The 66-year-old male client has his blood pressure (BP) checked at a health fair. The B/P is 168/98. Which action should the nurse implement first? 1. Recommend that the client have his blood pressure checked in one (1) month. 2. Instruct the client to see his health-care provider as soon as possible. 3. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet. 4. Explain that this B/P is within the normal range for an elderly person.
2. The diastolic blood pressure should be less than 85 according to the American Heart Association; therefore, this client should see the health-care provider.
The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing exercise? 1. Walk at least 30 minutes a day on flat surfaces. 2. Perform light weight lifting three (3) times a week. 3. Recommend high-level aerobics daily. 4. Encourage the client to swim laps once a week.
1. Walking 30 to 45 minutes a day will help in reducing blood pressure, weight, and stress and will increase a feeling of overall wellbeing.
The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication? 1. ACE inhibitors prevent the beta-receptor stimulation in the heart. 2. This medication blocks the alpha receptors in the vascular smooth muscle. 3. ACE inhibitors prevent vasoconstriction and sodium and water retention. 4. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
3. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II, and this, in turn, prevents vasoconstriction and sodium and water retention.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 1. Notify the health-care provider if the potassium level is 3.8 mEq. 2. Question administering the medication if the blood pressure is 90/60 mmHg. 3. Do not administer the medication if the client’s radial pulse is 100. 4. Monitor the client’s blood pressure while he or she is lying, standing, and sitting.
2. The nurse should question administering the beta blocker if the B/P is low because this medication will cause the blood pressure to drop even lower, leading to hypotension.
The male client diagnosed with essential hypertension has been prescribed an alphaadrenergic blocker. Which intervention should the nurse discuss with the client? 1. Eat at least one (1) banana a day to help increase the potassium level. 2. Explain that impotence is an expected side effect of the medication. 3. Take the medication on an empty stomach to increase absorption. 4. Change position slowly when going from lying to sitting position.
4. Orthostatic hypotension may occur when the blood pressure is decreasing and may lead to dizziness and light-headedness so the client should change position slowly.
The nurse just received the A.M. shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with deep vein thrombosis who is complaining of chest pain. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis who has nonbloody diarrhea.
2. The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by the nurse
The client diagnosed with essential hypertension asks the nurse, “Why do I have high blood pressure?” Which response by the nurse would be most appropriate? 1. “You probably have some type of kidney disease that causes the high BP.” 2. “More than likely you have had a diet high in salt, fat, and cholesterol.” 3. “There is no specific cause for hypertension, but there are many known risk factors.” 4. “You are concerned that you have high blood pressure. Let’s sit down and talk.”
3. There is no known cause for essential hypertension, but many factors, both modifiable (obesity, smoking, diet) and nonmodifiable (family history, age, gender) are risk factors for essential hypertension.
The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands the client teaching concerning the DASH diet? 1. “I should eat at least four (4) to five (5) servings of vegetables a day.” 2. “I should eat meat that has a lot of white streaks in it.” 3. “I should drink no more than two (2) glasses of whole milk a day.” 4. “I should decrease my grain intake to no more than twice a week.”
1. The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.
The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse? 1. The telemetry reads normal sinus rhythm. 2. The client has a weight gain of 2 kg within 1–2 days. 3. The client’s blood pressure is 148/92. 4. The client’s serum potassium level is 4.5 mEq.
2. Rapid weight gain—for example, 2 kg in 1–2 days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lbs; 1 L of fluid weighs l kg.
The client diagnosed with essential hypertension asks the nurse, “I don’t know why the doctor is worried about my blood pressure. I feel just great.” Which statement by the nurse would be the most appropriate response? 1. “Damage can be occurring to your heart and kidneys even if you feel great.” 2. “Unless you have a headache your blood pressure is probably within normal limits.” 3. “When is the last time you saw your doctor? Does he know you are feeling great?” 4. “Your blood pressure reflects how well your heart is working.”
10. 1. Even if the client feels great, the blood pressure can be elevated, causing damage to the heart, kidney, and blood vessels.
The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1480 mL. What is the total intake for this client?_______
1520 mL total intake. The urinary output is not used in this calculation. The nurse must add up both intravenous fluids and oral fluids to obtain the total intake for this client; 880 100 980 IV fluids; (1 ounce 30 mL) 8 ounces 30 mL 240 mL, 4 ounces 30 mL 120 mL, 6 ounces 30 mL 180 mL; 240 120 180 540 oral fluids. Total intake is 980 540 1520.
The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 1. Include information on retinopathy and nephropathy. 2. Discuss sedentary lifestyle and smoking cessation. 3. Include discussions on family history and gender. 4. Provide information on a low-fiber and high-salt diet.
2. Sedentary lifestyle is discouraged in clients with hypertension, and daily isotonic exercises are recommended. Smoking increases the atherosclerotic process in vessels; causes vasoconstriction of vessels; and adheres to hemoglobin, decreasing oxygen levels.
The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client’s record? 1. Peripheral vascular disease (PVD). 2. Intermittent claudication. 3. Deep vein thrombosis (DVT). 4. Dependent rubor.
