Black Panther
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client?
A. "Herbal substances are not safe and should never be used."
b. "I will teach you how to take your blood pressure so that it can be monitored closely."
c. "You will need to talk to your primary health care provider (PHCP) before using an herbal substance."
d. "If you take an herbal substance, you will need to have your blood pressure checked frequently."
Ans: C
Rationale:
Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the PHCP.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Take Action
Level of Cognitive Ability: Applying
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Hypertension
Integrated Process: Nursing Process/Implementation
Priority Concepts: Health Promotion, Patient Education
Strategy(ies): Closed-ended Word, Comparable or Alike Options, Strategic Words
A client has a diagnosis of asymptomatic diverticular disease. Which type of diet would the nurse anticipate being prescribed?
a. High-iron diet
b. High-fiber diet
c. Low-purine diet
d. Low-sodium diet
Ans: B
Rationale:
A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Diverticulosis/Diverticulitis
Integrated Process: Nursing Process/Planning
Priority Concepts: Nutrition, Elimination
Strategy(ies): Subject
A client has been diagnosed with acute gastroenteritis. Which diet would the nurse anticipate to be prescribed for the client?
a. Low fat
b. Low fiber
c. High fiber
d. High carbohydrate
Ans: B
Rationale:
A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Gastritis/Gastroenteritis
Integrated Process: Nursing Process/Planning
Priority Concepts: Nutrition, Inflammation
Strategy(ies): Subject
Which infection control method would the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure?
a. Hepatitis B vaccine
b. Proper personal hygiene
c. Use of immune globulin
d. Correct hand-washing technique
Ans: A
Rationale:
Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin may be used to prevent hepatitis A and is used for prophylaxis if the client is traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A.
Client Needs: Safe and Effective Care Environment
Clinical Judgment/Cognitive Skills: Generate Solutions, Prioritize Hypotheses
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Hepatitis
Integrated Process: Nursing Process/Planning
Priority Concepts: Immunity, Infection
Strategy(ies): Strategic Words
The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition?
a. Dyspnea
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation
Ans: C
Rationale:
Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Heart Failure
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Fluids and Electrolytes, Clinical Judgment
Strategy(ies): Subject, Comparable or Alike Options
A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?
a. Baked turkey
b. Tomato soup
c. Boiled shrimp
d. Chicken gumbo
Ans: A
Rationale:
Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Evaluate Outcomes
Level of Cognitive Ability: Evaluating
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Hypertension
Integrated Process: Nursing Process/Evaluation
Priority Concepts: Fluids and Electrolytes, Nutrition
Strategy(ies): Comparable or Alike Options
The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?
a. "This diet will help lower my blood pressure."
b. "Fresh foods such as fruits and vegetables are high in sodium."
c. "This diet is not a replacement for my antihypertensive medications."
d. "The reason I need to lower my salt intake is to reduce fluid retention."
Ans: B
Rationale:
A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Evaluate Outcomes
Level of Cognitive Ability: Evaluating
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Hypertension
Integrated Process: Teaching and Learning
Priority Concepts: Fluids and Electrolytes, Nutrition
Strategy(ies): Negative Event Query, Strategic Words
The nurse is providing care for a client suspected of having appendicitis. Which priority intervention would the nurse anticipate will be prescribed for this client?
a. Full liquid diet
b. Clear liquid diet
c. Mechanical soft diet
d. No oral intake of liquids or food
Ans: D
Rationale:
For a client with suspected or known appendicitis, the nurse should ensure the client remains on nothing by mouth status in anticipation of emergency surgery and also to avoid worsening the inflammation. Options 1, 2, and 3 are not prescribed for the client with suspected appendicitis.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions, Prioritize Hypotheses
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Appendicitis
Integrated Process: Nursing Process/Planning
Priority Concepts: Inflammation, Safety
Strategy(ies): Comparable or Alike Options, Strategic Words
The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?
a. "Antacids will coat my stomach."
b. "Omeprazole will coat the ulcer and help it heal."
c. "Sucralfate will change the fluid in my stomach."
d. "The nizatidine will cause me to produce less stomach acid."
