NURSING 3140 - Chapter 36: Care of Patients with Vascular Problems Ignatavicius: Medical-Surgical Nursing, 8th Edition. Questions and Answers ( Explanations provided )

MULTIPLE CHOICE 1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time ANS: D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated. DIF: Remembering/Knowledge REF: 707 KEY: Nursing assessment| neurologic system| neurologic assessment MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL ANS: D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males. DIF: Remembering/Knowledge REF: 708 KEY: Laboratory values| lipid alterations MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread ANS: B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables. DIF: Evaluating/Synthesis REF: 708 KEY: Nutrition| fiber| self-care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance 4. A nurse is working with a client who takes atorvastatin (Lipitor). The client’s recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis. ANS: A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered. DIF: Applying/Application REF: 709 KEY: Laboratory values| statins| nursing assessment| medication-food interaction MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. “Do you have trouble affording your medications?” b. “Most people with hypertension do not have symptoms.” c. “You are lucky; most people get severe morning headaches.” d. “You need to take your medicine or you will get kidney failure.” ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance. DIF: Understanding/Comprehension REF: 711 KEY: Hypertension| antihypertensive medications| medication adherence MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation