Perfusion - Nursing Test Questions

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 16 Perfusion
The Concept of Perfusion
1) What will the nurse most likely assess in a client with right heart failure?
A) Leg cramps
B) Indigestion
C) Reduced circulation to the pulmonary structures
D) Reduced urine output
Answer: C
Explanation: A) Circulation to the pulmonary structures begins with the right side of the heart. The
client with right heart failure will have reduced circulation to these structures. There is no evidence to
suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with
right heart failure experience leg cramps.
B) Circulation to the pulmonary structures begins with the right side of the heart. The client with right
heart failure will have reduced circulation to these structures. There is no evidence to suggest that
right heart failure will cause indigestion or reduced urine output. Not all clients with right heart
failure experience leg cramps.
C) Circulation to the pulmonary structures begins with the right side of the heart. The client with right
heart failure will have reduced circulation to these structures. There is no evidence to suggest that
right heart failure will cause indigestion or reduced urine output. Not all clients with right heart
D) Circulation to the pulmonary structures begins with the right side of the heart. The client with
right heart failure will have reduced circulation to these structures. There is no evidence to suggest
that right heart failure will cause indigestion or reduced urine output. Not all clients with right heart
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the cardiovascular system related to perfusion.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Cluster activities.
B) Instruct on deep breathing.
C) Medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider teaching
the client the importance of deep breathing to increase the amount of oxygen in the body tissues.
Clustering activities would negatively impact oxygenation. Periods of rest should occur between
activities. The client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in the high-
Fowler position to improve oxygenation. Positions to increase blood flow to the heart would include
Trendelenburg, which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the
importance of deep breathing to increase the amount of oxygen in the body tissues. Clustering
activities would negatively impact oxygenation. Periods of rest should occur between activities. The
client with oxygenation issues will have tachycardia. The nurse should consider medications that
would reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart would include Trendelenburg,
which would negatively impact oxygenation.
C) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the
D) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the
Page Ref: 1051
Nursing Process: Planning
Learning Outcome: 2. Examine the relationship between perfusion and other concepts/systems.
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the
nurse expect to be indicated for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
Answer: A
Explanation: A) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin should be
avoided because it increases the force of contractions. The client should be on a sodium and fluid
restriction and not be encouraged to drink fluids.
B) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
C) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
D) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
Page Ref: 1052
Learning Outcome: 3. Identify commonly occurring alterations in perfusion and their related
therapies.
4) A client is admitted with complaints of lower extremity edema and occasional shortness of breath.
Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric
Answer: C
Explanation: A) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds
indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and
round. The ST segment should be isoelectric. The U wave is not normally seen.
B) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay
in conduction from the SA node to the ventricles. A P wave should be smooth and round. The ST
segment should be isoelectric. The U wave is not normally seen.
C) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay
D) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay
Page Ref: 1072
Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's perfusion
status.
5) The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease. What
should be included in this teaching?
Select all that apply.
A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake.
Answer: B, C
Explanation: A) Interventions that would help the client prevent the onset of cardiovascular disease
would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing
elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of exercise
a day may not be enough exercise to prevent the onset of cardiovascular disease.
B) Interventions that would help the client prevent the onset of cardiovascular disease would be to
avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing elastic hose
are not known to prevent the onset of cardiovascular disease. Fifteen minutes of exercise a day may
not be enough exercise to prevent the onset of cardiovascular disease.
C) Interventions that would help the client prevent the onset of cardiovascular disease would be to
D) Interventions that would help the client prevent the onset of cardiovascular disease would be to
E) Interventions that would help the client prevent the onset of cardiovascular disease would be to
Page Ref: 1054
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Explain management of cardiovascular health and prevention of
cardiovascular illness.
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not
sleeping well. What should the nurse suspect this client is experiencing?
A) Pancreatic disease
B) Cardiac disease
C) Normal changes of aging
D) Signs of anemia
Answer: B
Explanation: A) Many elderly women complain of vague symptoms when having a myocardial
infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present
pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia
would present with fatigue but not with nausea or chest discomfort.
B) Many elderly women complain of vague symptoms when having a myocardial infarction including
fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the
abdominal region. These symptoms are not considered normal changes of aging. Anemia would
present with fatigue but not with nausea or chest discomfort.
C) Many elderly women complain of vague symptoms when having a myocardial infarction including
D) Many elderly women complain of vague symptoms when having a myocardial infarction including
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Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring
interventions across the life span for individuals with common alterations in perfusion.
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about
this medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.
Answer: B
Explanation: A) Metoprolol is a beta blocker. The client should be instructed to use care when
ambulating and to change positions slowly since this medication causes orthostatic hypotension. This
medication does not cause a rapid heart rate. The client should not be instructed to increase fluids.
Protein restriction is not indicated with this medication.
B) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to
change positions slowly since this medication causes orthostatic hypotension. This medication does
not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein restriction
is not indicated with this medication.
C) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to
D) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to
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Learning Outcome: 8. Compare and contrast common independent and collaborative interventions
for clients with alterations in perfusion.
8) The nurse instructor is teaching a group of student nurses regarding the various layers of the heart.
Which statements will the nurse include?
A) "The endocardium covers the entire heart and great vessels."
B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat."
C) "The outermost layer of the heart is the epicardium."
D) "The myocardium consists of myofibril cells."
E) "The myocardium has four layers."
Answer: C, D
Explanation: A) The heart wall consists of three layers of tissue: the epicardium, the myocardium,
and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to
form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the
middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The
endocardium, which is the innermost layer, is a thin membrane composed of three layers. The
myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost
layer of the heart is the epicardium.
B) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form
the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the
C) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
D) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
E) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
Page Ref: 1032
Cognitive Level: Understanding
Learning Outcome: 1. Summarize the physiology of the cardiovascular system related to perfusion.
9) A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute. What is
the client's cardiac output (CO) rounded to the nearest whole number?
Answer: 6 Liters (L)
Explanation: CO = SV × HR
85mL = 0.085 L
CO = 0.085 × 71 = 6.035 = 6L
Page Ref: 1040
Learning Outcome: 4. Differentiate common assessment procedures used to examine cardiovascular
health across the life span.
10) A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse will
hear the client's murmur best at:
A) Right sternal border, second intercostal space.
B) Left sternal border, second intercostal space.
C) Right sternal border, third intercostal space.
D) Left sternal border, third to fifth intercostal space.
Answer: A
Explanation: A) The murmur associated with aortic stenosis is auscultated on the right sternal
border, second intercostal space.
B) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
C) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
D) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
Page Ref: 1039
Learning Outcome: 4. Differentiate common assessment procedures used to examine cardiovascular
health across the life span.
11) The nurse is caring for a client with hypertension. The nurse understands that the client's blood
pressure is determined by all the following factors except:
A) Pumping action of the heart.
B) Peripheral vascular resistance.
C) Heart rate.
D) Blood volume.
Answer: C
Explanation: A) The factors which determine blood pressure include the pumping action of the heart;
peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does not
determine blood pressure.
B) The factors which determine blood pressure include the pumping action of the heart; peripheral
vascular resistance; and blood volume and viscosity. Heart rate by itself does not determine blood
pressure.
C) The factors which determine blood pressure include the pumping action of the heart; peripheral
pressure.
D) The factors which determine blood pressure include the pumping action of the heart; peripheral
pressure.
Page Ref: 1045
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring
interventions across the life span for individuals with common alterations in perfusion.
Exemplar 16.1 Cardiomyopathy
1) An older client is diagnosed with dilated cardiomyopathy. What will the nurse most likely assess in
this client?
A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Jugular vein distention
Answer: A, B, D, E
Explanation: A) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity
edema, shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve,
arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation of
dilated cardiomyopathy.
B) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve, arrhythmias,
and blood clots may occur with disease progression. Syncope is not a manifestation of dilated
cardiomyopathy.
C) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
cardiomyopathy.
D) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
cardiomyopathy.
E) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
cardiomyopathy.
Page Ref: 1079
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and
indirect causes of cardiomyopathy.
2) A client tells the nurse that he knows he has high blood pressure but does not want to take any
medication. Which health problem is the client at risk of developing?
A) Gastritis
B) Diabetes
C) Cardiomyopathy
D) Metabolic syndrome
Answer: C
Explanation: A) Hypertension places the client at risk for development of cardiomyopathy.
Hypertension has not been associated with metabolic syndrome, diabetes, or gastritis.
B) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not
been associated with metabolic syndrome, diabetes, or gastritis.
C) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not
D) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not
Page Ref: 1079
Learning Outcome: 2. Identify risk factors associated with cardiomyopathy.
3) An older client diagnosed with cardiomyopathy reports having to rest between activities during the
day. What should the nurse realize is the reason for this client's fatigue?
A) Increased stroke volume
B) Decreased cardiac output
C) An elongated and dilated aorta
D) Increased blood pressure
Answer: B
Explanation: A) Decreased cardiac output is a result of decreased efficiency and contractibility of the
myocardium. Rest could be required after each activity that puts physiological stress on the heart.
Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this
has a direct effect on the activity level that can be tolerated. It is unknown if the client has high blood
pressure, an elongated and dilated aorta, or increased stroke volume.
B) Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium.
Rest could be required after each activity that puts physiological stress on the heart. Less blood is
pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct
effect on the activity level that can be tolerated. It is unknown if the client has high blood pressure, an
elongated and dilated aorta, or increased stroke volume.
C) Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium.
D) Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium.
Page Ref: 1081
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care across the
life span for individuals with cardiomyopathy.
4) A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation
and eating, and fatigued with routine care activities. The nurse would identify which of the following
nursing diagnoses as being appropriate for this client?
A) Imbalanced Nutrition: Less than Body Requirements
B) Deficient Knowledge
C) Activity Intolerance
D) Self-Care Deficit
Answer: C
Explanation: A) The client is short of breath with ambulation and eating, and fatigued with routine
care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time.
There is not enough information to determine if the client has a knowledge deficit. Shortness of
breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue with routine
care activities does not necessarily mean that the client has a Self-Care Deficit.
B) The client is short of breath with ambulation and eating, and fatigued with routine care activities.
The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. There is not
enough information to determine if the client has a knowledge deficit. Shortness of breath with meals
does not indicate that the client has Imbalanced Nutrition. Fatigue with routine care activities does
not necessarily mean that the client has a Self-Care Deficit.
C) The client is short of breath with ambulation and eating, and fatigued with routine care activities.
D) The client is short of breath with ambulation and eating, and fatigued with routine care activities.
Page Ref: 1080-1081
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
cardiomyopathy.
5) The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with
cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care?
A) Monitor brain natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.
Answer: C, E
Explanation: A) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include
assessing respiratory status and lung sounds every 4 hours and as needed and monitoring intake and
output. Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate
for the nursing diagnosis of Activity Intolerance.
B) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output.
Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
C) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
D) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
E) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
Page Ref: 1082
Learning Outcome: 6. Plan evidence-based care for an individual with cardiomyopathy and his or her
family in collaboration with other members of the healthcare team.
6) A client diagnosed with cardiomyopathy is being discharged to home. What client statement
indicates discharge teaching has been effective?
A) "I will exercise as much as possible, regardless of feeling weak and short of breath."
B) "My pants getting tight around the waist, means I'm eating too much and should cut back on food."
C) "I will eat foods containing sodium only if drinking water with them."
D) "I will see the physician to discuss implanting a cardiac defibrillator next week."
Answer: D
Explanation: A) Evidence that discharge instruction is effective for a client with cardiomyopathy
would be the statement "I will see the physician to discuss implanting a cardiac defibrillator next
week," as sudden cardiac death can occur with this medical diagnosis. The other client statements
would indicate that discharge teaching was not effective and the client needs additional instruction
and follow-up.
B) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
statement "I will see the physician to discuss implanting a cardiac defibrillator next week," as sudden
cardiac death can occur with this medical diagnosis. The other client statements would indicate that
discharge teaching was not effective and the client needs additional instruction and follow-up.
C) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
D) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
Page Ref: 1081
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with cardiomyopathy.
7) The nurse is preparing teaching for a client with hypertrophic cardiomyopathy. For which
medication classification should the nurse prepare to instruct this client?
A) Digitalis
B) Vasodilators
C) Nitrates
D) Beta blocker
Answer: D
Explanation: A) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal
episodes associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are
contraindicated for the client with hypertrophic cardiomyopathy.
B) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes associated
with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are contraindicated for the
client with hypertrophic cardiomyopathy.
C) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes associated
with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are contraindicated for the
client with hypertrophic cardiomyopathy.
D) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes
associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are contraindicated
for the client with hypertrophic cardiomyopathy.
Page Ref: 1080
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care
of an individual with cardiomyopathy.
8) A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours.
What should the nurse do to assist this client?
A) Assist the client to ambulate.
B) This is a normal urine output and the client does not need anything.
C) Notify the physician, as the client could be dehydrated.
D) Measure abdominal girth as a true assessment of the client's fluid status.
Answer: C
Explanation: A) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is
less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not
a normal urine output. The nurse should not assist the client out of bed to ambulate at this time. Daily
weights are an objective measurement of fluid volume and not abdominal girth.
B) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than 30
cc per hour. The client could be dehydrated despite having peripheral edema. This is not a normal
urine output. The nurse should not assist the client out of bed to ambulate at this time. Daily weights
are an objective measurement of fluid volume and not abdominal girth.
C) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than 30
D) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than 30
Page Ref: 1082
9) A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease.
The nurse will include all except:
A) Dilated.
B) Restrictive.
C) Hypotrophic.
D) Arrythmogenic right ventricular.
Answer: C
Explanation: A) The types of cardiomyopathy include dilated, restrictive, hypertrophic,
arrythmogenic right ventricular, and unclassified.
B) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
ventricular, and unclassified.
C) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
D) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
Page Ref: 1078
indirect causes of cardiomyopathy.
10) A client with cardiomyopathy is experiencing tachycardia. Which medication order does the
client's nurse anticipate?
A) ACE Inhibitor
B) Angiotensin II receptor blocker
C) Beta blocker
D) Cardiac glycoside
Answer: C
Explanation: A) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to
lower the heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure
in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not
assist in lowering the heart rate in a client with cardiomyopathy.
B) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart
rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure in a client with
cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not assist in lowering
the heart rate in a client with cardiomyopathy.
C) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart
D) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart
Page Ref: 1080
of an individual with cardiomyopathy.
11) A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity
Intolerance. The nurse plans all interventions except:
A) Spacing out nursing activities so client fatigue is lessened.
B) Assisting with client ADLs as necessary.
C) Using passive and active range-of-motion (ROM) exercises as tolerated.
D) Consulting with a physical therapist on an activity plan.
Answer: A
Explanation: A) The client who is experiencing activity intolerance should have nursing interventions
implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing
ROM exercises, and consulting with physical therapy are all interventions which support this nursing
diagnosis. The nurse should cluster nursing activities, not space them out, in order to conserve client
energy.
B) The client who is experiencing activity intolerance should have nursing interventions implemented
that encourage and preserve client energy. Assisting the client with ADLs, utilizing ROM exercises,
and consulting with physical therapy are all interventions which support this nursing diagnosis. The
nurse should cluster nursing activities, not space them out, in order to conserve client energy.
C) The client who is experiencing activity intolerance should have nursing interventions implemented
D) The client who is experiencing activity intolerance should have nursing interventions implemented
Page Ref: 1082
Client Need: Safe and Effective Care Environment
cardiomyopathy.