Ans: D
Rationale:
Nizatidine, a histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid (HCL). Antacids are used as adjunct therapy and neutralize acid in the stomach. Omeprazole is a proton pump inhibitor. Sucralfate promotes healing by covering the ulcer, thus protecting it from erosion caused by gastric acids.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Evaluate Outcomes
Level of Cognitive Ability: Evaluating
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Peptic Ulcer Disease
Integrated Process: Nursing Process/Evaluation
Priority Concepts: Tissue Integrity, Patient Education
Strategy(ies): Subject, Strategic Words
A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure?
a. Digoxin
b. Warfarin
c. Amiodarone
d. Potassium chloride
Ans: A
Rationale:
Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Heart Failure
Integrated Process: Nursing Process/Planning
Priority Concepts: Perfusion, Clinical Judgment
Strategy(ies): Subject
The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription would the nurse most question?
a. Lorazepam
b. Furosemide
c. Omeprazole
d. Acetaminophen
Ans: D
Rationale:
Acetaminophen can cause hepatotoxicity, and its use is avoided in the client with liver disease. Furosemide and omeprazole do not adversely affect liver function. Lorazepam can cause liver damage in high doses or with long-term therapy but can still be used (with caution) in the client with liver disease.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Gastrointestinal
Integrated Process: Nursing Process/Implementation
Priority Concepts: Clinical Judgment, Safety
Strategy(ies): Subject, Strategic Words
The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet?
a. Beef chili
b. Grilled steak
c. Mashed potatoes
d. Turkey and lettuce sandwich
Ans: D
Rationale:
The client with cholecystitis should decrease overall intake of dietary fat. Red meats (hamburger and steak) contain fat. Mashed potatoes are usually made with milk and butter. The correct food item that is low in fat is the turkey and lettuce sandwich.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Evaluate Outcomes
Level of Cognitive Ability: Evaluating
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Gallbladder Disease
Integrated Process: Teaching and Learning
Priority Concepts: Nutrition, Patient Education
Strategy(ies): Comparable or Alike Options, Strategic Words
The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?
a. Vitamin A
b. Vitamin C
c. Vitamin E
d. Vitamin B12
Ans: D
Rationale:
Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 2, and 3 are incorrect.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Recognize Cues
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Gastritis/Gastroenteritis
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Nutrition, Clinical Judgment
Strategy(ies): Subject
A client has undergone esophagogastroduodenoscopy (EGD). The nurse would place highest priority on which action as part of the client's care plan?
a. Monitoring the temperature
b. Checking for return of a gag reflex
c. Giving warm gargles for a sore throat
d. Monitoring for complaints of heartburn
Ans: B
Rationale:
The nurse places highest priority on managing the client's airway. This includes assessing for return of the gag reflex. The client's vital signs are also monitored, and a sudden sharp increase in temperature could indicate perforation of the gastrointestinal (GI) tract. This should be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway still takes priority.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions, Prioritize Hypotheses
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Integrated Process: Nursing Process/Planning
Priority Concepts: Clinical Judgment, Safety
Strategy(ies): ABCs—Airway, Breathing, Circulation, Strategic Words
The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history would the nurse determine is least likely associated with this disease?
a. History of alcohol abuse
b. History of tarry black stools
c. History of gastric pain 2 to 4 hours after meals
d. History of the use of acetaminophen for pain and discomfort
Ans: D
Rationale:
Unlike aspirin (acetylsalicylic acid), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. History of alcohol abuse, tarry black stools, and gastric pain 2 to 4 hours after meals, if reported by the client, are indications of peptic ulcer disease.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Recognize Cues
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Peptic Ulcer Disease
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Pain, Tissue Integrity
Strategy(ies): Subject
A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?
a. "Don't worry. Many others in your situation say the same thing."
b. "That is unusual. I wonder if the solution is being mixed correctly?"
c. "That is because the empty stomach sends signals to the brain to stimulate hunger."
d. "Maybe you should ask your primary health care provider about that; I've never heard of that before."
Ans: C
Rationale:
The stomach does send signals to the brain when it is empty to stimulate hunger. The client should be told that this is normal. Some clients also experience food cravings for the same reason. Options 1 and 4 will block the communication process. Option 2 will produce fear in the client.
Client Needs: Psychosocial Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems
Integrated Process: Nursing Process/Implementation
Priority Concepts: Nutrition, Patient Education
Strategy(ies): Therapeutic Communication Techniques, Strategic Words
A client is receiving total parenteral nutrition and has been NPO. The primary health care provider (PHCP) prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?
a. The client's appetite
b. The client's current weight
c. The presence of the swallow reflex
d. Adequate pulse and blood pressure readings
Ans: C
Rationale:
The nurse ensures that the client has intact gag and swallow reflexes before giving clear liquids. The nurse should also check for the presence of bowel sounds. The pulse, blood pressure, and weight require ongoing monitoring, but they are not the most important items given the wording of the question. The client may be expected to have a poor appetite after being without oral intake for a period of time.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Prioritize Hypotheses
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Nutrition, Safety
Strategy(ies): Subject, Maslow's Hierarchy of Needs Theory, Strategic Words
A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action?
a. Bathing the client with tepid water and mild soap only
b. Assessing and recording the client's weight twice daily
c. Monitoring red blood cell and white blood cell counts daily
d. Monitoring prothrombin and partial thromboplastin values
Ans: D
Rationale:
When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Daily weight is often part of a nursing care plan but is more related to fluid balance than safety; monitoring weight twice daily would not be necessary. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue either.
