Exam Prep Chapter 32 Vascular Disorders Nursing - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 32 Nursing Care of Patients with Vascular and Lymphatic Disorders
1) The nurse measures a patient's blood pressure as 144/88 mmHg. What intervention would be most appropriate for this patient?
1. Provide stress-reduction techniques.
2. Inform the physician so antihypertensive medication can be prescribed.
3. Offer the patient a glass of water.
4. Remeasure the blood pressure in a few minutes.
Page Ref: 1110
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
2) A patient with diabetes is beginning treatment for hypertension. What should the nurse explain as being the blood pressure treatment goal for this patient?
1. 140/90 mmHg
2. 135/85 mmHg
3. 130/80 mmHg
4. 120/80 mmHg
Page Ref: 1112
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
3) The nurse is instructing a patient with hypertension about lifestyle modifications. What would be appropriate to include in the teaching for this patient? Select all that apply.
1. Review the DASH diet.
2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.
3. Plan a weight lifting regimen.
4. Eliminate dairy products from the diet.
5. Restrict fluid intake.
Page Ref: 1113
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
4) A patient's blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. What should the nurse do at this time?
1. Ask if the patient is taking the prescribed medication.
2. Suggest to the physician that another medication be added.
3. Schedule the patient to have the blood pressure checked again in a week.
4. Realize the patient is anxious because of the diagnosis.
Page Ref: 1119
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Self-Care
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
5) During the abdominal assessment of an elderly patient, the nurse palpates a mass in the midabdomen. What should the nurse do next?
1. Percuss the mass.
2. Ask the patient to cough.
3. Get the physician.
4. Auscultate the mass.
Page Ref: 1126
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
6) The nurse suspects a patient recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. What finding did the nurse use to make this clinical decision? Select all that apply.
1. Urine output 45 mL/hr
2. Complaint of groin pain
3. Abdominal dressing dry and intact
4. Respiratory rate 16 and regular
5. Complaint of back discomfort
Page Ref: 1127
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
7) The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. What did the nurse most likely assess in this patient?
1. Rubor with extremity elevation
2. Normal hair distribution bilaterally over lower extremities
3. Peripheral pulses present bilaterally
4. Complaints of leg pain upon rest
Page Ref: 1131
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
8) A patient is having segmental pressure measurements conducted to help diagnose peripheral vascular disease. What finding would indicate the presence of this disorder?
1. Thigh pressure higher than the arm
2. Calf pressure higher than the arm
3. Calf pressure lower than the arm
4. No difference between the arm and leg
Page Ref: 1131
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
9) A patient is demonstrating signs of ineffective peripheral tissue perfusion. What intervention would be appropriate for this patient?
1. Encourage patient to reduce level of exercise.
2. Discuss smoking cessation techniques.
3. Keep extremities cool.
4. Assist with pillow placement under knees.
Page Ref: 1133
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
10) A patient is diagnosed with thromboangiitis obliterans. What would be appropriate teaching for this patient?
1. Medications are the only cure.
2. Surgical procedures can be performed to cure this disorder.
3. Management depends upon the patient's willingness to stop smoking.
4. Nothing can help manage this disorder.
Page Ref: 1136
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
11) A patient is being discharged on long-term oral anticoagulant therapy for arterial thrombus formation in the lower extremity. What should be included in this patient's discharge instructions?
1. Slight bleeding from the nose is expected.
2. Contact the physician's office for follow-up laboratory studies.
3. Pain in the limb is a sign of healing.
4. Take two doses of the prescribed anticoagulant if a dose is missed one day.
Page Ref: 1140
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
12) A patient is demonstrating signs of thrombophlebitis. Which mechanism should the nurse expect has occurred with this health problem? Select all that apply.
1. Pooling of blood in the vessel
2. Blood hypercoagulation
3. Stasis of blood flow
4. Elevated systemic blood pressure
5. Vessel damage
Page Ref: 1141
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
13) A patient is seen for increasing edema in his left lower extremity and pain in the limb with ambulation. What should the nurse suspect is occurring in this patient?
1. Arterial occlusion
2. Deep vein thrombosis
3. Superficial vein thrombosis
4. Varicose veins
Page Ref: 1141
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
14) A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. When should the nurse anticipate that oral warfarin sodium would be prescribed?
1. The same day the heparin is discontinued
2. The day before the heparin is discontinued
3. Four to five days before the heparin is discontinued
4. The same day as the heparin is started
Page Ref: 1143
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
15) The nurse is planning care for a patient who was diagnosed with deep vein thrombosis (DVT). What should be included in this plan of care?
