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Ati nur120 med surg exam
Ati nur120 med surg exam
Total Questions : 24
Showing 10 questions Sign up for moreA nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply).
Explanation
A) Family history: Family history is a significant non-modifiable risk factor for atherosclerosis. While individuals cannot change their genetic predisposition, awareness of family history can inform lifestyle choices and risk assessments. Those with a family history should be particularly vigilant about managing other risk factors.
B) High blood pressure: High blood pressure is a modifiable risk factor that can be controlled through lifestyle changes such as diet, exercise, and medication if necessary. Effective management of hypertension can significantly reduce the risk of atherosclerosis and related cardiovascular diseases.
C) Obesity: Obesity is another modifiable risk factor. Individuals can manage their weight through healthy eating, physical activity, and lifestyle modifications. Reducing obesity can improve overall cardiovascular health and decrease the risk of developing atherosclerosis.
D) Age: Age is a non-modifiable risk factor. As people age, the risk for atherosclerosis naturally increases due to various biological changes. While aging itself cannot be altered, awareness of age-related risks can prompt individuals to adopt healthier lifestyles.
E) Lack of physical activity: This is a modifiable risk factor. Increasing physical activity can improve cardiovascular health and reduce the likelihood of developing atherosclerosis. Regular exercise can help maintain a healthy weight and improve blood pressure and cholesterol levels, contributing to overall heart health.
F) Gender: Gender is also a non-modifiable risk factor. While certain genders may have different risks at various life stages (e.g., men often have a higher risk at a younger age), this characteristic cannot be changed. Understanding gender-related risks can aid in tailoring preventive strategies but does not offer a means of modification.
G) Smoking: Smoking is a critical modifiable risk factor for atherosclerosis. Quitting smoking can significantly lower the risk of cardiovascular diseases and improve overall health. Smoking cessation should be a priority for individuals looking to prevent or manage atherosclerosis effectively.
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 130/82 mm Hg places him in which of the following categories?
Explanation
A. Within the expected reference range: While a blood pressure of 130/82 mm Hg is close to normal, it is not considered fully within the expected reference range. The normal range is typically defined as less than 120/80 mm Hg.
B. Elevated: The reading of 130/82 mm Hg falls into the "elevated" category, which is defined as systolic blood pressure between 120-129 mm Hg and diastolic pressure less than 80 mm Hg. This indicates that while the client is not hypertensive, they are at increased risk for developing hypertension in the future.
C. Stage 2 hypertension: This category is defined by a systolic reading of 140 mm Hg or higher, or a diastolic reading of 90 mm Hg or higher. The client’s reading does not meet these criteria, so this option is not applicable.
D. Stage 1 hypertension: Stage 1 hypertension is characterized by systolic readings between 130-139 mm Hg and diastolic readings between 80-89 mm Hg. Although the systolic reading is in the Stage 1 range, the diastolic reading of 82 mm Hg places the overall reading in the "elevated" category, rather than Stage 1 hypertension.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
Explanation
A) Intermittent claudication: This symptom is indicative of arterial insufficiency, not chronic venous insufficiency. Intermittent claudication is characterized by pain in the legs during activity due to insufficient blood flow, which is not typical in venous conditions.
B) Decreased pedal pulses: In chronic venous insufficiency, pedal pulses are usually normal. Decreased pedal pulses suggest arterial disease, where blood flow is compromised. Thus, this finding would not be expected in a client with venous insufficiency.
C) Bronze/brown discoloration of the skin: This is a hallmark finding in chronic venous insufficiency. The discoloration occurs due to the deposition of hemosiderin from the breakdown of red blood cells, which is a result of prolonged venous stasis and chronic edema, particularly around the lower extremities.
D) Cool skin temperature: Skin temperature in chronic venous insufficiency is typically warm due to increased blood flow and stasis in the veins. Cool skin temperature is more characteristic of arterial insufficiency, where blood supply is reduced and can lead to cooler extremities.
E) Full screen mode is in effect during your proctored testing: This statement is irrelevant to the clinical assessment of chronic venous insufficiency and serves no purpose in understanding the client’s condition. It does not contribute to the assessment findings.
The nurse is assessing a client diagnosed with peripheral arterial disease (PAD). The client reports leg pain and cramping after walking a few blocks, which is relieved when the client stops and rests. The nurse documents that the client is experiencing which clinical manifestation?
Explanation
A) Intermittent claudication: This term describes the leg pain and cramping that occurs during physical activity, such as walking, and is relieved by rest. It is a classic symptom of peripheral arterial disease (PAD) and results from insufficient blood flow to the muscles due to narrowed or blocked arteries. The client's description aligns perfectly with this definition.
B) Neuropathy: While neuropathy can cause leg pain, it typically presents differently, often with sensations like tingling, numbness, or burning rather than cramping during activity. Neuropathy does not specifically correlate with the pattern of pain relief upon resting, which is characteristic of intermittent claudication.
C) Deep vein thrombosis (DVT): DVT generally presents with symptoms like swelling, warmth, and tenderness in the affected leg, rather than cramping pain that is related to activity. The pain associated with DVT is not typically relieved by rest, making this option inconsistent with the client’s symptoms.