12) A nurse is educating a client with cardiomyopathy about diet choices which are appropriate for the
client's condition. The nurse will include all statements except:
A) "It is important to monitor your sodium intake."
B) "Increasing your dietary protein helps with cardiac cell repair."
C) "Here is a list of high-fat, high-cholesterol foods to avoid."
D) "I have notified the dietitian regarding your condition in order to provide you with more
information."
Answer: B
Explanation: A) Diet is an important part of long-term management of heart failure. It also
contributes to reducing fluid retention. The nurse will instruct the client with cardiomyopathy to
monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase
protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting with
the dietitian is appropriate with this client.
B) Diet is an important part of long-term management of heart failure. It also contributes to reducing
fluid retention. The nurse will instruct the client with cardiomyopathy to monitor sodium intake and
to avoid high-fat, high-cholesterol food. Instructing the client to increase protein is not appropriate
and is not shown effective in managing cardiomyopathy. Consulting with the dietitian is appropriate
with this client.
C) Diet is an important part of long-term management of heart failure. It also contributes to reducing
with this client.
D) Diet is an important part of long-term management of heart failure. It also contributes to reducing
with this client.
Page Ref: 1082
Exemplar 16.2 Congenital Heart Defects
1) The mother of a baby born with a congenital heart defect is upset, as no one else in the family has
been born with this condition. About what should the nurse ask the mother during the assessment?
A) Use of alcohol during the pregnancy
B) Maternal father's history of diabetes
C) Father's exposure to toxins in the work environment
D) History of hypertension
Answer: A
Explanation: A) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a
combination of environmental and genetic factors. Fetal exposure to alcohol is one of the greatest
factors for the development of these defects. A history of hypertension will not cause a fetus to
develop a congenital heart defect. The father's exposure to toxins in the work environment is not
known to cause congenital heart defects of children. The maternal father's history of diabetes also is
not known to cause congenital heart defects in children.
B) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of
environmental and genetic factors. Fetal exposure to alcohol is one of the greatest factors for the
development of these defects. A history of hypertension will not cause a fetus to develop a congenital
heart defect. The father's exposure to toxins in the work environment is not known to cause
congenital heart defects of children. The maternal father's history of diabetes also is not known to
cause congenital heart defects in children.
C) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of
D) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of
Page Ref: 1089
Learning Outcome: 2. Identify risk factors associated with congenital heart defects.
2) The nurse is analyzing data collected after assessing a child with a congenital heart defect that
decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client?
A) Risk for Infection related to engorged pulmonary vasculature
B) Interrupted Family Processes
C) Decreased Cardiac Output
D) Excess Fluid Volume
Answer: C
Explanation: A) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary
blood flow include Decreased Cardiac Output, Risk for Infection related to unfiltered bacteria in the
blood, Caregiver Role Strain, Activity Intolerance, and Delayed Growth and Development. Excess
Fluid Volume, Risk for Infection related to engorged pulmonary vasculature, and Interrupted Family
Processes are nursing diagnoses seen in the care of a client with a congenital heart defect that
increases pulmonary blood flow.
B) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow
include Decreased Cardiac Output, Risk for Infection related to unfiltered bacteria in the blood,
Caregiver Role Strain, Activity Intolerance, and Delayed Growth and Development. Excess Fluid
Volume, Risk for Infection related to engorged pulmonary vasculature, and Interrupted Family
C) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow
D) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow
Page Ref: 1101
congenital heart defects.
3) The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart
defect. Which intervention should the nurse include to support the client's fluid status?
A) Encourage fluids.
B) Limit fluids.
C) Monitor output.
D) Maintain intravenous therapy until day before discharge.
Answer: A
Explanation: A) The child should be encouraged to begin oral fluids and nutrition when permitted.
Although oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and
antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the line
can be converted to a heparin or saline lock. Both intake and output should be monitored.
B) The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral
fluids are rarely limited, intake and output should be carefully assessed. Fluids and antibiotics should
be provided as ordered until the child's oral intake is normal. Once normal, the line can be converted
to a heparin or saline lock. Both intake and output should be monitored.
C) The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral
D) The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral
Page Ref: 1102
Learning Outcome: 6. Plan evidence-based care for an individual with a congenital heart defect and
his or her family in collaboration with other members of the healthcare team.
4) The nurse provides discharge instructions to the parents of a child recovering from surgery to
repair a congenital heart defect. What statement indicates that teaching provided to these parents has
been effective?
A) "Our child should be restricted in play and activity for at least 6 months."
B) "Our child will need to take antibiotics prior to having dental surgery."
C) "Fluids should be restricted to maximize lung function."
D) "Our child should not return to normal activities for at least 2 years."
Answer: B
Explanation: A) Since the child is at risk for infective endocarditis, prophylactic antibiotics are
indicated for invasive procedures. The child should not be restricted in play and activities for at least 6
months. The child should not restrict fluids. The parents should be encouraged to have the child live a
normal life and not be restricted for 2 years.
B) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
invasive procedures. The child should not be restricted in play and activities for at least 6 months. The
child should not restrict fluids. The parents should be encouraged to have the child live a normal life
and not be restricted for 2 years.
C) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
D) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
Page Ref: 1103
Learning Outcome: 7. Evaluate expected outcomes for an individual with a congenital heart defect.
5) The nurse is caring for an infant diagnosed with patent ductus arteriosus. Which medication should
the nurse plan to provide this client?
A) Indomethacin
B) NSAIDS
C) Antidepressant
D) Insulin
Answer: A
Explanation: A) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in
premature infants. The infant will most likely not be prescribed an NSAID or an antidepressant. The
infant would be prescribed insulin if diabetes were diagnosed.
B) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
infants. The infant will most likely not be prescribed an NSAID or an antidepressant. The infant
would be prescribed insulin if diabetes were diagnosed.
C) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
D) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
Page Ref: 1084
of an individual with a congenital heart defects.
6) A baby will be having surgery to correct a congenital heart defect. On which topic should the
parents be instructed regarding the care of the child before surgery?
A) Restricting immunizations until after the surgery
B) Preventing exposure to infection
C) Implementing no particular precautions
D) Restricting fluids
Answer: B
Explanation: A) Preoperative care of a baby having surgery to correct a congenital heart defect should
include prevention from infection with good hand washing. There are precautions that the parents
should take to ensure the child is in optimal health prior to the surgery. Fluids are not to be restricted
but encouraged. Immunizations should be continued.
B) Preoperative care of a baby having surgery to correct a congenital heart defect should include
prevention from infection with good hand washing. There are precautions that the parents should
take to ensure the child is in optimal health prior to the surgery. Fluids are not to be restricted but
encouraged. Immunizations should be continued.
C) Preoperative care of a baby having surgery to correct a congenital heart defect should include
D) Preoperative care of a baby having surgery to correct a congenital heart defect should include
Page Ref: 1102
7) The nurse is assessing a toddler diagnosed with tetralogy of Fallot. Which assessment findings
should the nurse determine as being consistent with this child's diagnosis?
A) Palpable thrill in the pulmonic area
B) Nail clubbing
C) Cough
D) Apneic periods
E) Knee e-chest position
Answer: A, B, E
Explanation: A) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area,
clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the child will
perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods are
not manifestations of this congenital heart defect.
B) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of the
fingers due to reduce oxygenation, and the knee-chest position, which the child will perform to
decrease the return of systemic venous blood to the heart. A cough and apneic periods are not
manifestations of this congenital heart defect.
C) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of the
D) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of the
E) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of the
Page Ref: 1088
indirect causes of congenital heart defects.
8) A nurse working in the Neonatal Intensive Care Unit (NICU) is caring for a preterm infant with a
congenital heart defect. The nurse knows that these conditions are categorized by:
A) Severity of defect.
B) Pathophysiology and hemodynamics of defect.
C) Location of defect.
D) Age when defect diagnosed.
Answer: B
Explanation: A) Congenital heart defects are categorized by their pathophysiology and
hemodynamics.
B) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
C) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
D) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
Page Ref: 1077
9) A nurse working in Labor and Delivery is assessing a term newborn for congenital heart defects.
The nurse understands that manifestations of an atrial septal defect (ASD) may include:
A) Pulmonary artery hypotension and congestive heart failure.
B) Midsystolic murmur at lower right sternal border, due to increased blood flow across the tricuspid
valve.
C) Mitral valve regurgitation with cleft on mitral valve.
D) S1 heart tone may be split due to forceful left ventricular contraction.
Answer: C, D
Explanation: A) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum
permitting left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left
sternal border, due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may
occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular
contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.
B) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting left-
to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal border,
due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may occur with a
cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular contraction.
Finally, pulmonary artery hypertension and congestive heart failure may occur.
C) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting left-
D) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting left-
Page Ref: 1084-1085
10) A nurse is educating the parents of a child born with tetralogy of Fallot. Which statement will the
nurse include regarding this defect?
A) "Increased pulmonary blood flow causes symptoms with this disease."
B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect,
and an overriding aorta."
C) "Your child has a decreased amount of red blood cells because of this disease."
D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal
defect, and an overriding aorta."
Answer: D
Explanation: A) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular
hypertrophy, ventricular septal defect, and an overriding aorta. This disease is also characterized by
decreased pulmonary blood flow, and polycythemia (increased red blood cells due to hypoxia).
B) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased
pulmonary blood flow, and polycythemia (increased red blood cells due to hypoxia).
C) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
D) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
Page Ref: 1088
life span for individuals with congenital heart defects.
11) A physician caring for a client with hypoplastic left heart syndrome has provided the client's family
with information regarding the surgical repair necessary for this condition. The client's nurse knows
that this procedure is named the:
A) Glenn procedure.
B) Jatene procedure.
C) Fontan procedure.
D) Damus-Kaye-Stansel procedure.
Answer: A
Explanation: A) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The
Jatene procedure and the Damus-Kaye-Stansel procedure surgically repairs the Transportation of
Great Arteries. The Fontan procedure surgically repairs tricuspid atresia, pulmonary atresia, and
hypoplastic left heart syndrome.
B) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
procedure and the Damus-Kaye-Stansel procedure surgically repairs the Transportation of Great
Arteries. The Fontan procedure surgically repairs tricuspid atresia, pulmonary atresia, and
C) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
D) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
Page Ref: 1099
Exemplar 16.3 Coronary Artery Disease
1) A client with angina complains that the pain is prolonged and severe, and occurs at the same time
each day while at rest. There are no precipitating factors to the pain. How should the nurse describe
this type of angina pain?
A) Non-anginal pain
B) Atypical angina (Prinzmetal angina)
C) Unstable angina
D) Stable angina
Answer: B
Explanation: A) Atypical or Prinzmetal angina often occurs at the same time each day and typically at
rest. Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is
not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with angina,
and, therefore, the pain the client is experiencing is angina.
B) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest. Stable
angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is not relieved
by rest or nitroglycerin and is less predictable. The client has been diagnosed with angina, and,
therefore, the pain the client is experiencing is angina.
C) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest. Stable
D) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest. Stable
Page Ref: 1107
indirect causes of coronary artery disease.
2) A client with a history of myocardial infarctions tells the nurse that he has been smoking for 35
years and it does not matter now if he stops. What should the nurse respond to this client?
A) "Your risk of continued coronary heart disease will decrease by half when you stop."
B) "It will enhance the effects of your medications."
C) "It will reduce your risk of lung cancer."
D) "It will decrease any complications you might develop."
Answer: A
Explanation: A) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how
long the person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance
medication effects, but the primary focus for this client is the effect on coronary heart disease.
B) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance
C) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
D) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
Page Ref: 1110
Learning Outcome: 2. Identify risk factors associated with coronary artery disease.
3) The nurse is preparing preoperative teaching for an older client scheduled for a ventricular assist
device. What should the nurse include in these instructions?
A) Need to stay on bed rest for a week or more
B) Cardiac pain postoperatively is to be expected.
C) Risk for postoperative infection
D) Expect to be ambulating the evening of surgery.
Answer: C
Explanation: A) Clients with VAD are at considerable risk for infection; strict aseptic technique is
used with all invasive catheters and dressing changes. The client may or may not be on bed rest for a
week or more after the surgery. The client, however, will most likely not be ambulating the evening of
the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial
infarction.
B) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all
invasive catheters and dressing changes. The client may or may not be on bed rest for a week or more
after the surgery. The client, however, will most likely not be ambulating the evening of the surgery.
Cardiac pain postoperatively is not to be expected and could indicate a myocardial infarction.
C) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all
D) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all
Page Ref: 1123
life span for individuals with coronary artery disease.
4) A client, admitted with irregular chest pain and shortness of breath, complains of fatigue with
activity. The client's body mass index (BMI) is 30.5. Which nursing diagnosis would be a priority for
the client at this time?
A) Ineffective Coping
B) Fear
C) Imbalanced Nutrition: More than Body Requirements.
D) Fluid Volume Deficit
Answer: C
Explanation: A) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain
and shortness of breath, and complains of fatigue with activity. The priority nursing diagnosis for the
client at this time would be Imbalanced Nutrition: More than Body Requirements. Fear and
Ineffective Coping would be applicable to the client diagnosed with an acute myocardial infarction.
There is no evidence that the client has Fluid Volume Deficit.
B) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and shortness
of breath, and complains of fatigue with activity. The priority nursing diagnosis for the client at this
time would be Imbalanced Nutrition: More than Body Requirements. Fear and Ineffective Coping
would be applicable to the client diagnosed with an acute myocardial infarction. There is no evidence
that the client has Fluid Volume Deficit.
C) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and shortness
D) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and shortness
Page Ref: 1124
coronary artery disease.
5) The nurse is instructing an older client about atorvastatin (Lipitor) to treat elevated cholesterol.
What side effects should the nurse advise the client to report to the healthcare provider?
A) Headaches
B) Muscle pain and weakness
C) Bruising and excessive bleeding
D) Shortness of breath
Answer: B
Explanation: A) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation,
elevated enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms
while on these medications. The other symptoms are unrelated to statin drugs.
B) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms while on
these medications. The other symptoms are unrelated to statin drugs.
C) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
D) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
Page Ref: 1118
Learning Outcome: 6. Plan evidence-based care for an individual with coronary artery disease and his
or her family in collaboration with other members of the healthcare team.
6) The nurse is providing care to a client who has experienced several episodes of angina. What is the
primary outcome for this client?
A) The client will experience relief of chest pain with therapeutic lifestyle changes.
B) The client will experience relief of chest pain with aspirin therapy.
C) The client will experience relief of chest pain with nitrate therapy.
D) The client will experience relief of chest pain with anticoagulant therapy.
Answer: C
Explanation: A) A primary goal in the treatment of angina is to reduce the intensity and frequency of
angina episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina
episode. Anticoagulant therapy is used to prevent additional thrombi from forming post-myocardial
infarction; it will not relieve angina pain. Therapeutic lifestyle changes are significant if the client is to
maintain a healthy heart, but they will not relieve chest pain; this is accomplished with medications.
Aspirin therapy following an acute myocardial infarction dramatically reduces mortality due to its
antiplatelet function; it will not relieve angina pain.
B) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina
C) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
D) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
Page Ref: 1124
Learning Outcome: 7. Evaluate expected outcomes for an individual with coronary artery disease.
7) A client recovering from an acute myocardial infarction is prescribed aspirin. What should the
nurse instruct the client about this medication?
A) Report any itching after seven days of taking.
B) Check with your healthcare provider before taking herbal remedies.
C) Take at a different time of day than warfarin.
D) Report bleeding or bruising to the healthcare provider.
E) Do not skip any scheduled appointments to have blood drawn for labs.
