ch 18 Flashcards
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement?
a. “Central perfusion is monitored only by the physician.”
b. “Central perfusion involves the entire body.”
c. “Central perfusion is decreased with hypertension.”
d. “Central perfusion is toxic to the cardiac system.”
ANS: B
Central perfusion does involve the entire body as all organs are supplied with oxygen and vital nutrients. The physician does not control the body’s ability for perfusion. Central perfusion is not decreased with hypertension. Central perfusion is not toxic to the cardiac system.
A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse’s best response?
a. “Hypertension happens to everyone sooner or later. Don’t be concerned about it.”
b. “Hypertension can happen from eating a poor diet, so change what you are
eating.”
c. “Hypertension can happen from arterial changes that block the blood flow.”
d. “Hypertension happens when people do not exercise, so you should walk every
day.”
ANS: C
Hardening of the arteries from atherosclerosis can cause hypertension in the patient. Hypertension does not happen to everyone. Changing the patient’s diet and exercising may be a positive life change, but these answers do not explain to the patient how the disease could have happened.
The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse’s best response?
a. “It stimulates the heart to beat in a normal rhythm.”
b. “It protects the heart from atherosclerotic changes.”
c. “It provides the heart with oxygenated blood.”
d. “It protects the heart from infection.”
ANS: A
The sinoatrial node is the natural pacemaker of the heart, and it assists the heart to beat in a normal rhythm. The sinoatrial node does not protect from atherosclerotic changes or infection, and it does not directly provide the heart with oxygenated blood.
The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient?
a. Mental alertness
b. Perfusion
c. Pain
d. Reaction to medications
ANS: B
Perfusion is the correct answer, because with internal bleeding, the nurse should monitor vital signs to be sure perfusion is happening. Mental alertness, pain, and medication reactions are important but not the primary concern.
A patient’s serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient?
a. Tissue ischemia
b. Brain malformations
c. Intestinal blockage
d. Cardiac dysrhythmia
ANS: D
Cardiac dysrhythmia is a possibility when serum potassium is high or low. Tissue ischemia, brain malformations, or intestinal blockage do not have a direct correlation to potassium irregularities.
A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement?
a. “Perfusion is a normal function of the body, and I don’t have to be concerned
about it.”
b. “Perfusion is monitored by the physician.”
c. “Perfusion is monitored by vital signs and capillary refill.”
d. “Perfusion varies as a person ages, so I would expect changes in the body.”
ANS: C
The best method to monitor perfusion is to monitor vital signs and capillary refill. This allows the nurse to know if perfusion is adequate to maintain vital organs. The nurse does have to be concerned about perfusion. Perfusion is not only monitored by the physician but the nurse too. Perfusion does not always change as the person ages.
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment?
a. Elevated blood pressure
b. Bounding pedal pulses
c. Night blindness
d. Reflux disease
ANS: A
Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.