Client Needs: Safe and Effective Care Environment
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Hepatitis
Integrated Process: Nursing Process/Planning
Priority Concepts: Infection, Safety
Strategy(ies): Subject, Closed-ended Word
A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition?
Ans: B
Rationale:
The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Renal and Urinary: Acute Kidney Injury and Chronic Kidney Disease
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Fluids and Electrolytes, Perfusion
Strategy(ies): Subject
A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?
a. Enteral feedings are a frequent cause of sepsis.
b. Tube feedings should be refrigerated until just before use.
c. The caloric value of enteral feedings is generally 5 to 10 kcal/mL.
d. Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.
Ans: D
Rationale:
Enteral nutrition can include providing nutrients by mouth, nasogastric tube, gastrostomy tubes, or a percutaneous endoscopic gastrostomy (PEG) tube. The common element in each of these methods of delivery is that the client must have normal GI digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as parenteral nutrition. Enteral feedings may cause aspiration pneumonia because of regurgitation of formula into the lungs; however, they are not generally associated with sepsis. Tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1 to 2 kcal/mL.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Mental Health: Eating Disorders
Integrated Process: Nursing Process/Planning
Priority Concepts: Nutrition, Health Promotion
Strategy(ies): Subject
Rationale Strategy
A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
a. Sepsis
b. Air embolism
c. Fluid overload
d. Hyperglycemia
Ans: C
Rationale:
The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis. Signs and symptoms of an air embolus include confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. Polyuria, polydipsia, and polyphagia are manifestations of hyperglycemia.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Take Action
Level of Cognitive Ability: Applying
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Nutrition/Malabsorption Problems
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Fluids and Electrolytes, Nutrition
Strategy(ies): Subject
A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6°F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question would the nurse ask the client first?
a. "Do you exercise regularly?"
b. "Would you consider losing weight?"
c. "Is there a history of diabetes mellitus in your family?"
d. "When was the last time you had your blood pressure checked?"
Ans: D
Rationale:
The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Analyze Cues
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Hypertension
Integrated Process: Nursing Process/Data Collection
Priority Concepts: Clinical Judgment, Health Promotion
Strategy(ies): Comparable or Alike Options, Strategic Words
The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client would the nurse recognize as best supporting the diagnosis of gastric ulcer?
a. "The pain doesn't usually come right after I eat."
b. "The pain gets so bad that it wakes me up at night."
c. "The pain that I get is located on the right side of my chest."
d. "My pain comes shortly after I eat, maybe a half hour or so later."
Ans: D
Test-Taking Strategy(ies):
Focus on the subject, the pain associated with a gastric ulcer. Note the strategic word, best. Recalling the differences between the types of pain associated with gastric and duodenal ulcers will direct you to the option in which the pain occurs shortly after eating.
The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse would include which items on a list of suggestions to be given to the client? Select all that apply.
Wear elastic stockings.
Be careful not to injure the legs or feet.
Use a heating pad on the legs to aid vasodilation.
Walk each day to increase circulation to the legs.
Cut down on the amount of fats consumed in the diet.
a. Wear elastic stockings.
b. Be careful not to injure the legs or feet.
c. Use a heating pad on the legs to aid vasodilation.
d. Walk each day to increase circulation to the legs.
e. Cut down on the amount of fats consumed in the diet.
Ans: BDE
Rationale:
Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.
Client Needs: Physiological Integrity
Clinical Judgment/Cognitive Skills: Generate Solutions
Level of Cognitive Ability: Analyzing
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Vascular Disorders
Integrated Process: Teaching and Learning
Priority Concepts: Perfusion, Patient Education
Strategy(ies): Subject
The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement?
a. "Smoking cessation is very important."
b. "Moving to a warmer climate should help."
c. "Sources of caffeine should be eliminated from the diet."
d. "Taking nifedipine as prescribed will decrease vessel spasm."
Ans: B
Rationale:
Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.
Client Needs: Health Promotion and Maintenance
Clinical Judgment/Cognitive Skills: Evaluate Outcomes
Level of Cognitive Ability: Evaluating
Content Area: Adult Health: Cardiovascular
Health Problem: Adult Health: Cardiovascular: Vascular Disorders
Integrated Process: Teaching and Learning
Priority Concepts: Health Promotion, Stress
Strategy(ies): Negative Event Query, Strategic Words