Answer: B, D
Explanation: A) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed
extract can increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation.
Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not a
common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently. No lab
appointments will be made just for aspirin therapy.
B) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation. Bleeding
and bruising can occur, and should be reported to the healthcare provider. Itching is not a common
side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently. No lab
C) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
D) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
E) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
Page Ref: 1120
of an individual with coronary artery disease.
8) A client with angina is experiencing acute chest pain. What actions would the nurse implement at
this time?
A) Administer antianxiety medication as prescribed.
B) Coach in non-pharmacological pain management techniques.
C) Keep on bed rest.
D) Administer morphine sulfate 2 mg intravenous push as prescribed.
E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.
Answer: C, D, E
Explanation: A) Interventions for the client experiencing acute chest pain include administering
oxygen as prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
pharmacologic pain management techniques are not appropriate for an episode of acute chest pain.
Antianxiety medications are not effective in acute chest pain.
B) Interventions for the client experiencing acute chest pain include administering oxygen as
prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
C) Interventions for the client experiencing acute chest pain include administering oxygen as
D) Interventions for the client experiencing acute chest pain include administering oxygen as
E) Interventions for the client experiencing acute chest pain include administering oxygen as
Page Ref: 1126
Learning Outcome: 6. Plan evidence-based care for an individual with coronary artery disease and his
9) A nurse is providing discharge education to a client who has been diagnosed with angina. Which
statement would the nurse exclude from teaching?
A) "Stable angina is the most common form of angina."
B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise."
C) "Unstable angina occurs with increasing frequency, severity, and duration."
D) "Clients with unstable angina are at risk for a heart attack."
Answer: B
Explanation: A) Angina results from ischemia and can be a one-time event or a chronic condition.
There are three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common
form of angina and is relieved with rest and nitrate medications. Unstable angina occurs with
increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart
attack, or myocardial infarction.
B) Angina results from ischemia and can be a one-time event or a chronic condition. There are three
types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form of angina
and is relieved with rest and nitrate medications. Unstable angina occurs with increasing frequency,
severity, and duration. Clients with unstable angina are at risk for a heart attack, or myocardial
infarction.
C) Angina results from ischemia and can be a one-time event or a chronic condition. There are three
infarction.
D) Angina results from ischemia and can be a one-time event or a chronic condition. There are three
infarction.
Page Ref: 1107
10) A nurse is caring for a client who has been successfully resuscitated after a myocardial infarction.
The client has now developed an arrhythmia. The nurse understands that the causes of this
arrhythmia are all of the following except:
A) Tissue alkalosis.
B) Cellular acidosis.
C) Electrolyte imbalance.
D) Hypoxia.
Answer: A
Explanation: A) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and
myocardial contractility. The risk for dysrhythmias increases, and myocardial contractility decreases,
reducing stroke volume, cardiac output, blood pressure, and tissue perfusion.
B) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and myocardial
contractility. The risk for dysrhythmias increases, and myocardial contractility decreases, reducing
stroke volume, cardiac output, blood pressure, and tissue perfusion.
C) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and myocardial
D) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and myocardial
Page Ref: 1090
indirect causes of coronary artery disease.
11) A nurse is caring for a client suspected of a cocaine-induced myocardial infarction. Cocaine may
cause a myocardial infarction because the drug:
A) Significantly increases the serum triglyceride level, leading to the development of an atheroma.
B) Alters the body's clotting mechanisms, leading to thrombus formation.
C) Increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction.
D) Alters electrolyte balance, leading to arrhythmias.
Answer: C
Explanation: A) Acute myocardial infarction may also develop as a result of cocaine intoxication.
Cocaine increases sympathetic nervous system activity by both increasing the release of
catecholamines from central and peripheral stores and interfering with the reuptake of
catecholamines. This increased catecholamine concentration stimulates the heart rate and increases
its contractility, increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes
vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.
B) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine increases
sympathetic nervous system activity by both increasing the release of catecholamines from central
and peripheral stores and interfering with the reuptake of catecholamines. This increased
catecholamine concentration stimulates the heart rate and increases its contractility, increases the
automaticity of cardiac tissues and the risk of dysrhythmias, and causes vasoconstriction and
hypertension. The other answers do not occur with cocaine intoxication.
C) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine increases
D) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine increases
Page Ref: 1108
Learning Outcome: 2. Identify risk factors associated with coronary artery disease.
12) A community care nurse is providing education to a group of adults regarding myocardial
infarction (MI). When discussing ways to decrease the number of MI-related deaths, the nurse will
include all of the following statements except:
A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR) techniques."
B) "Be sure to take a baby aspirin every day to help prevent an MI."
C) "Increase your knowledge of cardiac health and cardiac-related disease."
D) "Seek immediate medical attention when you suspect an MI."
Answer: B
Explanation: A) When educating clients regarding ways to decrease the number of MI-related deaths,
the nurse will stress the importance of prevention. Learning about cardiac health and cardiac disease,
as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical attention
when they suspect an MI. However, instructing all clients to take a baby aspirin every day to help
prevent an MI is inappropriate, as not all clients should take this medication.
B) When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will
stress the importance of prevention. Learning about cardiac health and cardiac disease, as well as
learning CPR, is appropriate. Clients should be taught to seek immediate medical attention when they
suspect an MI. However, instructing all clients to take a baby aspirin every day to help prevent an MI
is inappropriate, as not all clients should take this medication.
C) When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will
D) When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will
Page Ref: 1118
Exemplar 16.4 Deep Venous Thrombosis
1) The nurse is completing an assessment on a newly admitted client. What assessment finding would
suggest to the nurse that a client is experiencing a deep venous thrombosis?
A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with pitting edema
D) Bilateral calf tenderness after walking up a flight of stairs
Answer: C
Explanation: A) Manifestations of deep venous thrombosis include swelling in one leg with pitting
edema because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be
a normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity
and two-plus palpable pulses are not manifestations of deep venous thrombosis.
B) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema because
the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal
reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity and two-plus
palpable pulses are not manifestations of deep venous thrombosis.
C) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema because
D) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema because
Page Ref: 1131
indirect causes of deep venous thrombosis.
2) The nurse is planning care for a group of clients. Which client should the nurse realize has the
greatest risk for developing deep venous thrombosis?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery
Answer: D
Explanation: A) Up to 60% of clients recovering from total knee replacement surgery can develop a
deep venous thrombosis. This is because of the procedure and prolonged immobility after surgery.
The client admitted with new-onset type II diabetes mellitus, the client admitted with community-
acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a
lower risk for deep venous thrombosis because prolonged immobility will not occur.
B) Up to 60% of clients recovering from total knee replacement surgery can develop a deep venous
thrombosis. This is because of the procedure and prolonged immobility after surgery. The client
admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired
pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk
for deep venous thrombosis because prolonged immobility will not occur.
C) Up to 60% of clients recovering from total knee replacement surgery can develop a deep venous
D) Up to 60% of clients recovering from total knee replacement surgery can develop a deep venous
Page Ref: 1131
Learning Outcome: 2. Identify risk factors associated with deep venous thrombosis.
3) A client recovering from a cesarean section is afebrile but is experiencing tenderness, localized
heat, and redness of the left leg. What would be the best intervention for the client at this time?
A) Encourage to ambulate freely.
B) Provide aspirin 650 mg by mouth.
C) Place on bed rest.
D) Provide Methergine IM.
Answer: C
Explanation: A) These symptoms indicate the presence of superficial thrombophlebitis. The
treatment involves bed rest and elevation of the affected limb, analgesics, and the use of elastic
support hose. Ambulation would increase the inflammation. Aspirin does have anticoagulant
properties but may not be the medication of choice at this time. Methergine is given only for
postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.
B) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed
rest and elevation of the affected limb, analgesics, and the use of elastic support hose. Ambulation
would increase the inflammation. Aspirin does have anticoagulant properties but may not be the
medication of choice at this time. Methergine is given only for postpartum hemorrhage and would
cause vasoconstriction of an already inflamed vessel.
C) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed
D) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed
Page Ref: 1130
life span for individuals with deep venous thrombosis.
4) The nurse is planning care for a client with deep venous thrombosis. Which nursing diagnosis
would be a priority for this client?
A) Risk for Infection related to obstructed venous return
B) Excess Fluid Volume related to tissue edema
C) Ineffective Tissue Perfusion related to obstructed venous return
D) Disturbed Sleep Pattern related to tissue hypoxia
Answer: C
Explanation: A) Ineffective Tissue Perfusion related to obstructed venous return is the correct
diagnosis because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and
Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the
underlying cause. Risk for Infection related to obstructed venous return would be a priority if
complications of infection were present, however this is not the case.
B) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it
identifies the underlying cause. Excess Fluid Volume related to tissue edema and Disturbed Sleep
Pattern related to tissue hypoxia are incorrect because they do not identify the underlying cause. Risk
for Infection related to obstructed venous return would be a priority if complications of infection were
present, however this is not the case.
C) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it
D) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it
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Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with deep
venous thrombosis.
5) The nurse is providing discharge instructions to a postpartum client recovering from deep venous
thrombosis. What should these instructions include?
A) Avoid crossing the legs.
B) Avoid long car trips.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
E) Take a daily aspirin dose of 650 mg.
Answer: A, C, D
Explanation: A) The client should be instructed to avoid crossing the legs because it increases
pressure on the veins of the lower extremities. The client should be instructed also to avoid prolonged
standing or sitting, which contributes to venous stasis. The client should also be instructed to take
frequent walks to promote venous return. The client should not be instructed to take a daily aspirin,
because it will increase anticoagulant activity and could interact with other medication prescribed for
the treatment of the deep venous thrombosis. The client does not need to be instructed to avoid long
car trips but rather to take frequent breaks during long car trips.
B) The client should be instructed to avoid crossing the legs because it increases pressure on the veins
of the lower extremities. The client should be instructed also to avoid prolonged standing or sitting,
which contributes to venous stasis. The client should also be instructed to take frequent walks to
promote venous return. The client should not be instructed to take a daily aspirin, because it will
increase anticoagulant activity and could interact with other medication prescribed for the treatment
of the deep venous thrombosis. The client does not need to be instructed to avoid long car trips but
rather to take frequent breaks during long car trips.
C) The client should be instructed to avoid crossing the legs because it increases pressure on the veins
D) The client should be instructed to avoid crossing the legs because it increases pressure on the veins
E) The client should be instructed to avoid crossing the legs because it increases pressure on the veins
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Learning Outcome: 6. Plan evidence-based care for an individual with deep venous thrombosis and
6) A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What does the
nurse identify as the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows.
Answer: C
Explanation: A) An absence of bleeding is a priority outcome for any client receiving anticoagulant
therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate
with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding.
Elevation of the affected extremity is important but not as high a priority as an absence of bleeding.
B) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with
heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding.
C) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
D) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
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Learning Outcome: 7. Evaluate expected outcomes for an individual with deep venous thrombosis.
7) A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and
shortness of breath. Suspecting a pulmonary embolism, what action should the nurse perform first?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.
Answer: B
Explanation: A) Applying oxygen and elevating the head of the bed will promote ventilation and gas
exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing
the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
Reassuring the client and notifying family members are not priorities, although these measures can
decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to
increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be
performed following the initiation of oxygen therapy and bed elevation.
B) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in
those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of
heparin infusion cannot be done by the nurse without an order from a healthcare provider.
C) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in
D) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in
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of an individual with deep venous thrombosis.
8) A client being treated for a deep venous thrombosis is experiencing pain. What can the nurse do to
assist this client?
A) Apply an egg-crate mattress on the bed.
B) Maintain bed rest as ordered.
C) Apply warm moist heat to the area four times a day.
D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily.
Answer: B, C, E
Explanation: A) Interventions to address pain include applying warm moist heat to the area four
times a day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying
an egg-crate mattress on the bed and encouraging position changes every 2 hours would be
appropriate for the client experiencing Ineffective Tissue Perfusion.
B) Interventions to address pain include applying warm moist heat to the area four times a day,
maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate
mattress on the bed and encouraging position changes every 2 hours would be appropriate for the
client experiencing Ineffective Tissue Perfusion.
C) Interventions to address pain include applying warm moist heat to the area four times a day,
D) Interventions to address pain include applying warm moist heat to the area four times a day,
E) Interventions to address pain include applying warm moist heat to the area four times a day,
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Learning Outcome: 6. Plan evidence-based care for an individual with deep venous thrombosis and
Exemplar 16.5 Disseminated Intravascular Coagulation
1) A client is admitted to the Intensive Care Unit with disseminated intravascular coagulation. What
will the nurse most likely assess in this client?
A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions
Answer: A, C, D
Explanation: A) Clinical manifestations of disseminated intravascular coagulation include decreased
breath sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are
not associated with this health problem.
B) Clinical manifestations of disseminated intravascular coagulation include decreased breath sounds,
tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are not associated
with this health problem.
C) Clinical manifestations of disseminated intravascular coagulation include decreased breath sounds,
D) Clinical manifestations of disseminated intravascular coagulation include decreased breath
sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are not
associated with this health problem.
E) Clinical manifestations of disseminated intravascular coagulation include decreased breath sounds,
Page Ref: 1140
indirect causes of disseminated intravascular coagulation.
2) The nurse is planning an educational program to instruct clients on disseminating intravascular
coagulation (DIC). What should the nurse include as risk factors for this health problem?
A) Multiparity
B) Abruptio placentae
C) Preterm labor
D) Prolonged retention of a fetus after demise
E) Diabetes mellitus
Answer: B, D
Explanation: A) Abruptio placentae leave intrauterine arteries open and bleeding. This results in
release of thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal
tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the
formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.
Diabetes, multiparity, and preterm labor do not cause the same release of thromboplastin that
triggers DIC.
B) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In prolonged
retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into
the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of
multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Diabetes,
multiparity, and preterm labor do not cause the same release of thromboplastin that triggers DIC.
C) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
D) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
E) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
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Learning Outcome: 2. Identify risk factors associated with disseminated intravascular coagulation.
3) The nurse is caring for a child with disseminated intravascular coagulation (DIC).What will the
nurse include as a priority intervention for this client?
A) Frequent ambulation
B) Maintenance of skin integrity
C) Preparation for radiograph procedures
D) Monitoring of fluid restriction
Answer: B
Explanation: A) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should
be placed on bed rest. Fluids need to be monitored but will not be restricted. DIC is not diagnosed
with radiograph examination but by serum lab studies.
B) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on
bed rest. Fluids need to be monitored but will not be restricted. DIC is not diagnosed with radiograph
examination but by serum lab studies.
C) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on
D) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be placed on
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life span for individuals with disseminated intravascular coagulation.
4) A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen
saturation. Which nursing diagnosis is the most appropriate for the client at this time?
A) Pain
B) Impaired Gas Exchange
C) Ineffective Tissue Perfusion
D) Anxiety
Answer: B
Explanation: A) The decrease in oxygen saturation is causing an impairment in the client's gas
exchange. Anxiety could contribute to the client's impaired gas exchange but is not the primary
problem to address. Decreased oxygen saturation and anxiety would not be addressed with the
diagnoses of Ineffective Tissue Perfusion and Pain.
B) The decrease in oxygen saturation is causing an impairment in the client's gas exchange. Anxiety
could contribute to the client's impaired gas exchange but is not the primary problem to address.
Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of Ineffective
Tissue Perfusion and Pain.
C) The decrease in oxygen saturation is causing an impairment in the client's gas exchange. Anxiety
D) The decrease in oxygen saturation is causing an impairment in the client's gas exchange. Anxiety
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disseminated intravascular coagulation.
