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 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.
Question 2 of 5
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
Correct Answer: B
Rationale: The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.
Question 3 of 5
A client has had oral anticoagulation ordered. What should the nurse monitor for when the client is taking oral anticoagulation?
Correct Answer: A
Rationale: The nurse should monitor PT or INR when oral anticoagulation is prescribed. Vascular sites for bleeding, urine output, and hourly IV infusions are generally monitored in all clients.
Question 4 of 5
The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
Correct Answer: C
Rationale: The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. Coughing and straining increase the risk of rupture. The client with Raynaud syndrome is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.
Question 5 of 5
The nurse is presenting a workshop at the senior citizens center about how the changes of aging predispose clients to vascular occlusive disorders. What would the nurse name as the most common cause of peripheral arterial problems in the older adult?
Correct Answer: C
Rationale: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with the aging process. The other choices may occur at any age.