1. Activity as tolerated.
2. Measure and apply elastic antiembolism stockings.
3. Encourage the patient to sit out of bed several hours every day.
4. Assist patient with putting on tight-fitting pants.
Page Ref: 1146
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
16) A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. What should the nurse do first?
1. Elevate the head of the bed and begin oxygen therapy.
2. Measure the patient's blood pressure.
3. Assess the extremity with the thrombosis.
4. Assess the pulses on the extremity with the thrombosis.
Page Ref: 1147
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
17) An older patient is diagnosed with chronic venous insufficiency. What should the nurse instruct this patient?
1. Keep legs in a dependent position as much as possible.
2. Avoid the use of knee-high hose or girdles.
3. Limit ambulation.
4. Dangle legs over the side of the bed several times per day.
Page Ref: 1150
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
18) An older patient is prescribed elastic graduated compression stockings. What should the nurse instruct the patient about these stockings?
1. Wear the stockings continuously, except when showering.
2. Expect areas of skin breakdown under the stockings.
3. Wear the stockings primarily while sleeping.
4. Remove the stockings once per day and while sleeping.
Page Ref: 1152
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
19) The nurse is teaching a community education class on hypertension and risk factors for this disorder. What is the primary risk factor leading to the higher incidence of hypertension in older adults?
1. Being a black adult
2. Being a white male
3. Having a family history of hypertension
4. Age-related increase in the systolic blood pressure
Page Ref: 1111
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
20) A patient is diagnosed with a disorder in which deoxygenated blood is having difficulty returning to the heart and lungs for reoxygenation. In which part of the peripheral vascular system is the origin of this patient's disorder?
1. Arteries
2. Arterioles
3. Capillaries
4. Venules
Page Ref: 1140
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
21) A patient with some blood loss is maintaining a blood pressure of 100/60 mmHg. Which structure is most likely maintaining the patient's blood pressure?
1. Arterioles
2. Venules
3. Capillaries
4. Veins
Page Ref: 1109
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
22) A patient is demonstrating a sign of blood pressure stabilization accompanied by a decreased urine output. What should the nurse explain is the body's mechanism responsible for this blood pressure stabilization?
1. Response to chemoreceptors in the aortic arch
2. Renal conservation of sodium and water
3. Change in body temperature
4. Intake of dietary fat and protein
Page Ref: 1109
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
23) The nurse suspects that a patient's hypertension is being influenced by sympathetic nervous system stimulation. Which substance should the nurse identify as contributing to this patient's elevated blood pressure? Select all that apply.
1. Epinephrine
2. Angiotensin II
3. Norepinephrine
4. Adrenomedullin
5. Antidiuretic hormone
Page Ref: 1109
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
24) A patient makes an appointment to see the primary healthcare provider because during a routine eye examination the ophthalmologist asked how long the patient had been treated for hypertension. What did the ophthalmologist observe that caused the health problem of hypertension to be discussed? Select all that apply.
1. Nystagmus
2. Papilledema
3. Astigmatism
4. Retinal exudates
5. Retinal hemorrhages
Page Ref: 1112
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
25) A patient with hypertension is prescribed the alpha-adrenergic blocker doxazosin (Cardura). What should the nurse instruct the patient about this medication? Select all that apply.
1. Take the medication at bedtime.
2. Change positions slowly and sit down if dizziness occurs.
3. Notify the primary healthcare provider if nasal congestion develops.
4. Restrict the intake of all alcoholic beverages and items containing caffeine.
5. Avoid engaging in hazardous activity for 12 to 24 hours after the first dose.
Page Ref: 1115
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
26) A patient with hypertension weighing 115 kg is advised by the primary healthcare provider to lose 10% of total body weight over the next 6 months. How many lbs. of weight loss per month should the nurse instruct the patient to establish as a goal? Record your answer rounding to the nearest whole number.
Page Ref: 1119
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
27) A patient is suspected as having secondary hypertension. For which diagnostic test should the nurse prepare this patient? Select all that apply.
1. Bladder scan
2. Renal lithotripsy
3. Renal ultrasound
4. Renal arteriogram
5. Intravenous pyelogram
Page Ref: 1123
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
28) While conducting an assessment, the nurse suspects that a patient is experiencing a hypertensive crisis. What did the nurse assess to make this clinical decision? Select all that apply.
1. Acute onset of confusion
2. Onset of projectile vomiting
3. Complaints of a severe headache
4. Systolic blood pressure 198 mmHg
5. Diastolic blood pressure 148 mmHg
Page Ref: 1123
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
29) A patient is experiencing a new onset of hoarseness. What additional assessment finding should the nurse use to suspect that this patient is experiencing a thoracic aneurysm? Select all that apply.
1. Brassy cough
2. Lumbar back pain
3. Edema of the face
4. Distended neck veins
5. Absent pulses in the wrists
Page Ref: 1125
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
30) A patient is diagnosed with an aortic dissection. Which medication should the nurse expect to be prescribed for this patient? Select all that apply.
1. Verapamil (Isoptin)
2. Esmolol (Brevibloc)
3. Diltiazem (Cardizem)
4. Hydralazine (Apresoline)
5. Sodium nitroprusside (Nipride)
Page Ref: 1127
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
31) The nurse is concerned that a patient recovering from surgery to repair an abdominal aneurysm is developing bowel ischemia. What assessment finding did the nurse use to come to this conclusion? Select all that apply.
1. Diarrhea
2. Obvious bloody stool
3. Abdominal distention
4. Onset of abdominal pain
5. Hyperactive bowel sounds
Page Ref: 1129
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
32) The nurse instructs a patient with peripheral atherosclerosis on foot care. Which observation indicates that teaching has been effective? Select all that apply.
1. The patient uses a razor to cut the toenails.
2. The patient walks barefoot in the bedroom.
3. The patient washes feet and legs with warm water.
4. The patient applies powder to the feet after a shower.
5. The patient inspects feet and legs each day with a mirror.
Page Ref: 1132
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
33) The nurse contacts the healthcare provider after assessing a patient's left lower leg. What did the nurse assess to make this decision? Select all that apply.
1. Absent pedal pulses
2. Skin cold to the touch
3. +4 edema on the ankle
4. Foot unresponsive to sensation
5. Line of demarcation across the foot
Page Ref: 1138
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.
34) A patient with a history of recurrent venous micro emboli is scheduled for an insertion of a Greenfield filter. What should the nurse explain to the patient about this procedure? Select all that apply.
1. The filter can be inserted under fluoroscopy.
2. Mortality from the insertion of the filter is low.
3. The filter will need to be replaced every 6 months.
4. The patient may only need local anesthesia for the procedure.
5. The filter traps emboli while maintaining the patency of the vena cava.
Page Ref: 1145
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
35) A patient with a history of deep venous thrombosis is prescribed rivaroxaban (Xarelto). What should the nurse instruct the patient about this medication? Select all that apply.
1. Use a straight razor to shave if necessary.
2. Limited amounts of alcohol are permitted.
3. A reversal agent for this medication is not available.
4. The cost of this medication is higher than for warfarin.
5. Laboratory test monitoring is not necessary for this medication.
Page Ref: 1144
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
36) The nurse completes an assessment with a patient and begins planning care for a venous leg ulcer. What manifestation did the nurse use to make this clinical decision? Select all that apply.
1. There is an ulcer located on the toe.
2. The ulcer is superficial and pink.
3. Pulses in the foot are decreased.
4. Skin over the leg is discolored brown.
5. The patient rates pain as 8 on a scale from 0 to 10.
Page Ref: 1149
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.
37) A patient is recovering from surgery for varicose veins. What information should the nurse include in this patient's postoperative teaching? Select all that apply.
1. Elevate the extremities.
2. Increase ambulation gradually.
3. Sit for no more than 1 hour at a time.
4. Avoid standing for more than 15 minutes.
5. Keep pressure dressing applied for 6 weeks.
Page Ref: 1152
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
38) A patient is diagnosed with lymphedema. Which treatment should the nurse expect to be prescribed for this patient? Select all that apply.
1. Consider microvascular surgery.
2. Apply powder to the feet after daily cleansing.
3. Measure for elastic graduate compression stockings.
4. Intermittent pneumatic compression device for home use.
5. Limit wearing of shoes when in the home or a controlled environment.
Page Ref: 1154-1155
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 32.5 Describe the pathophysiology and manifestations of disorders of the lymphatic system, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.
39) A patient with lymphedema asks why the legs need to be elevated throughout the day. Which information should the nurse include when responding to this patient? Select all that apply.
1. Prevents tissue hypoxia
2. Promotes venous return
3. Facilitates arterial circulation
4. Decreases venous congestion
5. Reduces fluid in interstitial spaces
Page Ref: 1155
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 32.5 Describe the pathophysiology and manifestations of disorders of the lymphatic system, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.
Document Information
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