5) The nurse has identified Ineffective Tissue Perfusion as a diagnosis for a client with disseminated
intravascular coagulation. What intervention would be appropriate for the client?
A) Carefully repositioning the client every 2 hours
B) Administering oxygen
C) Monitoring oxygen saturation
D) Encouraging deep breathing and coughing
Answer: A
Explanation: A) The intervention appropriate for the client experiencing ineffective tissue perfusion
is to carefully reposition the client every 2 hours because position changes facilitate circulation and
tissue perfusion. The other interventions would be appropriate if the client were experiencing
impaired gas exchange.
B) The intervention appropriate for the client experiencing ineffective tissue perfusion is to carefully
reposition the client every 2 hours because position changes facilitate circulation and tissue perfusion.
The other interventions would be appropriate if the client were experiencing impaired gas exchange.
C) The intervention appropriate for the client experiencing ineffective tissue perfusion is to carefully
D) The intervention appropriate for the client experiencing ineffective tissue perfusion is to carefully
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Learning Outcome: 6. Plan evidence-based care for an individual with disseminated intravascular
coagulation and his or her family in collaboration with other members of the healthcare team.
6) The nurse is evaluating care provided to a client with disseminated intravascular coagulation.
Which observation indicates care has been successful for this client?
A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 cc per hour
D) No evidence of bleeding
Answer: D
Explanation: A) Care provided to a client with disseminated intravascular coagulation is successful
when there is no further bleeding. Oxygen saturation of 86% is evidence that treatment is needed.
Heart rate of 110 beats per minute is evidence that treatment is needed. Urine output of 20 cc per
hour is below normal limits and would indicate the need for further treatment.
B) Care provided to a client with disseminated intravascular coagulation is successful when there is no
further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate of 110
beats per minute is evidence that treatment is needed. Urine output of 20 cc per hour is below normal
limits and would indicate the need for further treatment.
C) Care provided to a client with disseminated intravascular coagulation is successful when there is no
further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate of 110
D) Care provided to a client with disseminated intravascular coagulation is successful when there is
no further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate of 110
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Learning Outcome: 7. Evaluate expected outcomes for an individual with disseminated intravascular
coagulation.
7) A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through
the gastrointestinal tract. What will the nurse expect to provide for the client?
A) Aspirin
B) Coumadin
C) Fresh frozen plasma and platelets
D) Heparin
Answer: C
Explanation: A) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet
concentrates are given to restore clotting factors and platelets. Heparin may be administered if
bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic
problems. Coumadin and aspirin are not indicated in the treatment of DIC.
B) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates
are given to restore clotting factors and platelets. Heparin may be administered if bleeding is not
controlled by plasma and platelets and if the client has manifestations of thrombotic problems.
Coumadin and aspirin are not indicated in the treatment of DIC.
C) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates
D) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates
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of an individual with disseminated intravascular coagulation.
8) A client with disseminated intravascular coagulation is experiencing joint pain. Which nursing
intervention should the nurse use to help the client at this time?
A) Splints
B) Cool compresses
C) Heat
D) Ice
Answer: B
Explanation: A) Joint pain associated with disseminated intravascular coagulation can be reduced by
applying cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will
encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and are
not indicated for the care of this client. Ice should not be applied but rather cool compresses.
B) Joint pain associated with disseminated intravascular coagulation can be reduced by applying cool
compresses to the affected joints to reduce the transmission of pain impulses. Heat will encourage
bleeding and should not be applied to this client. Splints may hinder joint mobility and are not
indicated for the care of this client. Ice should not be applied but rather cool compresses.
C) Joint pain associated with disseminated intravascular coagulation can be reduced by applying cool
D) Joint pain associated with disseminated intravascular coagulation can be reduced by applying cool
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Learning Outcome: 6. Plan evidence-based care for an individual with disseminated intravascular
coagulation and his or her family in collaboration with other members of the healthcare team.
9) A nurse caring for a client with disseminated intravascular coagulation (DIC) is reviewing the
client's diagnostic tests. Which test result is common in DIC?
A) Decreased prothrombin time
B) Increased platelet count
C) Decreased fibrinogen level
D) Decreased partial thromboplastin time
Answer: C
Explanation: A) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for
hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the
depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting
factors.
B) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage.
DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting
factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors.
C) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage.
D) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage.
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of an individual with disseminated intravascular coagulation.
10) A nurse working in labor and delivery is caring for a client with suspected DIC. The nurse is aware
that DIC most often occurs in which pregnancy complication?
A) Gestational diabetes
B) Polyhydramnios
C) Placental abruption
D) Placenta previa
Answer: C
Explanation: A) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
B) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
C) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
D) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
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life span for individuals with disseminated intravascular coagulation.
11) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective
Tissue Perfusion. Which nursing action does not support this diagnosis?
A) Monitor the client's level of consciousness and mental status.
B) Elevate the client's knees on the bed or with a pillow.
C) Minimize the use of tape on the client's skin.
D) Assess extremity pulses, warmth, and capillary refill.
Answer: B
Explanation: A) Thrombi and emboli forming throughout the microcirculation in DIC affect the
perfusion of multiple organs and tissues. The nurse should monitor the client's level of consciousness
and mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin
ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth,
and capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not
elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow
to the lower legs and feet, increasing vascular stasis and the risk for thrombosis.
B) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
multiple organs and tissues. The nurse should monitor the client's level of consciousness and mental
status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin ensures
protecting the integrity of the client's skin. The nurse will assess extremity pulses, warmth, and
capillary refill, which facilitates the early treatment of impaired perfusion. The nurse should not
C) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
D) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
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12) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired
Gas Exchange. Which nursing action does not support this diagnosis?
A) Place client in low-Fowler position to improve gas exchange.
B) Monitor the client's oxygen saturation continuously.
C) Maintain bed rest.
D) Encourage deep breathing and coughing.
Answer: A
Explanation: A) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in
the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve
gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and
encouraging deep breathing and coughing are all interventions the nurse should implement.
B) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with
DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange.
Monitoring the client's oxygen saturation continuously, maintaining bed rest, and encouraging deep
breathing and coughing are all interventions the nurse should implement.
C) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with
D) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with
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Exemplar 16.6 Heart Failure
1) During hospitalization for congestive heart failure, a client awakens during the night frightened and
short of breath. What is this client most likely experiencing?
A) Cardiomyopathy
B) Paroxysmal nocturnal dyspnea
C) High-output failure
D) Multisystem heart failure
Answer: B
Explanation: A) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated
during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary
congestion. The client awakens at night short of breath and frightened. The client is not experiencing
multisystem heart failure, cardiomyopathy, or high-output failure.
B) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is
reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The
client awakens at night short of breath and frightened. The client is not experiencing multisystem
heart failure, cardiomyopathy, or high-output failure.
C) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is
D) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is
Page Ref: 1149
indirect causes of heart failure.
2) The nurse is planning care for several clients. Which client has the greatest risk of developing heart
failure?
A) A 69-year-old African-American male with hypertension
B) A 50-year-old African-American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma
Answer: A
Explanation: A) Age, race, and hypertension lead to an increased risk for developing heart failure.
Race and smoking are risk factors, but being female and younger decreases the overall risk. Age and
obesity are risk factors, but not as much as age, being African-American, and having hypertension.
Asthma is not considered a significant risk factor in the development of heart failure.
B) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
smoking are risk factors, but being female and younger decreases the overall risk. Age and obesity are
risk factors, but not as much as age, being African-American, and having hypertension. Asthma is not
considered a significant risk factor in the development of heart failure.
C) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
D) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
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Learning Outcome: 2. Identify risk factors associated with heart failure.
3) The nurse is caring for a child with heart failure. What will the nurse most likely assess in this
child?
A) Shortness of breath
B) Weight loss
C) Bradycardia
D) Tachycardia
E) Increased blood pressure
Answer: A, D
Explanation: A) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output
by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious
sign and can indicate impending cardiac arrest, but is not a typical assessment finding in a client with
CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases
because of retention of fluids.
B) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and can
indicate impending cardiac arrest, but is not a typical assessment finding in a client with CHF. Blood
pressure does not increase in CHF, and the weight, instead of decreasing, increases because of
retention of fluids.
C) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
D) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
E) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
Page Ref: 1148
life span for individuals with heart failure.
4) During an assessment, a client with congestive heart failure and severe shortness of breath tells the
nurse about not having enough money to purchase medications. What nursing diagnosis is of the
greatest initial importance when planning care?
A) Excess Fluid Volume related to shortness of breath
B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications
C) Fatigue related to shortness of breath
D) Activity Intolerance related to shortness of breath
Answer: A
Explanation: A) The client is experiencing acute shortness of breath because of the excess fluid.
Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and
Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of
Therapeutic Regime related to inability to purchase medications should be addressed after the client's
physiological problems are resolved.
B) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue will
improve once the Excess Fluid Volume is addressed. Ineffective Family Management of Therapeutic
Regime related to inability to purchase medications should be addressed after the client's
C) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
D) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
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Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with heart
failure.
5) The nurse is planning care for an infant with congestive heart failure. What should the nurse
include in this child's care?
A) Give larger feedings less often to conserve energy.
B) Organize activities to allow for uninterrupted sleep.
C) Monitor respirations during active periods.
D) Force fluids appropriate for age.
Answer: B
Explanation: A) It is important to allow for uninterrupted sleep in order to decrease metabolic
demands on the heart. Fluids should be restricted to those that are high in calories and low in volume
in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor during active
periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
B) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
heart. Fluids should be restricted to those that are high in calories and low in volume in order to avoid
overloading the lungs with fluid. Respirations are difficult to monitor during active periods, making
this an unrealistic goal. Small-volume, high-calorie feedings should be given.
C) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
D) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
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Learning Outcome: 6. Plan evidence-based care for an individual with heart failure and his or her
6) The nurse is assessing a client being treated for congestive heart failure. What physical findings
would indicate that the client's condition is not improving?
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus
Answer: A, D
Explanation: A) Wheezing heard when assessing breath sounds is indicative of abnormal breath
sounds, which are characteristic in congestive heart failure. These sounds would indicate that the
client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the
healthcare provider and is an indication of a worsening of congestive heart failure. A temperature
reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal
findings.
B) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are
characteristic in congestive heart failure. These sounds would indicate that the client's condition is
not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider
and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6°F,
moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
C) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are
D) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are
E) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are
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Learning Outcome: 7. Evaluate expected outcomes for an individual with heart failure.
7) A client is prescribed enalapril (Vasotec) for treatment of heart failure. What assessment finding
should cause the nurse concern following the initial administration of this drug?
A) Serious rash
B) Ototoxicity
C) Low blood pressure
D) Irregular pulse
Answer: C
Explanation: A) Severe hypotension can occur after the initial administration of enalapril (Vasotec).
Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an
irregular pulse are adverse effects of beta blockers.
B) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is
an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse
are adverse effects of beta blockers.
C) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is
D) Severe hypotension can occur after the initial administration of enalapril (Vasotec). Ototoxicity is
Page Ref: 1154
of an individual with heart failure.
8) The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position would
the client find the most comfortable?
A) Seated in a recliner with 2-3 pillows under feet
B) Lying on the left side with the head of the bed elevated 30°
C) Seated in a recliner with 2-3 pillows under head
D) Lying on either side with the head of the bed elevated 30°
Answer: A
Explanation: A) The client with left-sided cardiac failure could develop orthopnea. This is a result of
the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the
work of breathing. Side-lying positions will not help alleviate or prevent the development of
orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema,
but 2-3 pillows are not needed for sleep.
B) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary
congestion and decreased cardiac output. Being in an upright position will ease the work of breathing.
Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the
lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not
needed for sleep.
C) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary
needed for sleep.
D) The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary
needed for sleep.
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Learning Outcome: 6. Plan evidence-based care for an individual with heart failure and his or her
9) A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition. Which
condition would be excluded from the client's cause of heart failure?
A) Massive pulmonary embolus
B) Hyperthyroidism
C) Rheumatic fever
D) Volume overload
Answer: C
Explanation: A) Heart failure is caused by either impaired myocardial function, increased cardiac
workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary
embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired
myocardial function.
B) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus,
hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired
C) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
D) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
Page Ref: 1145
10) A nurse caring for clients with heart failure must be aware of the compensatory mechanisms
activated in heart failure. Which physiology is not associated with the neuroendocrine compensatory
mechanism?
A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate.
B) Decreased CO stimulates the sympathetic nervous system and catecholamine release.
C) Decreased CO and decreased renal perfusion stimulate the renin-angiotensin system.
D) Antidiuretic hormone is released from posterior pituitary.
Answer: A
Explanation: A) When the heart begins to fail, mechanisms are activated to compensate for the
impaired function and maintain the cardiac output. The primary compensatory mechanisms are as
follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to
hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine
response.
B) When the heart begins to fail, mechanisms are activated to compensate for the impaired function
and maintain the cardiac output. The primary compensatory mechanisms are as follows:
response.
C) When the heart begins to fail, mechanisms are activated to compensate for the impaired function
response.
D) When the heart begins to fail, mechanisms are activated to compensate for the impaired function
response.
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11) A client with heart failure is admitted to the hospital for the placement of an implantable
defibrillator. The client appears comfortable at rest but displays dyspnea with ADLs. In which stage of
heart failure does the nurse classify this client?
A) I
B) II
C) III
D) IV
Answer: C
Explanation: A) This client is in Stage III heart failure, or moderate heart failure. In this stage, the
client is comfortable at rest but displays dyspnea with less than normal physical activity. Also in this
stage, surgical intervention includes implantation of a defibrillator.
B) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
comfortable at rest but displays dyspnea with less than normal physical activity. Also in this stage,
surgical intervention includes implantation of a defibrillator.
C) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
D) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
Page Ref: 1149
of an individual with heart failure.
12) A client diagnosed with systolic heart failure is admitted to the Intensive Care Unit (ICU). The
nurse assigned to this client understands that systolic heart failure:
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the
arterial system.
B) Results when the heart cannot completely relax in diastole, disrupting normal filling.
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload.
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and
impaired relaxation of the heart muscle.
Answer: A
Explanation: A) Heart failure is commonly classified as either systolic or diastolic heart failure, based
on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract
adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of
diastolic heart failure, not systolic.
B) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to
eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart
failure, not systolic.
C) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
D) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
Page Ref: 1148
life span for individuals with heart failure.
Exemplar 16.7 Hypertension
1) A client reports morning headache that extends into the neck and goes away as the day wears on.
What should the nurse suspect this client is describing?
A) A symptom of hypertension
B) A sinus headache
C) A migraine headache
D) Spinal stenosis
Answer: A
Explanation: A) When symptoms of hypertension do appear, they are usually vague. Headache,
generally in the back of the head and neck, may be present on awakening, subsiding during the day.
The client is not describing a migraine or sinus headache. There is not enough information to
determine whether the client has spinal stenosis.
B) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the
back of the head and neck, may be present on awakening, subsiding during the day. The client is not
describing a migraine or sinus headache. There is not enough information to determine whether the
client has spinal stenosis.
C) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the
D) When symptoms of hypertension do appear, they are usually vague. Headache, generally in the
Page Ref: 1167
indirect causes of hypertension.
2) The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client
statement indicates teaching has been effective?
A) "I won't be able to run in marathons anymore."
B) "I know I need to give up my cigarettes and alcohol."
C) "I need to get started on my medications right away."
