MCA II Exam 2 UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
Which clinical finding would the nurse expect to identify when caring for a client with a left
leg venous thrombosis? select all that apply.
a. pain in the left calf
b. intermittent claudication
c. redness in the affected area
d. swelling of the lower left leg
e. ecchymotic areas at the left ankle
f. localized warmth in the lower left leg - CORRECT ANSWER A, C, D, F
pain is related to the edema associated with the inflammatory response. Redness is related to
vasodilation and the inflammatory response. Edema distal to the venous thrombosis occurs
because of increased venous pressure. Warmth in the affected part of the leg occurs due to the
inflammatory response. Intermittent claudication (pain when walking, resulting from tissue
ischemia) may occur with peripheral arterial disease. Ecchymosis is a sign of bleeding and
would not be seen with venous thrombosis.
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of
the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased
hair growth, and thickened toenails. The nurse understands that this may indicate:
a. Venous insufficiency
b. Arterial Insufficiency
c. Phlebitis
d. Lymphedema - CORRECT ANSWER b. Arterial Insufficiency
clients experiencing arterial insufficiency present with extremities that become pale when
elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses
may be absent or mild, and skin may be shiny and thin with decreased hair growth and
thickened nails. Clients with venous insufficiency often have normal-colored extremities,
normal temperature, normal pulses, marked edema, and brown pigmentation around the
ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel
,wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that
is a direct result of impaired flow of the lymphatic system.
a client is admitted to the hospital with a long history of uncontrolled hypertension. which
laboratory result will be important for the nurse to review?
a. blood glucose level
b. white blood cell count
c. blood urea nitrogen
d. lactic dehydrogenase - CORRECT ANSWER c. blood urea nitrogen
hypertension leads to changes in renal blood flow and eventually to decreased renal function,
which is tested with blood urea nitrogen levels. all of the other results would also be reviewed
by the nurse, but they are no associated with complications of hypertension. Changes in blood
glucose level are not associated with hypertension, although if the client also has diabetes
then there will be more risk for kidney disease. White blood cell count is not affected by
hypertension, but it would be assessed for any possible infectious or inflammatory process.
Lactic dehydrogenase is an enzyme associated with multiple other diagnoses, but it is not
affected by hypertension.
which clinical finding would the nurse expect for a client with hypertensive emergency?
a. increased urine output
b. severe pounding headache
c. heart rate 110 beats/min
d. weak & thready radial pulses - CORRECT ANSWER b. severe pounding headache
hypertensive emergency often causes hypertensive encephalopathy because of increased
cerebral capillary permeability, leading to severe headache, nausea, vomiting, and confusion
or coma. Increased urine output would not be expected because acute kidney injury can occur
with hypertensive emergency. Tachycardia is not typically seen with hypertensive emergency;
high blood pressure can lead to bradycardia because of increased pressure on the carotid sinus
and bodies. Radial pulses would be bounding with hypertensive emergency.
The nurse is teaching pursed-lip breathing to a client with COPD. The client asks about the
benefit of the exercises. Which explanation would the nurse give?
, a. prevents complications that are associated with COPD
b. relieves shortness of breath by increasing the breath rate
c. increases the amount of air that the client can inhale with each breath
d. keeps the airway open longer to decrease the work that goes into breathing - CORRECT
ANSWER d. keeps the airway open longer to decrease the work that goes into
breathing
pursed-lip breathing keeps the airway open longer to decrease the work that goes into
breathing. clients with COPD are taught to breathe out through pursed lips to help keep the
air passages open until exhalation is complete. pursed-lip breathing does not prevent COPD
complications. pursed-lip breathing may relieve shortness of breath by decreasing the breath
rate. pursed-lip breathing does not increase the amount of air taken in during inspiration.
which finding by the nurse will be of most concern when a client has venous insufficiency?
a. bilateral brown lower leg discoloration
b. calf pain when the feet are dorsiflexed
c. severe edema from ankles to calves
d. thickened and dry skin on lower legs - CORRECT ANSWER b. calf pain when the
feet are dorsiflexed
calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptoms of
possible venous thrombosis and would require further diagnostic testing and treatment.
bilateral brown lower leg discoloration is a common symptoms of chronic edema caused by
venous insufficiency and would be expected in this client. severe edema is a common and
expected symptom of venous insufficiency and may require actions such as leg elevation, but
is not as concerning as a positive Homans sign. thick and dry skin is common in chronic
venous insufficiency and the nurse will plan to use a lubricating ointment, but it is not as big
a concern as a possible venous thrombosis.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair
Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to
the nurse that teaching about medication administration has been successful?
a. The patient shakes the device before use.
b. The patient rapidly inhales the medication.
