Vascular/Cardiac/Respiratory Flashcards
The nurse is assessing the lower extremities of the client with peripheral artery disease. Which findings are expected? SATA
A. Excessively hairy legs B. Pallor C. Erythema D. Skin that is cool to the touch E. Moist skin
Answer: B,D
Rationale: arterial is a blockage of blood flow to the extremity this would lead to pallor, skin that is cool to the touch, decreased pulses etc.
A patient has PAD of both lower extremities. Which example indicates the patient is using appropriate care management strategies?
A. The patient rests with the legs elevated above the level of the heart.
B. The patient walks for 30 mins twice a day.
C. The patient limits activity to walking around the house.
D. The patient wears anti embolism stockings at all times when out of bed.
Answer: B
Rationale: arterial disease is treated with the use of gravity to promote better circulation
A client is receiving treatment for intermittent claudication pain. The nurse should determine the effectiveness of the treatment plan by asking if the client:
A. has less pain in the legs
B. can wiggle the toes
C. is urinating more frequently
D. is less dizzy
Answer: A
Rationale: claudication pain is also known as calf pain
A client has been diagnosed with Raynaud’s phenomenon on the tip of the nose and fingertips. The client often works outside in cold weather and also smokes two pack of cigarettes per day. Which directions should be included in the discharge plan for this client? SATA
A. Stop smoking
B. Wear a face covering and gloves in the winter.
C. Place fingertips in cool water
D. Find employment that can be done in a warm environment
Answer: A, B
Rationale: these are common precipitating factors to exacerbation and should be avoided
A client with Raynauds’ phenomenon is asking about the purpose of their treatment plan. The intended outcome is
A. Decreased heart rate
B. Regulate heart rate and rhythm
C. Reduced episodes of finger numbness
D. Increased SpO2 readings
Answer: C
Rationale: raynaud’s phenomenon often manifests as finger pain and numbness. It does not affect heart rate or oxygen levels
The nurse interviews a 22 year old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen based oral contraceptives. The client is at high risk for development of:
A. atherosclerlosis
B. diabetes
C. Raynaud’s disease
D. DVT
Answer: D
Rationale: patient has multiple risk factors when reviewing Virchow’s triad. Abdominal surgery may require bedrest which would put the patient at even higher risk
The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI)? SATA
A. Neck/Jaw Pain
B. Relief of pain at rest
C. Difficulty Breathing
D. Anxiety
Answer: A, C, D
Rationale: with a true MI pain would not be relieved by rest
A patient is being discharged home after hospitalization of left sided HF. As the nurse providing discharge teaching to the patient, which statement is NOT a correct statement about this condition?
A. “Signs and symptoms of this type of heart failure can include: dyspnea, persistent cough, difficulty breathing while lying down, and weight gain.”
B. “It is important to monitor your daily weights, fluid and salt intake.”
C. “Left-sided heart failure can lead to right-sided heart failure, if left untreated.”
D. “This type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema.”
Answer: D
Rationale: this is a description of the pathophysiology of right sided heart failure
Which of the following are NOT typical signs and symptoms of right-sided heart failure? SATA
A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea
Answer: B,D,F
Rationale: right sided heart failure would lead to congestion of the systemic circulation the other options (B,D,F) would be seen with left-sided heart failure
A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation? SATA
A. “I’ve noticed that I’ve gain 6 lbs in one week.”
B. “While I sleep I have to prop myself up with a pillow so I can breathe.”
C. “I haven’t noticed any swelling in my feet or hands lately.”
D. “I have had an easier time breathing lately”
Answer: A,B
Rationale: both A and B would indicate an increase in fluid volume status and are possible signs of exacerbation
What type of heart failure does this statement describe? The ventricle is unable to properly fill with blood because it is too stiff. Therefore, blood backs up into the lungs causing the patient to experience shortness of breath.
A. R Sided
B. L Sided
Answer: B
Rationale: left sided heart failure would lead to a back up of blood is the pulmonary circulation
Which of the following statements describes the etiology of hypertrophic cardiomyopathy best?
A. Increased strain on the heart muscles leads to breakdown
B. Genetic mutation leads to thickening of the ventricular septum
C. Atherosclerotic buildup of the coronary arteries
D. Fluid backs up into the lungs leading to increased work of breathing
Answer: B
An elderly client is being monitored for evidence of CHF. To detect early signs of heart failure, the nurse would instruct the UAP to do which of the following during care of the patient?
A. Observe electrocardiogram readings and report deviations to the nurse.
B. Assist the client with ambulation three times during the shift.
C. Monitor vital signs every 15 minutes and report each reading to the nurse.
D. Accurately weigh the patient, and report and record the readings.
Answer: D
Rationale: daily weights are your best indicator of fluid volume status and also the least invasive while also within the scope of practice of UAP
Which of the following symptoms should the nurse teach the client with a history of stable angina to report immediately to her physician?
A. A change in the pattern of her pain
B. Pain during sex
C. Pain during an argument with her husband
D. Pain during or after an activity such as lawn mowing
Answer: A
Rationale: with stable angina chest pain with activity is expected. Chest pain that is unrelieved by rest is a sign of a possible MI. Any new or worsening chest pain should be reported to the PCP.
A patient with a tricuspid valve disorder will have impaired blood flow between the
A. vena cava and right atrium.
B. left atrium and left ventricle.
C. right atrium and right ventricle.
D. right ventricle and pulmonary artery.
Answer: C
Rationale: the tricuspid valve is located on the right side of the heart between the atrium and ventricle