D) "My father had hypertension, did nothing, and lived to be 90 years old."
Answer: B
Explanation: A) Limiting intake of alcohol and discontinuing tobacco products are important
nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may
eliminate the need for pharmacotherapy, so the client may not have to take medication right away.
Increasing physical activity is an important lifestyle modification for controlling hypertension. The
fact that the client's father had hypertension and lived to be 90 years old does not mean that the client
will have the same experience; the client is in denial.
B) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological
methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need
for pharmacotherapy, so the client may not have to take medication right away. Increasing physical
activity is an important lifestyle modification for controlling hypertension. The fact that the client's
father had hypertension and lived to be 90 years old does not mean that the client will have the same
experience; the client is in denial.
C) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological
D) Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological
Page Ref: 1167
Learning Outcome: 2. Identify risk factors and prevention methods associated with hypertension.
3) A client has a nighttime cough related to taking enalapril (Vasotec). What is the best nursing
intervention to promote rest in this client?
A) Have the client sit up at an 80° angle in a comfortable chair at night.
B) Have the client sleep on 2 or 3 pillows at night.
C) Contact the physician for an order for a cough-suppressant medication.
D) Contact the physician for an order for a sedative-hypnotic medication.
Answer: B
Explanation: A) The client should sleep with the head elevated if a cough becomes troublesome when
in supine position. A cough induced by an angiotensin-converting enzyme inhibitor will not be
relieved by cough medication. Sitting up at an 80° angle would be effective but would be too
uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it does
nothing to address the client's cough.
B) The client should sleep with the head elevated if a cough becomes troublesome when in supine
position. A cough induced by an angiotensin-converting enzyme inhibitor will not be relieved by
cough medication. Sitting up at an 80° angle would be effective but would be too uncomfortable for
the client. A sedative-hypnotic medication would put the client to sleep, but it does nothing to address
the client's cough.
C) The client should sleep with the head elevated if a cough becomes troublesome when in supine
the client's cough.
D) The client should sleep with the head elevated if a cough becomes troublesome when in supine
the client's cough.
Page Ref: 1154
life span for individuals with hypertension.
4) The nursing diagnosis Noncompliance related to unknown factors is established for a client with
hypertension who admits to occasionally taking prescribed antihypertensive medications. Which
behavior should the nurse demonstrate when discussing reasons for noncompliance with this client?
A) Indifference
B) Nonjudgmental
C) Direct
D) Confrontational
Answer: B
Explanation: A) The nurse who listens to the client openly and nonjudgmentally will both validate the
client's self-esteem and communicate the idea of partnership in the treatment plan for the client.
Employing a confrontational attitude is unlikely to elicit a positive response from the client regarding
the reason for noncompliance. If the nurse issues a directive by telling the client what to do without
listening nonjudgmentally to the problems encountered when taking medications, the client is not
likely change his behavior. The nurse who adopts an attitude of indifference is communicating a lack
of caring, which will decrease the client's sense of self-esteem.
B) The nurse who listens to the client openly and nonjudgmentally will both validate the client's self-
esteem and communicate the idea of partnership in the treatment plan for the client. Employing a
confrontational attitude is unlikely to elicit a positive response from the client regarding the reason
for noncompliance. If the nurse issues a directive by telling the client what to do without listening
nonjudgmentally to the problems encountered when taking medications, the client is not likely
change his behavior. The nurse who adopts an attitude of indifference is communicating a lack of
caring, which will decrease the client's sense of self-esteem.
C) The nurse who listens to the client openly and nonjudgmentally will both validate the client's self-
D) The nurse who listens to the client openly and nonjudgmentally will both validate the client's self-
Page Ref: 1173
Client Need: Psychosocial Integrity
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for individuals with
hypertension.
5) An older client receiving medication for hypertension had a recent fall at home. What should the
nurse include in this client's plan of care?
A) Monitor serum sodium levels.
B) Assess postural blood pressures.
C) Monitor serum creatinine levels.
D) Monitor blood pressure every 2 hours.
Answer: B
Explanation: A) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is
more likely to occur. Also, clients treated for hypertension could have an increase in sensitivity to the
medications. Postural blood pressure assessment allows the nurse to prevent orthostatic hypotension
and falls. Every 2 hours is too frequent for assessments of a noncritical client. Sodium intake and
creatinine levels assess renal function.
B) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to
occur. Also, clients treated for hypertension could have an increase in sensitivity to the medications.
Postural blood pressure assessment allows the nurse to prevent orthostatic hypotension and falls.
Every 2 hours is too frequent for assessments of a noncritical client. Sodium intake and creatinine
levels assess renal function.
C) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to
D) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to
Page Ref: 1166
Learning Outcome: 6. Plan evidence-based care for an individual with hypertension and his or her
6) The nurse instructs a client about the medication nifedipine (Procardia) for hypertension. Which
client statement indicates that additional teaching is needed?
A) "This medication will cause my ankles to swell, which is normal."
B) "I need to drink 6-8 glasses of water each day."
C) "I will call my doctor if I gain weight or become short of breath."
D) "I need to eat foods high in fiber when taking this medication."
Answer: A
Explanation: A) Swelling in the feet or ankles when taking this medication should be reported to the
healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water each
day and increasing fiber in the diet are appropriate interventions cited by the client. The client should
notify the healthcare provider with weight gain or shortness of breath.
B) Swelling in the feet or ankles when taking this medication should be reported to the healthcare
provider. This medication can cause constipation, so drinking 6-8 glasses of water each day and
increasing fiber in the diet are appropriate interventions cited by the client. The client should notify
the healthcare provider with weight gain or shortness of breath.
C) Swelling in the feet or ankles when taking this medication should be reported to the healthcare
D) Swelling in the feet or ankles when taking this medication should be reported to the healthcare
Page Ref: 1171
Learning Outcome: 7. Evaluate expected outcomes for an individual with hypertension.
7) The home care nurse assesses an older client's blood pressure as being 150/100 mmHg. When
reviewing medications, the client reports taking the blood pressure medication only when feeling
tense. What should the nurse instruct this client to do?
A) Continue to take medication when feeling tense.
B) Take the blood pressure medication as prescribed regardless of feeling tense.
C) Take the blood pressure medication at twice the prescribed dosage for 1 day and then resume the
daily schedule.
D) Contact the physician for an increase in blood pressure medication.
Answer: B
Explanation: A) Clients sometimes mistakenly take blood pressure medication only on an as-needed
basis. This is incorrect; the client should take the medication as prescribed on a daily basis. The
dosage prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To
advise the client to increase the medication without a physician consultation would be out of the
scope of nursing practice.
B) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is
incorrect; the client should take the medication as prescribed on a daily basis. The dosage prescribed
may be appropriate if taken daily; therefore, it would not need to be increased. To advise the client to
increase the medication without a physician consultation would be out of the scope of nursing
practice.
C) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is
practice.
D) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is
practice.
Page Ref: 1174
Learning Outcome: 6. Plan evidence-based care for an individual with hypertension and his or her
8) A client is admitted to determine the cause of secondary hypertension. Which diagnostic tests
should the nurse suspect the client will be prescribed and need teaching?
A) Cerebral angiogram
B) Intravenous pyelogram
C) Renal angiogram
D) Cardiac catheterization
E) Myelogram
Answer: B, C
Explanation: A) When secondary hypertension is suspected, diagnostic tests include an intravenous
pyelogram and renal ultrasound to determine if the renal system is the cause of the hypertension.
Cerebral angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the
cause for secondary hypertension.
B) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and
renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral
angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the cause for
secondary hypertension.
C) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and
D) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and
E) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and
Page Ref: 1168
Cognitive Level: Creating
of an individual with hypertension.
9) A client has a blood pressure of 142/92. The nurse recognizes this as:
A) Normal.
B) Hypertension Stage I.
C) Prehypertension.
D) Hypertension Stage II.
Answer: B
Explanation: A) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II (>
or =160/> or =100).
B) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
or =160/> or =100).
C) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
or =160/> or =100).
D) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
or =160/> or =100).
Page Ref: 1169
10) A nurse working in the Intensive Care Unit (ICU) is caring for a client in a hypertensive
emergency due to acute nephritis. The nurse understands that the client's renal system affects blood
pressure by:
A) Releasing the catecholamines epinephrine and norepinephrine.
B) Stimulating the release of renin.
C) Stimulating the release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).
D) Synthesizing and releasing adrenomedullin.
Answer: B
Explanation: A) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen
to angiotensin I, which is then converted to angiotensin II in the lungs. ANP and BNP are released
from the atrial cells, not the renal system. The catecholamines epinephrine and norepinephrine are
released from the adrenal cortex, not from the kidneys.
B) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to angiotensin
I, which is then converted to angiotensin II in the lungs. ANP and BNP are released from the atrial
cells, not the renal system. The catecholamines epinephrine and norepinephrine are released from the
adrenal cortex, not from the kidneys.
C) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to angiotensin
D) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to angiotensin
Page Ref: 1163-1164
indirect causes of hypertension.
11) A nurse is caring for a pregnant client who is hypertensive. What additional symptom likely
indicates this client has early preeclampsia?
A) Persistent headache
B) Excessive protein in the urine
C) Right-sided abdominal pain
D) Severe epigastric pain
Answer: B
Explanation: A) Early signs of preeclampsia include high blood pressure and evidence of protein in
the urine. Later symptoms include persistent headache and right-sided abdominal pain. Severe
epigastric pain is a symptom of HELLP syndrome.
B) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later
symptoms include persistent headache and right-sided abdominal pain. Severe epigastric pain is a
symptom of HELLP syndrome.
C) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later
D) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later
Page Ref: 1166
12) A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. The
nurse caring for this client understands that the mechanism of action for this medication is:
A) Prevents conversion of angiotensin I to angiotensin II.
B) Prevents beta-receptor stimulation in the heart.
C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells.
D) Blocks alpha-receptors in the vascular smooth muscle.
Answer: D
Explanation: A) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in
the vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to
angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium
channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and
cardiac cells.
B) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the vascular
smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to angiotensin II.
Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium channel blockers
inhibit the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells.
C) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the vascular
D) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the vascular
Page Ref: 1171
of an individual with hypertension.
Exemplar 16.8 Life-Threatening Dysrhythmias
1) During a blood pressure screening, an older client tells the nurse about chest fluttering while doing
yard work. The client reports no other symptoms and the frequency is intermittent. How should the
nurse interpret this client's finding?
A) Exercise intolerance
B) Nonspecific cardiac changes with aging
C) Underlying illness that requires a medical evaluation
D) Hypothyroidism
Answer: C
Explanation: A) New-onset atrial fibrillation and other arrhythmias may signal the onset of a serious
underlying illness that requires further medical evaluation. Chest fluttering can be a sign of
hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes. Exercise
intolerance would include shortness of breath, which the client does not report. Nursing Process:
Assessment Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations,
and direct and indirect causes of life-threatening dysrhythmias.
2) The nurse is assessing an older client with a cardiac dysrhythmia. What finding would the nurse
identify as contributing to this client's dysrhythmia?
A) Drinks caffeinated coffee in the morning and for lunch.
B) Does not smoke or ingest any alcohol.
C) Plays golf three times a week and gardens daily.
D) Takes antihypertensive medication as prescribed.
Answer: A
Explanation: A) Aging affects the heart and the cardiac conduction system, increasing the incidence
of dysrhythmias and conduction defects. Caffeine increases the risk of ectopic beats and rapid heart
rates. Antihypertensive medications are not associated with cardiac dysrhythmias. Engaging in
routine physical activity will not cause dysrhythmias or conduction defects. The client is a non-
smoker and does not ingest alcohol, both of which would contribute to cardiac dysrhythmias.
Nursing Process: Assessment Learning Outcome: 2. Identify risk factors and prevention methods
associated with life-threatening dysrhythmias.
3) A 35-year-old female client is experiencing paroxysmal supraventricular tachycardia. What should

the nurse prepare to do to assist this client?
A) Massage the carotid arteries.
B) Prepare for cardioversion.
C) Begin anticoagulation therapy.
D) Administer intravenous adenosine.
E) Administer a beta blocker.
Answer: A, B, D, E
Explanation: A) Management of paroxysmal supraventricular tachycardia includes carotid sinus
massage, adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a
part of the management for this dysrhythmia. Nursing Process: Implementation Learning Outcome:
3. Illustrate the nursing process in providing culturally competent care across the life span for
individuals with life-threatening dysrhythmias.
4) A client admitted with a cardiac dysrhythmia reports being easily fatigued and frustrated with the
inability to perform normal daily activities. Which nursing diagnosis should the nurse select to
address this client's issue?
A) Excess Fluid Volume
B) Activity Intolerance
C) Depression
D) Situational Low Self-Esteem
Answer: B
Explanation: A) The client is experiencing fatigue and frustration with the inability to perform
normal daily activities. The nursing diagnosis to address this client's issue would be Activity
Intolerance. There is no evidence that the client is experiencing excess fluid volume. The client may or
may not be experiencing depression. The client may develop situational low self-esteem if the
diagnosis of Activity Intolerance is not addressed. Nursing Process: Planning Learning Outcome: 4.
Formulate priority nursing diagnoses appropriate for an individual with life-threatening
dysrhythmias.
5) The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be
the most appropriate for this client?
A) Restrict fluids.
B) Encourage bed rest.
C) Monitor serum electrolyte levels.
D) Instruct in a low-fat diet.
Answer: C
Explanation: A) The nurse should monitor serum electrolyte levels because electrolyte imbalances
affect cardiac depolarization and repolarization, and may cause dysrhythmias. More information is
needed before determining whether the client needs to be on bed rest. There is no evidence to suggest
the client needs to have fluids restricted. There is no evidence to suggest the client needs instruction
on a low-fat diet. Nursing Process: Planning Learning Outcome: 6. Plan evidence-based care for an
individual with a life-threatening dysrhythmias and his or her family in collaboration with other
members of the healthcare team.
6) A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia. Which

outcome indicates the client is adhering to the provided medication instruction?
A) The client will monitor the pulse and not take the medication if the pulse is less than 60.
B) The client will take the medication as directed, even when feeling well.
C) The client will take the medication on an empty stomach.
D) The client will take the medication with food.
Answer: B
Explanation: A) It is very important for clients to understand that medication must be taken as
directed, even if the client is feeling well. Procainamide hydrochloride (Pronestyl) can be taken on an
empty stomach. The beta-adrenergic blocking drugs cause bradycardia, not Group 1A cardiac
antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide hydrochloride
(Pronestyl) can be taken with food. Nursing Process: Evaluation Learning Outcome: 7. Evaluate
expected outcomes for an individual with a life-threatening dysrhythmia.
7) A client is scheduled for permanent pacemaker instruction. What instruction will this client need?
A) Dizziness is to be expected.
B) There are no special precautions.
C) Wear a tight-fitting shirt to help hold the pacemaker in place.
D) Use battery-powered equipment.
Answer: D
Explanation: A) The client should be instructed to use electrical equipment with a grounded plug and
avoid using adapters or extension cords. Battery-powered equipment should be used instead. There
are special precautions for the client to be aware of with a permanent pacemaker. The client should
wear loose-fitting clothing. Dizziness is not to be expected and should be reported to the healthcare
provider. Nursing Process: Implementation Learning Outcome: 5. Summarize therapies used by
interdisciplinary teams in the collaborative care of an individual with a life-threatening dysrhythmia.
8) A client with sepsis has a temperature of 40°Celsius. Which potentially life-threatening

dysrhythmia is most likely to occur in this client?
