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NUR 325 Exam 3 Questions And Accurate Answers
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NUR 325 Exam 3 Questions And Accurate AnswersThe nurse is performing an examination of a female patient at the neighborhood clinic.
The patient states that she "feels tired all of the time." The nurse recognizes that fatigue
can be an underlying symptom of which of the following conditions?
a. Ischemia
b. Pneumonia
c. Myocardial infarction
d. Peptic ulcer disease - Answer C (Fatigue is an atypical symptom of myocardial
infarction in women. Ischemia is associated with pain. Pneumonia is associated with
pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal
discomfort.)
A patient is asking the nurse about circulation and perfusion. What is the nurse's best
response?
a. Perfusion helps the body by preventing clots and increasing endurance.
b. Perfusion aids the cell by delivering oxygen and then removing the waste product.
c. Perfusion aids the heart by increasing the cardiac output.
d. Perfusion aids the brain by increasing mental alertness. - Answer B (Perfusion
delivers much needed oxygen to the cells of the body and then helps to remove waste
products. Perfusion does not prevent clots, does not increase cardiac output, and does
not increase mental alertness.)
A 72-year-old male is admitted to the emergency department. The patient is diaphoretic
and anxious and also reports peripheral edema. Vital signs include blood pressure
100/40, pulse 130 and irregular, respiratory rate 26. The nurse interprets these findings
to mean that:
a. The patient is experiencing a myocardial infarction.
b. The patient has effective central perfusion.
,c. The patient is septic.
d. This patient needs to be given pain medication. A This patient demonstrates the
classic signs and symptoms of impaired central perfusion. Central perfusion refers to
the process in which cardiac output is optimized and blood is being appropriately
pumped from the arteries into the capillaries and returning to the heart through the
veins. Interventions: The nurse should administer oxygen. Chest pain is typically
associated with myocardial infarction and accompanied by elevated blood pressure and
electrocardiogram changes. Viral illness is often accompanied by other presenting
signs and symptoms such as generalized body aches or other gastrointestinal type
symptoms. Viral illnesses also typically have little to no effect on the heart rate.
Medication for pain is not indicated in the patient who is experiencing no pain. Further,
the question is a question of assessment that the nurse has made, and not an
intervention question.
The nurse recognizes the development of a plan of care for this patient to include
teaching about impaired perfusion modifiable risk factors includes: a. Impaired
perfusion is related to increased age. b. Genetics are predisposing impaired perfusion.
c. Exercise is to be minimized in an effort to avoid having a myocardial infarction. d. A
smoking cessation plan is to be developed. Answer D The significance of identifying
modifiable versus nonmodifiable risk factors is related to determining what type of
lifestyle changes can be discussed when formulating the patient's plan of care. Impaired
perfusion can occur to all people and age groups regardless of gender, race, or
economic status. Smoking cessation is an example of a modifiable risk factor for
impaired perfusion that can be included in the patient's plan of care. Modifiable risk
factors can be changed by the patient through teaching from the nurse. Although
impaired perfusion can increase with age, this is an example of an unmodifiable risk
factor (something that the patient cannot change). Impaired perfusion would have
non-modifiable risk factors include genetics, for instance. Obese condition may be
attributed to a sedentary lifestyle in that case; hence, obesity becomes a modified risk
to impaired perfusion.)
The nurse understands that AHA primary prevention strategies by the American Heart
Association are designed to avoid the onset of impaired perfusion in the patient and
include the following: The routine monitoring of blood pressure
b. The administration of furosemide (Lasix) to a client with active symptoms of CHF
c. A healthy diet and exercise on most days of the week
d. Answer C Primary prevention strategies are those that promote health and prevent
the development of a disease. Primary prevention strategies for CHF according to the
American Heart Association include eating a heart-healthy diet, exercising most days of
the week, taking a low-dose aspirin, and not smoking. Routine blood pressure
monitoring is a secondary prevention strategy, which includes screening and the early
,diagnosis of problems. Administering a diuretic such as furosemide to a patient who
presents with symptoms of active CHF is an optimal treatment of symptoms; however,
this is not considered a primary prevention strategy. Testing for routine serum lipids is
considered secondary prevention.
The nurse no-tices that upon morning care, this patient is complaining of leg pain when
ambulating to the bathroom. The nurse assists the patient back into bed and notices
that the patient's leg pain is relieved. Further assessment reveals bilateral pedal edema.
The nurse knows that the cause of the patient's leg pain is most likely which of the
following:
a. The pain is an indication of inadequate blood supply to deliver oxygen to meet the
demands of leg muscles.
b. The pain suggests a spasm of the muscle.
c. The patient is having a myocardial infarction.
d. The pain is due to overexertion from morning care. -Answer A (Impaired perfusion
often results in leg pain related to peripheral arterial disease [PAD]. PAD leg pain is
often relieved with rest and worsens with walking. Leg pain that is relieved with rest is
called intermittent claudication and means that there is an inadequate supply of blood
being transported to the muscles. Edema also develops from the obstruction of venous
blood flow. Although pain is common during a muscle spasm, it is usually not relieved
with rest. With a myocardial infarction, there is typically chest pain and not lower
extremity pain. There can be pain associated with exertion, but with acute leg pain and
edema present, there is an issue with perfusion and further investigation is warranted.
A client with no history of cardiovascular disease is seen in an ambulatory clinic due to
the presence of flu-like symptoms. The client suddenly complains of chest pain. For a
nurse to discriminate pain caused by a non-cardiac problem, the best question would be
:
a. "Have you ever had this pain before?"
b. "Can you describe the pain to me?"
c. "Does the pain get worse when you breathe in?"
d. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?" -Answer C
(Chest pain is assessed by using the standard pain assessment parameters. Options 1,
2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary
origin usually worsens on inspiration.)
, You are reading Mr. Smith's medical record and note that he was diagnosed with stage 1
hypertension and was initiated on a diuretic. Which of the following statements defines
stage 1 hypertension?
a. A systolic reading of less than 120 mm Hg, and a diastolic reading of less than 80 mm
Hg
b. A systolic reading of 120-139 mm Hg, or a diastolic reading of 80-89 mm Hg
c. A systolic reading of 140-159 mm Hg, or a diastolic reading of 90-99 mm Hg
d. A systolic reading of 160 mm Hg or greater, or a diastolic reading of 100 mm Hg or
greater - Answer C
A nurse finds that a client who was admitted 2 days ago with myocardial infarction has
2+ edema bilaterally in the lower extremities. Which of the following would the nurse
plan to do next?
a. Review the intake and output records for the previous 2 days
b. Change the diuretic administration time from morning to evening
c. Request an order from the physician to limit sodium intake to 1 g/day
d. Order daily weights starting the following morning - Answer A Edema, the
accumulation of excess fluid in the interstitial spaces, can be measured by intake
greater than output and by a sudden increase in weight. Diuretics should be given in the
morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved
for clients with severe symptoms.
For all persons without a normal blood pressure, treatment recommendations vary by
blood pressure classification. The classification of blood pressure should be based on:
a. an average of two or more blood pressure readings taken at one health care visit
b. an average of two or more blood pressure readings taken at each of two healthcare
visits
c. the highest pressure over a week
d. the lowest pressure over a week - Answer B (Blood pressure classification should be
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