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- The nurse is admitting 53 year old Caucasian male with a pre-existing condition of hypertension to the unit. The nurse would identify which of the following as risk factors for his condition? (Select all that apply)
- 2g of sodium daily
- History of smoking
- BMI of 35
- The nurse is teaching a young client with a family history of hypertension about initial symptoms of hypertension. The nurse would inform the patient that which of the following is an early symptom?
- Decreased urine output
- A patient with a history of well-controlled hypertension is admitted to the hospital with a blood pressure of 250/160 and elevated BUN and creatinine levels. The nurse knows that assessing for which of the following is most appropriate in determining what caused the hypertensive crisis?
- Adherence to the medication regimen
- Neurologic status
- Alcohol consumption
- Nutritional status
- The nurse is preparing to discharge a young client with a family history of hypertension. The nurse should include which of the following as part of patient teaching to prevent hypertension? (Select all that apply)
- Low-fat diet
- HDL <40
- A patient is taking metoprolol and captopril. What is the priority nursing assessment before administering these drugs?
- Respiratory rate and depth
- Presence of bowel sounds
- Neurologic status
- Apical pulse and blood pressure
- A patient with severe asthma is scheduled to receive metoprolol at 0900. The most appropriate action by the nurse is. . .
- Question the patient about use of inhalers
- Administer the medication as prescribed
- Administer half the prescribed dose
- Hold the medication and contact the physician
- What statement by the patient demonstrates an understanding of the teaching regarding atenolol (Tenormin)?
- “I may experience dry-mouth while taking this medication and can suck on hard candy to help with this.”
- “A decrease in urination is common with the medicine I am taking.”
- “I do not need to worry about sexual dysfunction while taking this drug.”
- “I will closely monitor for a change in my bowel habits.”
- A patient is admitted with a cholesterol level of 250. The nurse identifies which of the following as modifiable risk factors for an elevated cholesterol level?
- BMI of 25
- Triglyceride level of 100
- A patient has a total cholesterol level of 200 and an HDL of 50. The nurse understands that this patient has. . .
- No risk for CAD
- A low risk for CAD
- An average risk for CAD
- A high risk for CAD
- A patient demonstrates understanding of considerations for taking a statin drug when he states which of the following?
- “I can take this drug with alcohol as long as I limit my intake to 2 drinks per day since I am a male.”
- “I should have my liver enzymes checked frequently while taking this drug.”
- “Since I am taking the drug to lower my cholesterol, I do not need to worry about diet and exercise.”
- “I can stop taking this drug once I am feeling better.”
- A middle-aged man complains of feeling a “tightness” in his chest and “achiness” in his arm after he climbs the stairs at his workplace every day. The nurse understands this pattern of pain is most consistent with
- Unstable angina
- Chronic stable angina
- Silent ischemia
- Acute angina
- A woman asks the nurse what signs and symptoms of angina she should be aware of to report to her doctor. The nurse knows it is most appropriate to educate the woman about
- Sharp, shooting chest pain
- A feeling of tightness in the chest
- Fatigue and nausea
- Chest pain that radiates to the arm and shoulder
- A patient is at home and begins to experience chest pain. The best action is to
- Call 911 immediately
- Sit and breathe deeply
- Call 911 and then take a Nitroglycerin tablet
- Take a Nitroglycerin tablet, wait 5 minutes, and take another tablet and call 911 if pain is unrelieved
- A patient reports that every time he walks up the hill to his mailbox, he experiences anginal pain. An appropriate suggestion for this patient would be to
- Take a Nitroglycerin tablet before beginning his walk
- Sit down immediately upon reaching the mailbox
- Avoid walking to the mailbox
- Call 911 next time he experiences this pain
- What is the most important dietary consideration for a patient experiencing heart failure?
- Restrict intake of sodium
- Increase intake of potassium
- Reduce intake of potassium
- Restrict fluid intake
- A patient has been taking furosemide (Lasix) for three days now. The nurse knows it is important to
- Check the potassium level and prepare for an order for a potassium supplement
- Restrict the patient’s intake of potassium
- Exercise the patient more frequently
- Catheterize the patient
- A patient is receiving digoxin. The nurse tells the nursing assistant to immediately report which of the following
- Blood pressure >140/90
- Increased urine output
- Patient complaints of nausea and visual disturbances
- Patient says they “feel cold”
- A nurse is preparing to admit a patient with left-sided heart failure. The nurse should anticipate which of the following? (Select all that apply)
- A nurse is caring for a patient with left-sided heart failure. Which of the following is the priority intervention?