A) Bradyarrhythmia
B) Tachyarrhythmia
C) Wolff-Parkinson-White dysrhythmia
D) Long QT dysrhythmia
Answer: B
Explanation: A) This client is febrile and at risk for developing a tachyarrhythmia. Fever does not
cause bradyarrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are caused by
genetic cardiac problems. Nursing Process: Assessment Learning Outcome: 1. Describe the
pathophysiology, etiology, clinical manifestations, and direct and indirect causes of life-threatening
dysrhythmias.
9) A nurse caring for a client in the in the ICU notes that the client's cardiac rhythm indicates a
ventricular tachycardia dysrhythmia. Which rhythm is classified as supraventricular?
A) Sinus tachycardia
B) Atrial flutter
C) Junctional escape
D) Torsades de Pointes
Answer: B
Explanation: A) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus
dysrhythmia, atrial flutter is a supraventricular dysrhythmia, and junctional escape is a junctional
dysrhythmia.
B) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus dysrhythmia,
atrial flutter is a supraventricular dysrhythmia, and junctional escape is a junctional dysrhythmia.
C) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus dysrhythmia,
D) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus dysrhythmia,
Page Ref: 1185
life span for individuals with life-threatening dysrhythmias.
10) A nurse working in the Emergency Department is participating in the resuscitation of a client
experiencing sudden cardiac death. After 5 cycles of CPR, the nurse evaluates the client's cardiac
rhythm as asystole. What is the next action by the nurse?
A) Administer epinephrine.
B) Immediately defibrillate the client.
C) Assess the cardiac monitor electrodes.
D) Assess the client's pulse.
Answer: D
Explanation: A) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the
client's pulse. All other choices are incorrect actions by the nurse.
B) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the client's pulse.
All other choices are incorrect actions by the nurse.
C) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the client's pulse.
All other choices are incorrect actions by the nurse.
D) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the client's
pulse. All other choices are incorrect actions by the nurse.
Page Ref: 1193
of an individual with a life-threatening dysrhythmia.
Exemplar 16.9 Peripheral Vascular Disease
1) A client admitted with chronic venous insufficiency has an infected wound of the left lower
extremity. What will the nurse find when assessing this wound?
A) Pulses absent in the extremity with the wound
B) Wound that is pink with skin warm
C) Ulceration that is pale in color
D) Skin surrounding ulcer that is cool to the touch
E) Surrounding skin brown in color
Answer: B, E
Explanation: A) Manifestations of a venous status ulcer would be a pink wound with warm skin and
areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent
pulses is manifestations of arterial ulcers.
B) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is
manifestations of arterial ulcers.
C) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
D) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
E) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
Page Ref: 1200
indirect causes of peripheral vascular disease.
2) A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette
smoking, and works as a contractor. What should the nurse instruct the client about the diagnosis?
A) Nicotine is a vasoconstrictor.
B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease.
C) Nicotine primarily affects coronary arteries and the lungs.
D) The client's occupation is a major risk factor.
Answer: A
Explanation: A) The vasoconstrictive properties of nicotine will worsen the client's peripheral
vascular disease (PVD) by further decreasing peripheral blood flow. One of the most important parts
of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to
PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus
on smoking cessation as a first priority with this client.
B) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
(PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is
the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity
is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking
cessation as a first priority with this client.
C) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
D) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
Page Ref: 1201
Learning Outcome: 2. Identify risk factors and prevention methods associated with peripheral
vascular disease.
3) The nurse is planning care for an older client with chronic venous insufficiency. What should the
nurse plan to teach this client?
A) Keep the legs dependent as much as possible and elevate only when asleep.
B) Wear elastic hose as prescribed.
C) Standing will prevent the progression of the disease.
D) Cross legs only at the knees.
Answer: B
Explanation: A) Care and treatment of a client with peripheral vascular disease includes instruction.
The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the
client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and
when asleep. Crossing the legs should be avoided.
B) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to
avoid sitting or standing for long periods of time. The legs should be elevated during rest and when
asleep. Crossing the legs should be avoided.
C) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
D) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
Page Ref: 1202-1203
life span for individuals with peripheral vascular disease.
4) The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased
arterial flow to extremities as appropriate for a client. What should the nurse instruct the client to do
to improve blood flow?
A) Cross the legs at the knees when seated.
B) Use a heating pad to increase warmth.
C) Elevate the feet while reclining.
D) Position with the extremities dependent.
Answer: D
Explanation: A) Positioning with the extremities dependent is correct because gravity promotes
arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees
when seated is not recommended because this position compresses partially obstructed arteries and
impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet
works against gravity and will further impede blood flow. Using a heating pad to increase warmth is
not recommended because external heating devices could increase the risk of burns in a client with
impaired circulation and decreased sensation.
B) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the
dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not
recommended because this position compresses partially obstructed arteries and impairs blood flow.
Elevating the feet while reclining is not recommended because elevating the feet works against gravity
and will further impede blood flow. Using a heating pad to increase warmth is not recommended
because external heating devices could increase the risk of burns in a client with impaired circulation
and decreased sensation.
C) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the
D) Positioning with the extremities dependent is correct because gravity promotes arterial flow to the
Page Ref: 1203
peripheral vascular disease.
5) The nurse is planning care for a client with peripheral vascular disease who is at risk for Impaired
Skin Integrity. What would be included in this client's plan of care?
A) Restrict fluids.
B) Keep the skin clean and dry, and moisturize areas of dryness.
C) Encourage bed rest with legs elevated on pillows.
D) Consult a dietitian for low-protein diet.
Answer: B
Explanation: A) The client with peripheral vascular disease who is at risk for impaired skin integrity
should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin
breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this
client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs
elevated on pillows could increase the client's pain and would not help with preventing skin
breakdown.
B) The client with peripheral vascular disease who is at risk for impaired skin integrity should have
meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A
low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid
restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows
could increase the client's pain and would not help with preventing skin breakdown.
C) The client with peripheral vascular disease who is at risk for impaired skin integrity should have
D) The client with peripheral vascular disease who is at risk for impaired skin integrity should have
Page Ref: 1203
Learning Outcome: 6. Plan evidence-based care for an individual with peripheral vascular disease
and his or her family in collaboration with other members of the healthcare team.
6) The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which client
observation indicates teaching has been effective?
A) Sitting in a chair with a pillow behind knees
B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer
C) Sitting in a chair with left leg crossed over the right
D) Smoking a pipe instead of cigarettes
Answer: B
Explanation: A) The client who is observed washing the legs with mild soap, drying the legs, and
applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease.
Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further
instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction
regarding the hazards of tobacco.
B) The client who is observed washing the legs with mild soap, drying the legs, and applying a
moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a
chair with legs crossed or with a pillow behind the knees would indicate further instruction was
needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the
hazards of tobacco.
C) The client who is observed washing the legs with mild soap, drying the legs, and applying a
hazards of tobacco.
D) The client who is observed washing the legs with mild soap, drying the legs, and applying a
hazards of tobacco.
Page Ref: 1203
Learning Outcome: 7. Evaluate expected outcomes for an individual with peripheral vascular disease.
7) A client with peripheral vascular disease asks the nurse what types of exercise would improve the
client's condition and overall health. About what should the nurse instruct this client?
A) Bicycling
B) Weight lifting
C) Yoga
D) Jogging
Answer: C
Explanation: A) Yoga is considered a complementary therapy used to reduce stress and improve
circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis
of peripheral vascular disease.
B) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of peripheral
vascular disease.
C) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
vascular disease.
D) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
vascular disease.
Page Ref: 1201
of an individual with peripheral vascular disease.
8) A client with peripheral vascular disease is experiencing pain. What can the nurse do to assist this
client?
A) Elevate legs in bed with pillows under the knees.
B) Keep the extremities warm with blankets.
C) Encourage to ambulate and stand on legs 4 times each day.
D) Apply cool compresses to the extremities.
Answer: B
Explanation: A) The nurse should help keep the client's extremities warm with blankets, as heat
promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain.
Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive.
Pillows should not be placed under the knees.
B) The nurse should help keep the client's extremities warm with blankets, as heat promotes
vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain.
C) The nurse should help keep the client's extremities warm with blankets, as heat promotes
D) The nurse should help keep the client's extremities warm with blankets, as heat promotes
Page Ref: 1202
Learning Outcome: 6. Plan evidence-based care for an individual with peripheral vascular disease
and his or her family in collaboration with other members of the healthcare team.
9) A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. The
nurse caring for this client understands that intermittent claudication:
A) Causes pain that occurs during periods of inactivity.
B) Causes pain that increases when the legs are elevated and decreases when the legs are dependent.
C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a
predictable level of activity.
D) Is often described as a burning sensation in the lower legs.
Answer: C
Explanation: A) Intermittent claudication is a cramping or aching pain in the calves of the legs, the
thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied
by weakness and is relieved by rest.
B) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the
buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness
and is relieved by rest.
C) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the
D) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the
Page Ref: 1199
10) A client is admitted to the hospital in order to have surgical intervention due to peripheral
vascular disease (PVD). Which procedure is the likely intervention?
A) Stent placement
B) Endarterectomy
C) Percutaneous transluminal angioplasty
D) Atherectomy
Answer: B
Explanation: A) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other
choices are non-surgical interventions for PVD.
B) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are
non-surgical interventions for PVD.
C) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are
D) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are
Page Ref: 1201
11) A nurse is caring for a client with venous stasis whose lower extremities have a brown
pigmentation appearance. Which is this pigmentation appearance best attributed to?
A) The necrosis of subcutaneous fat due to tissue hypoxia
B) Breakdown of red blood cells in the congested tissues
C) The inflammatory and immune response from congested circulation
D) Skin atrophy caused by lack of circulation
Answer: B
Explanation: A) Breakdown of red blood cells in the congested tissues causes brown skin
pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of
brown pigmentation to the skin.
B) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the
other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to
the skin.
C) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the
the skin.
D) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the
the skin.
Page Ref: 1200
12) A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement will
the nurse include when providing client education regarding this therapy?
A) "A nurse will change this dressing every 2 days."
B) "It is important that you maintain strict bed rest."
C) "The dressing will be applied to the entire length of your leg."
D) "The dressing I am applying is semi-rigid."
Answer: D
Explanation: A) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The
dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to
be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg
and part of the thigh but not the entire leg.
B) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory
and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the
thigh but not the entire leg.
C) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
D) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
Page Ref: 1200
Exemplar 16.10 Hypertensive Disorders in Pregnancy
1) The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would
require immediate intervention by the nurse?
A) Blood pressure of 142/92
B) Pulse of 92 beats per minute
C) Respiratory rate of 24 per minute
D) Weight gain of 16 oz per week
Answer: A
Explanation: A) A pregnant client's blood pressure should not be greater than 140/90, and if it is
elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart
and respiratory rates will increase slightly as a result of an increased circulatory volume and a
decrease in intrathoracic space. Weight gain should average a pound per week in the second and third
trimesters.
B) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could
be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory
rates will increase slightly as a result of an increased circulatory volume and a decrease in
intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.
C) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could
D) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it could
Page Ref: 1205
indirect causes of pregnancy-induced hypertension.
2) The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse
recognize as increasing this client's risk for the development of eclampsia?
A) Treatment for vitamin D deficiency
B) Surgery for ruptured appendix 1 year prior
C) Fibrocystic breast disease
D) Obesity
Answer: D
Explanation: A) Risk factors for the development of eclampsia include obesity. The other choices will
not predispose the client to developing eclampsia.
B) Risk factors for the development of eclampsia include obesity. The other choices will not
predispose the client to developing eclampsia.
C) Risk factors for the development of eclampsia include obesity. The other choices will not
D) Risk factors for the development of eclampsia include obesity. The other choices will not
Page Ref: 1205
Learning Outcome: 2. Identify risk factors and prevention methods associated with pregnancy-
induced hypertension.
3) The nurse identifies assessment findings for an African-American client with preeclampsia. Blood
pressure is 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+
edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would
indicate worsening of the condition?
A) Blood pressure 158/100
B) Platelet count 150,000
C) Urinary output 20 mL/hour
D) Reflexes 2+
Answer: C
Explanation: A) The decrease in urine output is an indication of decrease in glomerular filtration rate,
which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening
is the urine output change. The blood pressure increase is not significant. The reflexes are normal at
2+. The platelet count is normal, though it is at the lower end.
B) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the
urine output change. The blood pressure increase is not significant. The reflexes are normal at 2+. The
platelet count is normal, though it is at the lower end.
C) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
D) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
Page Ref: 1222
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
individuals with pregnancy-induced hypertension.
4) During a routine prenatal visit, a client who is 24 weeks pregnant has an increased blood pressure.
The nurse identifies which nursing diagnosis as appropriate for the client at this time?
A) Fluid Volume Excess
B) Anxiety
C) Excess Fluid Volume
D) Ineffective Coping
Answer: A
Explanation: A) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia.
The client would be at risk for fluid volume excess. Not enough information is provided to determine
if the client is experiencing fluid volume overload. There is no information to support ineffective
coping or anxiety in the client.
B) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client
would be at risk for fluid volume excess. Not enough information is provided to determine if the client
is experiencing fluid volume overload. There is no information to support ineffective coping or anxiety
in the client.
C) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client
in the client.
D) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The client
in the client.
Page Ref: 1215
pregnancy-induced hypertension.
5) The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia.
What should the nurse include in this client's plan of care?
A) Suggest family and friends phone frequently.
B) Place in a semiprivate room.
C) Provide stimulation with television and visitors.
D) Limit phone calls and visitors.
Answer: D
Explanation: A) The client with preeclampsia who is at risk for injury needs to be placed in a private
room near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The
semiprivate room might provide too much stimulation. Television and visitors should be limited to
reduce stimulation. Frequent phone calls would provide too much stimulation and should be limited.
B) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the
nurses' station. The room should be a quiet, with phone calls and visitors limited. The semiprivate
room might provide too much stimulation. Television and visitors should be limited to reduce
stimulation. Frequent phone calls would provide too much stimulation and should be limited.
C) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the
D) The client with preeclampsia who is at risk for injury needs to be placed in a private room near the
Page Ref: 1208
Learning Outcome: 6. Plan evidence-based care for an individual with pregnancy-induced
hypertension and his or her family in collaboration with other members of the healthcare team.
6) The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with
preeclampsia. Which statement indicates that the client requires additional teaching?
A) "My urine may become darker and smaller in amount each day."
B) "I should call the doctor if I develop a headache or blurred vision."
C) "Pain in the top of my abdomen is a sign my condition is worsening."
D) "Lying on my left side as much as possible is good for the baby."
Answer: A
Explanation: A) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign
that the condition is worsening. It is not an expected outcome and should be reported to the
physician. Headache and blurred vision or other visual disturbances are an indication of worsening
preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and
renal blood flow, and therefore is the optimal position for a client with preeclampsia. Epigastric pain
is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported
to the physician.
B) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
condition is worsening. It is not an expected outcome and should be reported to the physician.
Headache and blurred vision or other visual disturbances are an indication of worsening
to the physician.
C) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
to the physician.
D) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
to the physician.
Page Ref: 1206
Learning Outcome: 7. Evaluate expected outcomes for an individual with pregnancy-induced
hypertension.
7) A pregnant client with preeclampsia delivers the fetus. What care will the client need within the
first 48 hours after delivery?