QUESTIONS AND CORRECT ANSWERS
Which clinical finding would the nurse expect to identify when caring for a client with a left
leg venous thrombosis? select all that apply.
a. pain in the left calf
b. intermittent claudication
c. redness in the affected area
d. swelling of the lower left leg
e. ecchymotic areas at the left ankle
f. localized warmth in the lower left leg - CORRECT ANSWER A, C, D, F
pain is related to the edema associated with the inflammatory response. Redness is related to
vasodilation and the inflammatory response. Edema distal to the venous thrombosis occurs
because of increased venous pressure. Warmth in the affected part of the leg occurs due to the
inflammatory response. Intermittent claudication (pain when walking, resulting from tissue
ischemia) may occur with peripheral arterial disease. Ecchymosis is a sign of bleeding and
would not be seen with venous thrombosis.
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of
the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased
hair growth, and thickened toenails. The nurse understands that this may indicate:
a. Venous insufficiency
b. Arterial Insufficiency
c. Phlebitis
d. Lymphedema - CORRECT ANSWER b. Arterial Insufficiency
clients experiencing arterial insufficiency present with extremities that become pale when
elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses
may be absent or mild, and skin may be shiny and thin with decreased hair growth and
thickened nails. Clients with venous insufficiency often have normal-colored extremities,
normal temperature, normal pulses, marked edema, and brown pigmentation around the
ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel
,wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that
is a direct result of impaired flow of the lymphatic system.
a client is admitted to the hospital with a long history of uncontrolled hypertension. which
laboratory result will be important for the nurse to review?
a. blood glucose level
b. white blood cell count
c. blood urea nitrogen
d. lactic dehydrogenase - CORRECT ANSWER c. blood urea nitrogen
hypertension leads to changes in renal blood flow and eventually to decreased renal function,
which is tested with blood urea nitrogen levels. all of the other results would also be reviewed
by the nurse, but they are no associated with complications of hypertension. Changes in blood
glucose level are not associated with hypertension, although if the client also has diabetes
then there will be more risk for kidney disease. White blood cell count is not affected by
hypertension, but it would be assessed for any possible infectious or inflammatory process.
Lactic dehydrogenase is an enzyme associated with multiple other diagnoses, but it is not
affected by hypertension.
which clinical finding would the nurse expect for a client with hypertensive emergency?
a. increased urine output
b. severe pounding headache
c. heart rate 110 beats/min
d. weak & thready radial pulses - CORRECT ANSWER b. severe pounding headache
hypertensive emergency often causes hypertensive encephalopathy because of increased
cerebral capillary permeability, leading to severe headache, nausea, vomiting, and confusion
or coma. Increased urine output would not be expected because acute kidney injury can occur
with hypertensive emergency. Tachycardia is not typically seen with hypertensive emergency;
high blood pressure can lead to bradycardia because of increased pressure on the carotid sinus
and bodies. Radial pulses would be bounding with hypertensive emergency.
The nurse is teaching pursed-lip breathing to a client with COPD. The client asks about the
benefit of the exercises. Which explanation would the nurse give?
, a. prevents complications that are associated with COPD
b. relieves shortness of breath by increasing the breath rate
c. increases the amount of air that the client can inhale with each breath
d. keeps the airway open longer to decrease the work that goes into breathing - CORRECT
ANSWER d. keeps the airway open longer to decrease the work that goes into
breathing
pursed-lip breathing keeps the airway open longer to decrease the work that goes into
breathing. clients with COPD are taught to breathe out through pursed lips to help keep the
air passages open until exhalation is complete. pursed-lip breathing does not prevent COPD
complications. pursed-lip breathing may relieve shortness of breath by decreasing the breath
rate. pursed-lip breathing does not increase the amount of air taken in during inspiration.
which finding by the nurse will be of most concern when a client has venous insufficiency?
a. bilateral brown lower leg discoloration
b. calf pain when the feet are dorsiflexed
c. severe edema from ankles to calves
d. thickened and dry skin on lower legs - CORRECT ANSWER b. calf pain when the
feet are dorsiflexed
calf pain when the feet are dorsiflexed, which is referred to as Homans sign, is a symptoms of
possible venous thrombosis and would require further diagnostic testing and treatment.
bilateral brown lower leg discoloration is a common symptoms of chronic edema caused by
venous insufficiency and would be expected in this client. severe edema is a common and
expected symptom of venous insufficiency and may require actions such as leg elevation, but
is not as concerning as a positive Homans sign. thick and dry skin is common in chronic
venous insufficiency and the nurse will plan to use a lubricating ointment, but it is not as big
a concern as a possible venous thrombosis.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair
Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to
the nurse that teaching about medication administration has been successful?
a. The patient shakes the device before use.
b. The patient rapidly inhales the medication.
