The nurse would evaluate the patient as understanding reinforcement of teaching for peripheral arterial occlusive disease if the patient stated that which of the following is the classic symptom?

Ecchymosis

Stasis ulcers

Angina

Intermittent claudication

Answer and Explanation

The Correct Answer is D

A. Ecchymosis: Ecchymosis (bruising) is not a typical symptom of peripheral arterial occlusive disease. It generally indicates bleeding or trauma to the skin and subcutaneous tissues.
B. Stasis ulcers: Stasis ulcers are associated with chronic venous insufficiency, not peripheral arterial disease.
C. Angina: Angina refers to chest pain due to reduced blood flow to the heart, and it is associated with coronary artery disease, not peripheral arterial occlusive disease.
D. Intermittent claudication: This is the classic symptom of peripheral arterial occlusive disease, characterized by muscle pain or cramping in the legs triggered by physical activity and relieved by rest. It is due to insufficient blood flow to the muscles during exercise.

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Correct Answer is C

Explanation

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

A. Impaired Physical Mobility B. Readiness for Enhanced Health Literacy C. Decreased Activity Tolerance D. Ineffective Airway Clearance

Correct Answer is B

Explanation

A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.

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The nurse would evaluate the patient as understanding reinforcement of teaching for peripheral arterial occlusive disease if the patient stated that which of the following is the classic symptom?

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Naxlex Comprehensive Predictor Exams

The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Correct Answer is C

Explanation

The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

Correct Answer is B

Explanation

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