A) Antihypertensives as prescribed
B) Frequent assessment of serum electrolytes
C) Oxygen 2 liters nasal cannula as prescribed
D) Seizure precautions
E) Vital sign assessment every 4 hours
Answer: A, D, E
Explanation: A) Even though the client with preeclampsia usually improves rapidly after giving birth,
seizures can still occur during the first 48 hours postpartum. The client may also continue to receive
antihypertensives as prescribed. Nursing management during the postpartal period also includes vital
sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and not
necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
B) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can
still occur during the first 48 hours postpartum. The client may also continue to receive
C) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can
D) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can
E) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can
Page Ref: 1206
of an individual with pregnancy-induced hypertension.
8) A client with preeclampsia begins to seize. What should the nurse should do to protect the client
and fetus from injury?
A) Elevate the client's legs.
B) Place the client on the left side and protect the airway.
C) Place the client in the supine position.
D) Elevate the head of the bed.
Answer: B
Explanation: A) The client should be placed on the side to aid in circulation to the placenta. The
airway needs to be maintained to ensure oxygenation throughout the seizure. The client should not be
placed in the supine position. The head of the bed should not be elevated. The client's legs should not
be elevated.
B) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be
maintained to ensure oxygenation throughout the seizure. The client should not be placed in the
supine position. The head of the bed should not be elevated. The client's legs should not be elevated.
C) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be
D) The client should be placed on the side to aid in circulation to the placenta. The airway needs to be
Page Ref: 1208
hypertension and his or her family in collaboration with other members of the healthcare team.
9) A nurse working in Labor and Delivery is teaching a group of pregnant clients regarding seizures
associated with eclampsia. The nurse will include which statement?
A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the
muscles."
B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity."
C) "Seizures are rare in eclampsia, but they occur sometimes."
D) "Seizures do not occur in preeclampsia."
Answer: D
Explanation: A) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a
seizure, so seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by
muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by alternate
contraction and relaxation of the muscles.
B) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by muscular
contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by alternate contraction
and relaxation of the muscles.
C) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
D) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
Page Ref: 1208
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
individuals with pregnancy-induced hypertension.
10) A nurse working in Labor and Delivery is caring for a client with preeclampsia. Which clinical
manifestation is the nurse most likely to find in this client?
A) Increased nitric oxide production
B) Decreased serum sodium
C) Decreased blood urea nitrogen (BUN)
D) Increased serum creatinine
Answer: D
Explanation: A) Preeclampsia decreases renal perfusion, causing an increase in both serum
creatinine and blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide
production and the retention of serum sodium.
B) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood
urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide production and the retention
of serum sodium.
C) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood
of serum sodium.
D) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood
of serum sodium.
Page Ref: 1206
11) A pregnant client is diagnosed with HELLP syndrome. The client's nurse understands that which
clinical finding is not a manifestation of this condition?
A) Elevated liver enzymes
B) Hemolysis
C) Elevated lipid panel
D) Decreased platelet count
Answer: C
Explanation: A) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is
thought to be related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP
syndrome.
B) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be
related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.
C) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be
D) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be
Page Ref: 1205
12) Which clinical consideration should the nurse implement for the client in labor who has been
diagnosed with preeclampsia?
A) Place the client in the room closest to the nurse's station, even if it is a shared room.
B) Place the client in left lateral position when the client feels the urge to push.
C) Monitor client's fetus intermittently while client is in first stage of labor.
D) Encourage the client to be alone in the room without family in order to maintain a quiet
environment.
Answer: B
Explanation: A) A laboring client with preeclampsia is at risk for the development of eclampsia with
subsequent seizures. The nurse should place the client in left lateral position when the client feels the
urge to push because this position improves circulation to the placenta and fetus. If possible, the
nurse should place the client in a private room to promote a non-stimulating environment. However,
the client should always have support with her, not be alone during labor. The nurse will monitor the
client's fetus continuously during labor.
B) A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent
seizures. The nurse should place the client in left lateral position when the client feels the urge to push
because this position improves circulation to the placenta and fetus. If possible, the nurse should
place the client in a private room to promote a non-stimulating environment. However, the client
should always have support with her, not be alone during labor. The nurse will monitor the client's
fetus continuously during labor.
C) A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent
D) A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent
Page Ref: 1206
hypertension and her family in collaboration with other members of the healthcare team.
13) A nurse working in Labor and Delivery cares for clients with preeclampsia. The nurse understands
that the exact cause of this condition is not known; however, research suggests:
A) It is a disorder of placental dysfunction.
B) It is a disorder of fetal liver compromise.
C) It is a disorder of maternal hyporesponsiveness to vasoactive peptides.
D) It is a disorder of excess trophoblast invasion within the placenta.
Answer: A
Explanation: A) The exact cause of preeclampsia is unknown. However, it has been identified as a
disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated
vasospasm.
B) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm.
C) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
D) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
Page Ref: 1205
indirect causes of pregnancy-induced hypertension.
Exemplar 16.11 Pulmonary Embolism
1) The nurse caring for a client recovering from an abdominal hysterectomy suspects the client is
experiencing a pulmonary embolism. What did the nurse assess in this client?
A) Nausea
B) Decreased urine output
C) Dyspnea and shortness of breath
D) Activity intolerance
Answer: C
Explanation: A) Manifestations of a pulmonary embolism include dyspnea, shortness of breath,
pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade
fever. Decreased urine output, activity intolerance and nausea are not clinical manifestations of a
pulmonary embolism.
B) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever.
Decreased urine output, activity intolerance and nausea are not clinical manifestations of a
pulmonary embolism.
C) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pulmonary embolism.
D) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pulmonary embolism.
Page Ref: 1212
indirect causes of pulmonary embolism.
2) The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus
formation. What assessment information caused the nurse to come to this conclusion?
A) Body mass index (BMI) 35.8
B) Former cigarette smoker
C) Blood pressure 132/88 mmHg
D) Age 45 years
Answer: A
Explanation: A) Risk factors for the development of thrombus formation that could lead to a
pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and
advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk
of developing a thrombus and possible pulmonary embolism. The client's age, status as a former
smoker, and blood pressure would not have as significant an impact on the development of a
thrombus as the client's weight.
B) Risk factors for the development of thrombus formation that could lead to a pulmonary embolism
include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI
of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus
and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure
would not have as significant an impact on the development of a thrombus as the client's weight.
C) Risk factors for the development of thrombus formation that could lead to a pulmonary embolism
D) Risk factors for the development of thrombus formation that could lead to a pulmonary embolism
Page Ref: 1212
Learning Outcome: 2. Identify risk factors and prevention methods associated with pulmonary
embolism.
3) The nurse is providing discharge instructions to an older client who is going home after having a
total knee replacement. What teaching will the nurse include to prevent the development of a
thrombosis or pulmonary embolism?
A) Place pillows under the knees when in bed.
B) Use compression stockings.
C) Limit ambulation.
D) Limit fluids.
E) Continue with leg exercises.
Answer: B, E
Explanation: A) A client being discharged after having orthopedic surgery is at increased risk for
pulmonary embolism. The nurse should instruct the client to continue with leg exercises and use
compression stockings to reduce the risk of deep vein thrombosis formation. The client should be
encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another
physiological condition exists that would necessitate a fluid restriction.
B) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
embolism. The nurse should instruct the client to continue with leg exercises and use compression
stockings to reduce the risk of deep vein thrombosis formation. The client should be encouraged to
ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological
condition exists that would necessitate a fluid restriction.
C) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
D) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
E) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
Page Ref: 1214
life span for individuals with pulmonary embolism.
4) A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level
and dyspnea. The nurse would identify which diagnosis as a priority for this client?
A) Ineffective Tissue Perfusion
B) Anxiety
C) Impaired Gas Exchange
D) Impaired Physical Mobility
Answer: C
Explanation: A) A reduction in arterial oxygen saturation level and dyspnea indicate the client is
experiencing impaired gas exchange. This would be the priority for the client at this time. The client
may have ineffective tissue perfusion; however, this is not the priority. The client may be experiencing
anxiety; however, this is not the priority at this time either. There is not enough information to
determine whether the client is at risk for impaired mobility.
B) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
impaired gas exchange. This would be the priority for the client at this time. The client may have
ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety;
however, this is not the priority at this time either. There is not enough information to determine
whether the client is at risk for impaired mobility.
C) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
D) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
Page Ref: 1215
pulmonary embolism.
5) The nurse is planning care for a client with a pulmonary embolism. Which intervention would
assist with the client's decrease in cardiac output?
A) Provide oxygen.
B) Keep protamine sulfate at the bedside.
C) Monitor pulmonary arterial pressures.
D) Assess for bleeding.
Answer: C
Explanation: A) The client with a pulmonary embolism and decreased cardiac output is at risk for
developing right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for
bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with
ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.
B) The client with a pulmonary embolism and decreased cardiac output is at risk for developing right
heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for bleeding and
keeping protamine sulfate at the bedside would be appropriate for the client with ineffective
protection. Oxygen would be appropriate for the client with impaired gas exchange.
C) The client with a pulmonary embolism and decreased cardiac output is at risk for developing right
D) The client with a pulmonary embolism and decreased cardiac output is at risk for developing right
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Learning Outcome: 6. Plan evidence-based care for an individual with pulmonary embolism and his
6) The nurse has instructed a client recovering from a pulmonary embolism on long-term
anticoagulant therapy. Which client statement indicates that instruction has been effective?
A) "I will expect bloody sputum when I brush my teeth."
B) "I need to use a soft toothbrush and an electric razor, and avoid injuries."
C) "I need to eat a well-balanced diet with green salads."
D) "I can expect to be bruised, since this is normal."
Answer: B
Explanation: A) Instruction on anticoagulant therapy should include the need to avoid injury, use a
soft toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert
bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the
vitamin K content. The statements about bruising being normal and expecting bloody sputum mean
the client is in need of additional instruction on anticoagulant therapy.
B) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush,
and use an electric razor. The client should be instructed to obtain a Medic-Alert bracelet that
identifies anticoagulant therapy. The client should avoid green salads because of the vitamin K
content. The statements about bruising being normal and expecting bloody sputum mean the client is
in need of additional instruction on anticoagulant therapy.
C) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush,
and use an electric razor. The client should be instructed to obtain a Medic-Alert bracelet that
identifies anticoagulant therapy. The client should avoid green salads because of the vitamin K
D) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft
toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert bracelet
that identifies anticoagulant therapy. The client should avoid green salads because of the vitamin K
Page Ref: 1215
Learning Outcome: 7. Evaluate expected outcomes for an individual with pulmonary embolism.
7) A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression
device. For the prevention of which postoperative complication are these instructions being provided?
A) Infection
B) Delayed wound healing
C) Contractures
D) Deep vein thrombosis
Answer: D
Explanation: A) The best care for a pulmonary embolism is prevention. Since surgical clients have an
increased risk of developing a pulmonary embolism postoperatively, instructions should include ways
to encourage movement, such as leg exercises, and the need for pneumatic compression devices to
maintain lower extremity circulation and prevent the development of a deep vein thrombosis.
Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or
prevent contractures.
B) The best care for a pulmonary embolism is prevention. Since surgical clients have an increased risk
of developing a pulmonary embolism postoperatively, instructions should include ways to encourage
movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower
extremity circulation and prevent the development of a deep vein thrombosis. Exercises and
pneumatic compression devices do not prevent infection, encourage wound healing, or prevent
contractures.
C) The best care for a pulmonary embolism is prevention. Since surgical clients have an increased risk
contractures.
D) The best care for a pulmonary embolism is prevention. Since surgical clients have an increased risk
contractures.
Page Ref: 1214
of an individual with pulmonary embolism.
8) The nurse is preparing to discharge a client recovering from a pulmonary embolism. How should
the nurse instruct this client?
A) Limit the use of over-the-counter medications.
B) Diet to include green leafy vegetables
C) Symptoms of recurrence
D) Anticoagulant administration schedule
E) Resume normal activity level.
Answer: C, D
Explanation: A) The client being discharged after treatment for a pulmonary embolism needs to be
instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to
the physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse
should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and the
schedule for anticoagulation administration.
B) The client being discharged after treatment for a pulmonary embolism needs to be instructed in
anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the
physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse should
instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule
for anticoagulation administration.
C) The client being discharged after treatment for a pulmonary embolism needs to be instructed in
D) The client being discharged after treatment for a pulmonary embolism needs to be instructed in
E) The client being discharged after treatment for a pulmonary embolism needs to be instructed in
Page Ref: 1215
Learning Outcome: 6. Plan evidence-based care for an individual with pulmonary embolism and his
9) Which client is at highest risk for a nonthrombotic pulmonary embolism?
A) The pregnant client with gestational diabetes
B) The client who postoperative from a femur fracture repair
C) The client with a primary lung tumor
D) The client who uses intravenous illicit drugs
Answer: B
Explanation: A) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism
usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the
circulation. The other clients may be at risk for pulmonary embolism; however, they are incorrect
choices for the most common cause of nonthrombotic pulmonary emboli.
B) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs
after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. The
other clients may be at risk for pulmonary embolism; however, they are incorrect choices for the most
common cause of nonthrombotic pulmonary emboli.
C) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs
D) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs
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Learning Outcome: 2. Identify risk factors and prevention methods associated with pulmonary
embolism.
10) A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result?
A) Patchy infiltrates on chest x-ray
B) Metabolic alkalosis on arterial blood gas
C) Elevated CO2 level found on end-tidal carbon dioxide monitor
D) Tachycardia and nonspecific T-wave changes on EKG
Answer: D
Explanation: A) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on
EKG. The client with a pulmonary embolism will likely have respiratory alkalosis from rapid
breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO 2) will be decreased,
not increased, due to rapid breathing.
B) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client
with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not metabolic
alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not increased, due to rapid
breathing.
C) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client
breathing.
D) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client
breathing.
Page Ref: 1214
11) The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism. The
nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for
the treatment of this condition?
A) It is considered second-line treatment.
B) Major hemorrhage is common.
C) Heparin and warfarin (Coumadin) are usually initiated at the same time.
D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.
Answer: C
Explanation: A) Heparin and warfarin are usually initiated at the same time for the treatment of
pulmonary embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary
embolism. While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters
the synthesis of vitamin K-dependent clotting factors.
B) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism. While
major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the synthesis of
vitamin K-dependent clotting factors.
C) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
D) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
Page Ref: 1214
Exemplar 16.12 Shock
1) The nurse is concerned that a client is demonstrating early signs of hypovolemic shock. What did
the nurse assess in this client?
A) Slight increase in pulse
B) Prolonged capillary refill time
C) Rapid weak pulse
D) Normal respirations
E) Normal blood pressure
Answer: A, B, D, E
Explanation: A) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
B) Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations,
prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a characteristic of
the irreversible stage of hypovolemic shock.
C) Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations,
D) Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations,
E) Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations,
Page Ref: 1224
indirect causes of shock.
2) A young client with a history of multiple allergies is prescribed epinephrine (EpiPen) for prevention
of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure."
What is the best response by the nurse?
A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure,
and liver failure."
B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of
blood."
C) "There are many kinds of shock that also include infection, nervous system damage, and loss of
blood."
D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and
respiratory failure."
Answer: C
Explanation: A) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord
suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection
may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of shock.
Liver failure is not a type of shock.
B) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
C) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
D) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
Page Ref: 1222-1224
Learning Outcome: 2. Identify risk factors and prevention methods associated with shock.
3) An older client is experiencing hypovolemic shock. Which treatment measure would be given the
highest priority for this client?
