Ch. 16 Altered Perfusion

Question 1

In evaluating modifiable cardiovascular risk factors for your patient, which one is NOT considered modifiable?

a. Poorly controlled diabetes mellitus

b. Hyperlipidemia

c. Hypertension

d. Female sex

Answer 1

d. Female sex

Question 2

Your patient is experiencing peripheral edema, hepatomegaly, ascites, and splenomegaly. Which of the following conditions would be consistent with the patient’s findings?

a. Endocarditis

b. Myocardial infarction

c. Right heart failure

d. Left heart failure

Answer 2

c. Right heart failure

Question 3

It is a hot summer day. Your neighbor stops at your house after jogging 5 miles. She is sweating and tells you she feels dizzy and thirsty and can’t make it home. You check her blood pressure and find it to be low. What could you do in your home to raise her blood pressure?

a. Place a cold washcloth on her head.

b. Have her drink a large glass of cool water.

c. Have her take a shower with warm water.

d. Encourage her to take slow, deep breaths.

Answer 3

b. Have her drink a large glass of cool water.

Question 4

Your neighbor comes to your door. She has been running in the snow and it is cold outside. She has a headache and her heart is pounding. You check her blood pressure and find it to be high. What could you do in your home to decrease her blood pressure?

a. Have her drink some hot chocolate.

b. Have her lay down on your couch.

c. Let her take a hot shower.

d. Give her something really salty to eat.

Answer 4

b. Have her lay down on your couch.

Question 5

Which of the following situations of altered perfusion could be triggered by chronic obstructive pulmonary disease (COPD)?

a. Impaired cardiac output

b. Impaired circulation

c. Ventilation–perfusion mismatching

d. Excessive cardiac demand

Answer 5

c. Ventilation–perfusion mismatching

Question 6

Which mechanism increases peripheral vascular resistance and contributes to the development of hypertension?

a. Impaired sodium excretion by the kidneys

b. Parasympathetic nervous system overstimulation

c. Reduced renin–angiotensin–aldosterone secretion

d. None of these

Answer 6

a. Impaired sodium excretion by the kidneys

Question 7

Which is not a requirement for effective perfusion?

a. Absence of chronic disease

b. Adequate blood volume

c. Functional systemic circulation

d. An open airway

Answer 7

a. Absence of chronic disease

Question 8

Your neighbor tells you that she was in the hospital, and they told her she had a bundle branch block. What does this mean?

a. She cannot conduct electrical impulses to stimulate the heart ventricle to contract.

b. She has had a cardiac arrest.

c. She is experiencing obstructed P wave depolarization of the atria.

d. She has an excessive calcium influx causing prolonged myocardial contraction.

Answer 8

a. She cannot conduct electrical impulses to stimulate the heart ventricle to contract.

Question 9

You are listening to your lab partner’s heart in skills lab, and you hear the “lub dub” sound. What are you hearing?

a. The sodium ions rapidly influxing into the cells

b. The closure of the heart valves

c. The contraction of the left ventricle

d. Blood forcing its way through the aorta

Answer 9

b. The closure of the heart valves

Question 10

At what point in the cardiac cycle do you measure preload?

a. Just after systole.

b. Just before systole.

c. During systole.

d. It is not possible to measure preload.

Answer 10

b. Just before systole.

Question 11

A nurse in a provider’s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.)

A. Smaller nipples
B. Less adipose tissue
C. Nipple discharge
D. More pendulous
E. Nipple inversion

Answer 11

A. CORRECT: In older adulthood, the nipples become smaller and flatter.
D. CORRECT: In older adulthood, breasts become softer and more pendulous.
E. CORRECT: Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

Question 12

A nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)

A. Rhonchi
B. Crackles
C. Resonance
D. Tactile fremitus
E. Bronchovesicular sounds

Answer 12

C. CORRECT: Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs.
E. CORRECT: Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

Question 13

During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

A. Fat
B. Fluid
C. Flatus
D. Hernias

Answer 13

C. CORRECT: With flatus, the protrusion is mainly midline, and there is no change in the flanks.

Question 14

During a cardiovascular examination, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth
intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.)

A. Ventricular gallop
B. Closure of the mitral valve
C. Closure of the pulmonic valve
D. Apical heart rate
E. Murmur

Answer 14

B. CORRECT: To auscultate the closure of the mitral valve, place the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space.
D. CORRECT: To auscultate the apical heart rate, place the diaphragm of the stethoscope over the apex of the heart, which is on the left midclavicular line at the fifth intercostal space.

Question 15

A nurse in a provider’s office is preparing to auscultate and percuss a client’s abdomen as part of a comprehensive physical examination.
Which of the following findings should the nurse expect? (Select all that apply.)

A. Tympany
B. High‑pitched clicks
C. Borborygmi
D. Friction rubs
E. Bruits

Answer 15

A. CORRECT: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach.
B. CORRECT: Typical bowel sounds are high‑pitched clicks and gurgles occurring about 35 times/min.

Question 16

A nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? (Select all that apply.)

A. Capillary refill less than 3 seconds
B. 1+ pitting edema in both feet
C. Pale nail beds in both hands
D. Thick skin on the soles of the feet
E. Numerous macules on the face darker than the surrounding skin color

Answer 16

A. CORRECT: Expect capillary refill in less than 3 seconds as an expected finding.
D. CORRECT: Expect thicker skin on the palms of the hands and the soles of the client’s feet.
E. CORRECT: Macules on the face that are darker than the skin color indicate freckles, which are an expected finding

Question 17

A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.)

A. Thin, parchment‑like skin
B. Loss of adipose tissue
C. Dehydration
D. Diminished skin elasticity
E. Excessive wrinkling

Answer 17

B. CORRECT: Tenting is a delay in the skin returning to its normal place after pinching. Tenting is a manifestation of aging skin and loss of subcutaneous
tissue that provides recoil in younger skin.
C. CORRECT: Tenting is a delay in the skin returning to its normal place after pinching. Dehydration can cause the skin to tent, which can easily develop in the older adult client.
D. CORRECT: Tenting is a delay in the skin returning to its normal place after pinching. Tenting in the older adult client is a manifestation of aging skin and loss of elasticity.

Question 18

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (Select all that apply.)

A. Range of motion
B. Skin color
C. Edema
D. Skin lesions
E. Skin temperature

Answer 18

B. CORRECT: Assess the peripheral vascular system to verify adequate circulation to the client’s legs, which includes skin color. Pallor and cyanosis reflect inadequate circulation.
C. CORRECT: Assess the peripheral vascular system to verify adequate circulation to the client’s legs, which includes edema. Edema reflects inadequate venous circulation.
E. CORRECT: Assess the peripheral vascular system to verify adequate circulation to the client’s legs, which includes skin temperature. Coolness of the extremity compared with the
nonoperative extremity indicates inadequate circulation

Question 19

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.)

A. Acne
B. Warts
C. Psoriasis
D. Herpes simplex
E. Varicella

Answer 19

D. CORRECT: Herpes simplex lesions are vesicles, which are circumscribed fluid‑filled skin elevations. Eczema and
impetigo also cause vesicles to appear on the skin.
E. CORRECT: Varicella (chickenpox) lesions are vesicles, which are circumscribed fluid‑filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin.

Question 20

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention?

A. Pallor
B. Cyanosis
C. Jaundice
D. Erythema

Answer 20

B. CORRECT: The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis,
which an indication of hypoxia (inadequate oxygenation).
Therefore, immediately report this finding to the provider.