2. This is the classic symptom of arterial occlusive disease.
Which instruction should be included when a client diagnosed with peripheral arterial disease is being discharged? 1. Encourage the client to use a heating pad on lower extremities. 2. Demonstrate to the client the correct way to apply elastic support hose. 3. Instruct the client to walk daily for at least 30 minutes. 4. Tell the client to check both feet for red areas at least once a week.
3. Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.
The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 3. Buy shoes in the morning hours only. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks.
1. Cold water causes vasoconstriction and hot water may burn the client’s feet; therefore, warm tepid water should be recommended. 2. Moisturizing prevents drying of the feet. 4. This will further decrease circulation to the legs. 5. Colored socks have dye and dirty socks may cause foot irritation that may lead to breaks in the skin.
Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 1. The client has 2 pedal pulses. 2. The client is able to move the toes. 3. The client has numbness and tingling. 4. The client’s feet are red when standing.
3. Numbness and tingling are paresthesia, which is a sign of a severely decreased blood supply to the lower extremities.
Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer? 1. Impaired skin integrity. 2. Activity intolerance. 3. Ineffective health maintenance. 4. Risk for peripheral neuropathy.
17. 1. The client has a foot ulcer, therefore the protective lining of the body—the skin— has been impaired.
The client diagnosed with arterial occlusive disease is one (1) day post-operative right femoral popliteal bypass. Which intervention should the nurse implement? 1. Keep the right leg in the dependent position. 2. Apply sequential compression devices to lower extremities. 3. Monitor the client’s pedal pulses every shift. 4. Assess the client’s leg dressing every four (4) hours.
4. The leg dressing needs to be assessed for hemorrhaging or signs of infection.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment. 2. Use the Doppler device. 3. Instruct the client to hang the feet off the side of the bed. 4. Wrap the legs in a blanket.
1. An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.
The wife of a client with arterial occlusive disease tells the nurse, “My husband says he is having rest pain. What does that mean?” Which statement by the nurse would be most appropriate? 1. “It describes the type of pain he has when he stops walking.” 2. “His legs are deprived of oxygen during periods of inactivity.” 3. “You are concerned that your husband is having rest pain.” 4. “This term is used to support that his condition is getting better.”
2. Rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs are not getting enough oxygen when the client is resting to prevent muscle ischemia.
The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs. 2. Brittle, flaky toe nails. 3. Petechiae on the soles of feet. 4. Nonpitting ankle edema.
1. The decreased oxygen over time causes the loss of hair on top of feet and ascends both legs.
The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement? 1. Explain that this procedure will be done at the bedside. 2. Discuss with the client that he or she will be on bed rest with bathroom privileges. 3. Inform the client that no intravenous access will be needed. 4. Inform the client that fluids will be increased after the procedure.
4. Fluids will help flush the contrast dye out of the body and help prevent kidney damage.
Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant.
3. Anti-platelet medications inhibit platelet aggregations in the arterial blood, such as aspirin or clopidogrel (Plavix).
The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who is four (4) hours post-operative bilateral femoral–popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant? 1. Monitor the continuous passive motion machine. 2. Assist the client to the bedside commode. 3. Feed the client the evening meal. 4. Elevate the foot of the client’s bed.
4. After the surgery, the client’s legs will be elevated to help decrease edema. The surgery has corrected the decreased blood supply to the lower legs.
The nurse is teaching a class on coronary artery disease. Which modifiable risk factors should the nurse discuss when teaching about atherosclerosis? 1. Stress. 2. Age. 3. Gender. 4. Family history.
1. A modifiable risk factor is a risk factor that can possibly be altered by modifying or changing behavior, such as developing new ways to deal with stress.
The client asks the nurse, “My doctor just told me that atherosclerosis is why my legs hurt when I walk. What does that mean?” Which response by the nurse would be the best response? 1. “The muscle fibers and endothelial lining of your arteries have become thickened.” 2. “The next time you see your HCP ask what atherosclerosis means.” 3. “The valves in the veins of your legs are incompetent so your legs hurt.” 4. “You have a hardening of your arteries that decreases the oxygen to your legs.”
4. This response explains in plain terms why the client’s legs hurt from atherosclerosis.
The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? 1. Being overweight. 2. Sedentary lifestyle. 3. High-fat, high-cholesterol diet. 4. Smoking cigarettes.
4. Tobacco use is the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. It also increases the risk of clot formation by increasing the aggregation of platelets.
The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement? 1. Praise the client for having a normal cholesterol level. 2. Explain that the client needs to lower the cholesterol level. 3. Discuss dietary changes that could help increase the level. 4. Allow the client to ventilate feelings about the blood test result.
2. The client needs to be taught ways to lower the cholesterol level.
The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning HDL? 1. A normal HDL is good because it has a protective action in the body. 2. HDL lipoprotein level measures the free fatty acids and glycerol in the blood. 3. HDLs are the primary transporters of cholesterol into the cell. 4. The client needs to decrease the amount of cholesterol and fat in the diet.
1. A normal HDL level is good because HDL transports cholesterol away from the tissues and cells of the arterial wall to the liver for excretion. This helps decrease the development of atherosclerosis.
Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Complaints of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers.
3. Intermittent claudication is a sign of generalized atherosclerosis and is a marker of atherosclerosis.