D) Venous insufficiency: This condition is characterized by symptoms such as swelling, varicosities, and skin changes, primarily in the lower extremities. Pain related to venous insufficiency tends to occur after prolonged standing or sitting and is not typically relieved by rest in the same way as intermittent claudication. Therefore, this option does not accurately describe the client’s experience.
The nurse is educating the patient about the diagnosis of hypertension. Which statement made by the nurse is most accurate?
Explanation
A. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions.": This statement accurately reflects the criteria for diagnosing hypertension. According to guidelines, a diagnosis is typically confirmed when blood pressure readings consistently exceed normal levels (usually defined as 130/80 mm Hg) on two or more separate visits.
B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion.": This statement is incorrect. A single low reading does not confirm a diagnosis of hypertension. In fact, it contradicts the concept of hypertension, which involves consistently high readings.
C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions.": This statement is misleading. While multiple readings are often taken, the threshold for diagnosis is two or more elevated readings, not three.
D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion.": This statement is inaccurate, as a single elevated reading is not sufficient for diagnosis. Consistent elevations over multiple occasions are necessary for a confirmed diagnosis.
A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.
(Selectable areas, or "Hot Spots," can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
Explanation
The T-wave is the final positive deflection of the ECG cycle. It represents the repolarization of the ventricles.
Therefore, you would select the area of the ECG graph that shows a rounded, positive peak following the QRS complex.
A nurse is assessing client with advanced peripheral arterial disease (PAD). Which of the following findings would the nurse expect?
Explanation
A) Shiny, hairless lower extremities: In advanced peripheral arterial disease (PAD), the skin on the lower extremities often appears shiny and hairless due to reduced blood flow. The lack of hair growth and the shiny appearance are indicative of ischemia and poor circulation, making this a common finding in clients with advanced PAD.
B) Warm lower extremities: This finding is not typical in advanced PAD. Due to compromised blood flow, the lower extremities are more likely to feel cool or cold to the touch rather than warm. Warm skin can indicate good blood flow, which is usually absent in cases of significant arterial disease.
C) Thin toenails: In advanced PAD, toenails may become thin and brittle due to insufficient blood supply, which can lead to impaired nail growth. This change is consistent with the overall effects of reduced circulation and is an expected finding in clients with advanced PAD.
D) Lower extremity bilateral pulse 3+: A 3+ pulse indicates a strong and bounding pulse, which is not typically present in advanced PAD. In fact, patients with PAD often exhibit diminished or absent pulses in the affected extremities due to poor arterial circulation. Therefore, this finding does not align with the expected assessment results for advanced PAD.
A nurse is teaching a client just diagnosed with mild hypertension. Which of the following information should the nurse include in the teaching?
Explanation
A. "Diuretics are the first line therapy to control hypertension.": This statement is accurate. Thiazide diuretics are commonly recommended as first-line treatment for mild hypertension, as they help reduce blood volume and lower blood pressure effectively.
B. "Reaching your goal blood pressure will occur within 2 months.": While treatment can lead to improvements in blood pressure, the timeline for reaching target levels can vary significantly among individuals based on adherence to lifestyle changes and medication. It's important to communicate that achieving the goal may take longer than two months.
C. "Plan to add saturated fats to 10 percent of your daily calorie intake.": This recommendation is misleading. Guidelines generally suggest limiting saturated fats to less than 10 percent of total daily calories to promote heart health, not adding them.
D. "Limit your alcohol consumption to three drinks a day.": This statement is also inaccurate. For most adults, the recommendation is to limit alcohol to no more than two drinks per day for men and one drink per day for women to help manage blood pressure effectively.
A nurse is reviewing the medication list for a client who has a new prescription for warfarin. The nurse should recognize which is incompatible with warfarin?
Explanation
A) Vitamin A: While vitamin A can affect various bodily functions, it is not known to have a direct interaction with warfarin. Therefore, it is not considered incompatible with warfarin therapy.
B) Alprazolam: This medication, a benzodiazepine, is primarily used to treat anxiety and does not have a significant interaction with warfarin. Thus, it is not incompatible with warfarin therapy.
C) Vitamin K: This vitamin is a critical consideration when a client is on warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, so an increased intake of vitamin K can counteract the effects of warfarin, making this the correct answer. Clients on warfarin should maintain a consistent intake of vitamin K to prevent fluctuations in their INR levels.
D) Furosemide: This loop diuretic is used to manage conditions such as heart failure and edema. While it may affect electrolyte levels, it does not have a direct interaction that would render it incompatible with warfarin. It can be safely used alongside warfarin with appropriate monitoring.
A nurse is preparing to administer hydrochlorothiazide 25 mg PO daily to a client. Available is hydrochlorothiazide 50 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
To calculate the correct dosage, we can use the following formula:
Desired dose / Available dose = Volume to administer
Plugging in the values, we get:
25 mg / 50 mg/5 ml = Volume to administer
Simplifying, we get:
2.5 ml = Volume to administer
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