- Administer diuretic
- Raise HOB and administer oxygen
- Check pulses in all extremities
- Provide distraction and imagry
- A patient presents to the unit with the following symptoms: Anorexia, dependent edema, hepatomegaly, weight gain, and fatigue. The nurse suspects
- Pulmonary edema
- Left-sided heart failure
- Right-sided heart failure
- A nurse is admitting a 75-year-old woman post-op from hip surgery from the PACU. She has smoked a half-pack per day for 40 years. What is the nurse’s priority intervention?
- Apply sequential compression devices
- Begin ambulating the patient immediately
- Provide information about smoking cessation
- Ask the patient about her normal activities of daily living
- A patient is on bed rest and at risk for developing a DVT. The nurse carefully assess for which of the following? (Select all that apply)
- Bilateral edema
- Patient reports of “leg cramp”
- Erythema of extremity
- Weeping wound
- Palpable venous cord
- Which of the following is an appropriate intervention in the management of a patient with DVT?
- Apply sequential compression devices
- Elevate the extremity
- Gently massage the affected area
- Restrict fluid intake
1. A, B, D, E
Age, gender, and cigarette smoking are risk factors for hypertension. A BMI >30 is considered a risk factor for hypertension, therefore a BMI of 35 is a risk factor. Excessive sodium intake ( >2g of sodium per day) is considered a risk factor for hypertension, therefore a diet of 2g of sodium per day is not a risk factor.
Other risk factors for hypertension include excessive alcohol consumption, elevated serum lipids, family history, ethnicity, sedentary lifestyle, socioeconomic status, and stress.
Fatigue and reduced activity intolerance is an initial symptom of hypertension. Headache and nosebleeds are symptoms of a hypertensive crisis, but are not early signs of hypertension. Decreased urine output can be a causative factor in hypertension, but it is not a symptom.
Other initial symptoms include dizziness, dyspnea, palpitations, and angina.
Lack of adherence to the prescribed medication regimen is the most common cause of hypertensive crisis. Therefore, this is the most appropriate response. Although monitoring the neurologic status is important, it will not give information pertinent to the cause of the hypertensive crisis. Alcohol consumption and improper nutrition can lead to hypertension, but they are not the most appropriate factors to assess for in hypertensive crisis.
4. A, D
A low-fat diet and regular exercise will help to prevent hypertension. An HDL >40 in men and >50 in women will help to prevent hypertension, therefore teaching the client to keep HDL <40 is not appropriate. Beta-blockers will treat hypertension, but are not used for prevention.
Beta-blockers (metoprolol) and ACE inhibitors (captopril) both lower blood pressure, therefore checking the blood pressure is a priority assessment. Beta-blockers also decrease heart rate, therefore it is important to assess the apical pulse before administration.
Beta-blockers are to be used cautiously in patients with asthma as they may cause bronchial constriction. Therefore, the most appropriate action by the nurse is to question the order for metoprolol in a patient with severe asthma.
Dry-mouth is a common side effect. Patients may notice frequent urination. Beta-blockers may cause sexual dysfunction. Bowel habits are unrelated to the effects of this drug.
Additionally, patients need education on the possibility of developing orthostatic hypotension and the need to rise slowly.
Hypertension is a modifiable risk factor for hyperlipidemia. Ethnicity is a risk factor for hyperlipidemia, however it is a nonmodifiable risk factor. A BMI >30 and fasting triglyceride level >150 are modifiable risk factors for hyperlipidemia, therefore a BMI of 25 and triglyceride level of 100 are not considered risk factors.
Other modifiable risk factors include tobacco use and physical inactivity.
Other nonmodifiable risk factors include age, gender, and family history.
Diving the total cholesterol by the HDL gives an idea of a person’s risk factor for CAD. < 3 = Low risk, 3-5 = average risk, 5+ = high risk. 200/50 = 4. Therefore, this patient has an average risk for developing CAD.
