Answer: B
Rationale: Teaching for clients with Raynaud syndrome and their family members is important. They need to understand what contributes to an attack. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.