A) Administering analgesics for control of pain
B) Assessing the cause of bleeding
C) Providing replacement of volume
D) Establishing invasive cardiac monitoring
Answer: D
Explanation: A) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta blocker,
tachycardia may not occur as an early sign of hypovolemic shock. The older client will require early
invasive monitoring in order to avoid excessive or inadequate volume restoration. This should be
done early in the treatment phase. Replacement of volume would occur after invasive cardiac
monitoring is established. Pain would be a consideration but would not be attended to as a first
priority. Assessing the cause of bleeding would also occur after establishing invasive cardiac
monitoring.
B) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have secondary
volume depletion because of diuretics or malnutrition, and if prescribed a beta blocker, tachycardia
may not occur as an early sign of hypovolemic shock. The older client will require early invasive
monitoring in order to avoid excessive or inadequate volume restoration. This should be done early in
the treatment phase. Replacement of volume would occur after invasive cardiac monitoring is
established. Pain would be a consideration but would not be attended to as a first priority. Assessing
the cause of bleeding would also occur after establishing invasive cardiac monitoring.
C) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have secondary
D) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have secondary
Page Ref: 1223
life span for individuals with shock.
4) The nurse has just completed the assessment of a client admitted with a gunshot wound to the
femoral artery. Which of the following would be the priority nursing diagnosis for this client?
A) Deficient Fluid Volume
B) Ineffective Coping
C) Ineffective Airway Clearance
D) Decreased Cardiac Output
Answer: D
Explanation: A) The client sustained a gunshot wound to the femoral artery, which would lead to
significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority
for the client is Decreased Cardiac Output because of low blood volume. There is not enough
information to determine whether the client has ineffective airway clearance. The client will most
likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not
enough information to determine whether the client is experiencing ineffective coping.
B) The client sustained a gunshot wound to the femoral artery, which would lead to significant
bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the
client is Decreased Cardiac Output because of low blood volume. There is not enough information to
determine whether the client has ineffective airway clearance. The client will most likely have
deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough
information to determine whether the client is experiencing ineffective coping.
C) The client sustained a gunshot wound to the femoral artery, which would lead to significant
D) The client sustained a gunshot wound to the femoral artery, which would lead to significant
Page Ref: 1231
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with shock.
5) The nurse is administering albumin 5% to a client in shock. What should the nurse include in this
client's plan of care?
A) Auscultate breath sounds for inspiratory stridor.
B) Auscultate breath sounds for crackles.
C) Auscultate breath sounds for hyperresonance.
D) Auscultate for an absence of breath sounds in the lower lobes.
Answer: B
Explanation: A) Because albumin 5% is a volume expander and pulls fluid into the vascular space,
circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be
heard with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not
with pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is
auscultated with airway obstruction, not pulmonary edema.
B) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with
pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with
pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is auscultated
with airway obstruction, not pulmonary edema.
C) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
D) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
Page Ref: 1229
Learning Outcome: 6. Plan evidence-based care for an individual with shock and his or her family in
collaboration with other members of the healthcare team.
6) The nurse explains the purpose of an infusion of albumin 5% to a client recovering from
hypovolemic shock. Which statement indicates that the client understands the instructions?
A) "It is a protein that causes my kidneys to conserve fluid."
B) "It is a protein that pulls water into my blood vessels."
C) "It is a liquid that has electrolytes in it to pull water into my blood vessels."
D) "It is a super-concentrated salt solution that helps me conserve body fluid."
Answer: B
Explanation: A) Colloids are proteins or other large molecules that stay suspended in the blood for
long periods because they are too large to easily cross membranes. They draw water molecules from
the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure.
Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations
resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin
5% does not act on the kidneys. Albumin 5% is not a concentrated saline solution.
B) Colloids are proteins or other large molecules that stay suspended in the blood for long periods
because they are too large to easily cross membranes. They draw water molecules from the cells and
tissues into the blood vessels through their ability to increase plasma oncotic pressure. Crystalloids
are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling
those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% does not
act on the kidneys. Albumin 5% is not a concentrated saline solution.
C) Colloids are proteins or other large molecules that stay suspended in the blood for long periods
D) Colloids are proteins or other large molecules that stay suspended in the blood for long periods
Page Ref: 1229
Learning Outcome: 7. Evaluate expected outcomes for an individual with shock.
7) A client being treated for hypovolemic shock is prescribed a low dose of dopamine. What will the
nurse assess after administering this medication?
A) Stabilization of fluid loss
B) Increased cardiac output
C) Vasoconstriction and increased blood pressure
D) Urinary output of at least 30 mL/hour
Answer: D
Explanation: A) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys,
leading to vasodilation and an increased blood flow through the kidneys. Increased cardiac output
occurs with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated.
Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine when
alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid loss.
B) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to
vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs with
high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated. Vasoconstriction
and increased blood pressure occur with high, not low, doses of dopamine when alpha-adrenergic
receptors are stimulated. Dopamine does not prevent or stabilize fluid loss.
C) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to
D) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading to
Page Ref: 1228
of an individual with shock.
8) A client is receiving intravenous nitroprusside (Nipride) as part of treatment for shock. For what
adverse effects should the nurse assess the client during this infusion?
A) Nausea, muscle spasms, and disorientation
B) Confusion, dizziness, and tachycardia
C) Intravenous site for infiltration
D) Gastrointestinal bleeding
E) Shortness of breath
Answer: A, B
Explanation: A) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which
can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be
reported immediately, with the infusion slowed to a keep-open rate. Although the intravenous site
should be assessed for infiltration, the local tissue reaction is less severe than that which can occur
with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not adverse
effects of this medication.
B) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if
the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be reported
immediately, with the infusion slowed to a keep-open rate. Although the intravenous site should be
assessed for infiltration, the local tissue reaction is less severe than that which can occur with a
vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not adverse effects
of this medication.
C) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if
of this medication.
D) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if
of this medication.
E) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if
of this medication.
Page Ref: 1228
Learning Outcome: 6. Plan evidence-based care for an individual with shock and his or her family in
9) A nurse is caring for a client who was involved in a motor vehicle accident and has lost
approximately 1,500 mL of blood. Which type of hemorrhagic shock describes this client?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: C
Explanation: A) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of
1,500-2,000mL or 30% to 40% of blood volume.
B) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
2,000mL or 30% to 40% of blood volume.
C) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
D) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
Page Ref: 1219
10) A nurse working in the ICU is caring for a client in progressive hemorrhagic shock. Which clinical
manifestation is likely present?
A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP)
B) A blood loss of 25%
C) A change from aerobic to anaerobic metabolism
D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space
Answer: C
Explanation: A) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to
anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs
when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to
50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic
pressure within the capillary, shifting fluid into the interstitial space.
B) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there
is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to 50%. The
acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure
within the capillary, shifting fluid into the interstitial space.
C) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
D) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
Page Ref: 1219
Exemplar 16.13 Stroke
1) While completing a health history with an older client, the nurse learns that the client experienced
a transient ischemic attack several months ago. What does this information suggest to the nurse?
A) The client is at risk for an ischemic thrombotic stroke.
B) The client will have minimal symptoms should a stroke occur.
C) The client will not experience a stroke in the future.
D) The client is at high risk for a hemorrhagic stroke.
Answer: A
Explanation: A) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke.
One or many transient ischemic attacks may precede a stroke, with the time between the attack and
the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral
blood vessel and is not related to a transient ischemic attack. There is no way to predict the symptoms
the client will experience after a stroke.
B) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many
transient ischemic attacks may precede a stroke, with the time between the attack and the stroke
ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood
vessel and is not related to a transient ischemic attack. There is no way to predict the symptoms the
client will experience after a stroke.
C) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many
D) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or many
Page Ref: 1235
indirect causes of stroke.
2) While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's
the most important thing for me to remember?" What is an appropriate response by the nurse?
A) "Be alert for sudden weakness or numbness."
B) "Know your family history."
C) "Keep a list of your medications."
D) "Call 911 if you notice a gradual onset of paralysis or confusion."
Answer: A
Explanation: A) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of
speech, confusion, dizziness, unsteadiness, and loss of balance–the key word is sudden. Family
history and past medical history can be indicators for risk, but they are not warning signs of stroke.
Gradual onset of symptoms is not indicative of a stroke.
B) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion,
dizziness, unsteadiness, and loss of balance–the key word is sudden. Family history and past medical
history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms
is not indicative of a stroke.
C) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion,
D) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion,
Page Ref: 1235
Learning Outcome: 2. Identify risk factors and prevention methods associated with stroke.
3) An older client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and
family, the nurse will provide teaching in which areas?
A) Time adjustment to complete activities
B) How to use a sign board
C) Nutrition support
D) Transfer techniques
E) Information about impulse control
Answer: A, B, D
Explanation: A) The left cerebral hemisphere is responsible for the language center, calculation skills,
and thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided
brain damage. The client also might display over-cautious behavior and might be slow to respond or
complete activities. Transfer techniques would apply regardless of the side involved. Impulse control
problems can arise with right-sided involvement. Nutritional support may or may not be an issue with
this client.
B) The left cerebral hemisphere is responsible for the language center, calculation skills, and
thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided brain
damage. The client also might display over-cautious behavior and might be slow to respond or
this client.
C) The left cerebral hemisphere is responsible for the language center, calculation skills, and
this client.
D) The left cerebral hemisphere is responsible for the language center, calculation skills, and
this client.
E) The left cerebral hemisphere is responsible for the language center, calculation skills, and
this client.
Page Ref: 1245
life span for individuals with stroke.
4) A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should the
nurse do?
A) Teach the client the "chin tuck" technique when swallowing.
B) Assist the client to a 90° sitting position, or as high as tolerated, during meals.
C) Check the client's mouth for pocketing of food.
D) Assist the client in maintaining a sitting position for 30 minutes after the meal.
Answer: D
Explanation: A) Keeping the client upright for a time after the meal will help prevent food from being
regurgitated back into the esophagus. The position of the client during the meals as well as teaching
the "chin tuck" technique will assist with the swallowing mechanism but will not help with
regurgitation. Pocketing food does not cause regurgitation.
B) Keeping the client upright for a time after the meal will help prevent food from being regurgitated
back into the esophagus. The position of the client during the meals as well as teaching the "chin tuck"
technique will assist with the swallowing mechanism but will not help with regurgitation. Pocketing
food does not cause regurgitation.
C) Keeping the client upright for a time after the meal will help prevent food from being regurgitated
D) Keeping the client upright for a time after the meal will help prevent food from being regurgitated
Page Ref: 1245
stroke.
5) The nurse is planning care for a client admitted with a stroke. Which intervention would support
the client's sensorimotor needs?
A) Encourage use of non-affected arm to feed self, bathe, and dress.
B) Speak in normal conversational pattern and tones.
C) Provide complete care.
D) Talk loudly and distinctly.
Answer: A
Explanation: A) To address the client's alteration in sensory and motor statuses, the nurse should
encourage the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not
provide all care for the client. The nurse should not talk loudly to the client but should articulate
slower and face the client when speaking. Speaking in normal conversational patterns and tones may
not be adequate when communicating with the client.
B) To address the client's alteration in sensory and motor statuses, the nurse should encourage the
client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide all care
for the client. The nurse should not talk loudly to the client but should articulate slower and face the
client when speaking. Speaking in normal conversational patterns and tones may not be adequate
when communicating with the client.
C) To address the client's alteration in sensory and motor statuses, the nurse should encourage the
D) To address the client's alteration in sensory and motor statuses, the nurse should encourage the
Page Ref: 1244
Learning Outcome: 6. Plan evidence-based care for an individual with stroke and his or her family in
6) A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During
discharge teaching, which statement by the client would reflect an understanding of the effects of this
medication?
A) "It will be okay for me to eat anything, as long as it is low-fat."
B) "I will stop taking this medicine if I notice any bruising."
C) "I'll check my blood pressure frequently while taking this medication."
D) "I will not eat spinach while I'm taking this medicine."
Answer: D
Explanation: A) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green,
leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.
Bruising is a common side effect, and the drug should not be stopped unless prescribed by the
physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not affect
the blood pressure.
B) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables
contain vitamin K and will therefore interfere with the therapeutic effects of the drug. Bruising is a
common side effect, and the drug should not be stopped unless prescribed by the physician. Low-fat
foods do not interfere with warfarin sodium therapy. Anticoagulants do not affect the blood pressure.
C) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables
D) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy vegetables
Page Ref: 1133
Learning Outcome: 7. Evaluate expected outcomes for an individual with stroke.
7) A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the
recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's
family about the use of this medication?
A) Used to treat thrombotic and hemorrhagic strokes
B) Not associated with serious complications
C) Indicated if the stroke symptoms have occurred within the last 6 hours
D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish
circulation to the involved part of the brain
Answer: D
Explanation: A) Thrombolytic therapy using recombinant tissue plasminogen activator is used to
dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral
circulation. The treatment can be used if the symptoms have occurred within the last 3 hours.
Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage
causing extensive brain damage and disability. The treatment is only used with thrombotic strokes.
B) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot
formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment
can be used if the symptoms have occurred within the last 3 hours. Bleeding is a complication
associated with the treatment, which may result in cerebral hemorrhage causing extensive brain
damage and disability. The treatment is only used with thrombotic strokes.
C) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot
D) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the clot
Page Ref: 1241
of an individual with stroke.
8) The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to
the affected limbs. What should the nurse explain regarding the purpose of these exercises?
A) Improve muscle strength.
B) Maintain cardiopulmonary function.
C) Improve endurance.
D) Maintain joint flexibility.
Answer: D
Explanation: A) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-
motion exercises improve muscle strength, improve endurance, and can help maintain
cardiopulmonary functioning. The nurse should instruct the spouse that the exercises will help with
joint flexibility.
B) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary
functioning. The nurse should instruct the spouse that the exercises will help with joint flexibility.
C) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
D) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
Page Ref: 1244
Learning Outcome: 6. Plan evidence-based care for an individual with stroke and his or her family in
9) A client with a suspected TIA presents to the Emergency Department with aphasia. Which is the
pathophysiology causing aphasia?
A) Middle cerebral artery involvement
B) Posterior cerebral artery involvement
C) Ischemia of the left hemisphere
D) Ischemia of the right hemisphere
Answer: C
Explanation: A) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be
involved in a TIA, but are not the causative pathology of aphasia.
B) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA,
but are not the causative pathology of aphasia.
C) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA,
D) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA,
Page Ref: 1238
indirect causes of stroke.
10) A nurse working in the Emergency Department is aware that there are various cultural and ethnic
risk factors for stroke. The nurse understands that which of the following is an example of this?
A) African-Americans have an increased incidence of intracerebral hemorrhage.
B) Hispanics have almost twice the number of first-ever strokes compared with whites.
C) African-Americans are more likely to die following a stroke than whites.
D) The prevalence of hypertension among Hispanics is the highest in the world.
Answer: C
Explanation: A) African-Americans are more likely to die following a stroke than whites. Also,
African-Americans have the highest prevalence of hypertension in the world and almost twice the
number of first-ever strokes compared with whites. Hispanics have an increased incidence of
intracerebral hemorrhage.
B) African-Americans are more likely to die following a stroke than whites. Also, African-Americans
have the highest prevalence of hypertension in the world and almost twice the number of first-ever
strokes compared with whites. Hispanics have an increased incidence of intracerebral hemorrhage.
C) African-Americans are more likely to die following a stroke than whites. Also, African-Americans
D) African-Americans are more likely to die following a stroke than whites. Also, African-Americans
Page Ref: 1237
life span for individuals with stroke.

Perfusion - Nursing Test Questions

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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

The Concept of Perfusion

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