Statins promote excretion of lipids via the hepatic metabolism. Therefore, patients should be screened periodically for liver damage. Statins should not be taken with alcohol and should be taken in conjunction with exercise and nutritional therapy. Patients should not stop taking a statin drug when they “feel better.”
A tightness in the chest radiating to the arm and/or neck is consistent with typical anginal pain. Therefore, the man is not experiencing silent ischemia, or atypical angina pain. The pain follows a consistent, predictable pattern. Therefore, this is considered chronic stable angina.
Women usually experience atypical anginal pain, known as silent ischemia. Signs and symptoms include fatigue, sore shoulder, nausea, and “not feeling well.” Sharp, shooting chest pain is most consistent with pleuritic pain. A feeling of tightness in the chest and pain radiating to the arm and shoulder are consistent with typical anginal pain.
The best action for chest pain is to take a Nitroglycerin tablet. If the pain is unrelieved after 5 minutes, the patient may take a second Nitroglycerin. It is recommended to call 911 for unrelieved chest pain. If after 5 more minutes, the pain is unrelieved, the patient may take a final, third Nitroglycerin.
The patient is experiencing chronic stable angina. An appropriate action would be to take a Nitroglycerin tablet before beginning the precipitating activity. Sitting down upon reaching the mailbox may help to decrease the oxygen demand and increase the oxygen supply to the heart, but it is not the best action. There is no evidence avoiding the activity or calling 911 is necessary.
The most important dietary consideration for a patient in heart failure is to restrict intake of sodium to 2.5g or less per day (no added salt) to help correct the sodium and water retention which lead to fluid overload. Fluid restriction is generally not required. A change in potassium intake may be necessary if the patient is taking a diuretic, however this is not the most important nutritional consideration for a patient in heart failure.
Furosemide (Lasix) is a potassium-wasting diuretic. Therefore, the nurse should check the patient’s most recent potassium level and prepare for an order for a potassium supplement. Since Lasix promotes excretion of potassium, the nurse should not restrict the client’s intake of potassium. There is no evidence to support the need to exercise the patient more frequently or catheterize the patient.
GI disturbances such as nausea and visual disturbances, especially seeing yellow halos, are classic signs of digoxin toxicity and should be reported to the nurse immediately. Although blood pressure and urine output are important to report to the nurse, they are not the priority. Feeling cold is not a symptom of digoxin toxicity.
18.B, C, E
Crackles, dyspnea, and fatigue are all symptoms of left-sided heart failure. Fluid backs up from the heart into the lungs, causing adventitious sounds and a decrease in available oxygen. Edema is a symptom of right-sided heart failure. Tachycardia, not bradycardia, is seen in left-sided heart failure as a result of a decrease in available oxygen.
Other symptoms of left-sided heart failure include cough, wheezes, blood-tinged sputum, tachypnea, restlessness, confusion, and cyanosis.
Left-sided heart failure usually causes pulmonary edema. Therefore, raising the head of the bead and administering oxygen are priority interventions. Although administering a diuretic and providing distraction/imagery to reduce anxiety are appropriate interventions, they are not the priority. Although checking the pulses of extremities is important, it is not a priority in left-sided heart failure as the focus is on the lungs.
These symptoms are consistent with right-sided heart failure, as fluid backs up into circulation. Weight gain and dependent edema is caused by excess fluid volume. Ascities leads to feelings of fullness and gastric upset, causing anorexia. The symptoms are consistent with excess fluid volume, therefore the nurse would not suspect hypovolemia. There is little evidence to support pulmonary edema (crackles, cough, shortness of breath).
The most important intervention is to apply SCDs. The patient has several risk factors for DVT (hip surgery, age, history of smoking, probable bed rest). Although early ambulation is important in preventing DVT, the patient may be on bed rest during the immediate post-op period. Although providing information about smoking cessation and determining the patient’s usual activities are appropriate interventions, they are not the priority.
22. B, C, E
A DVT can cause a cramp-like pain, redness, and a palpable venous cord in the effected extremity. The nurse would look for unilateral, not bilateral, edema when assessing for a DVT. Bilateral edema and a weeping wound are signs of venous insufficiency.
The nurse would elevate the extremity to promote venous return to the heart. The nurse would avoid applying SCDs to or massaging the affected area, as this could dislodge the clot and lead to a pulmonary embolism. The nurse would encourage, not restrict, fluid intake, to decrease the viscosity of blood.