Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement describes the cause of this finding?
A. Decreased hair is most likely a hereditary condition and nail changes are related to fungus.
Decreased hair is most likely a hereditary condition and nail changes are related to fungus is not the statement that describes the cause of this finding. This statement is not based on evidence and does not explain the relationship between peripheral vascular disease and the observed changes in the legs and feet.
B. A blood clot may be forming and the client needs immediate intervention.
A blood clot may be forming and the client needs immediate intervention is not the statement that describes the cause of this finding. This statement is an alarmist and inaccurate interpretation of the finding. A blood clot would cause more acute and severe symptoms, such as pain, swelling, redness, and warmth in the affected area.
C. Decreased oxygen to the tissues causes changes in hair growth and nail texture.
Decreased oxygen to the tissues causes changes in hair growth and nail texture is the statement that describes the cause of this finding. This statement is based on the pathophysiology of peripheral vascular disease, which is a chronic condition that reduces the blood flow to the extremities due to atherosclerosis or inflammation of the blood vessels. The reduced blood flow leads to tissue ischemia and necrosis, which can manifest as hair loss, thickening and yellowing of the nails, skin ulcers, and gangrene.
D. Depending on the client's age, the findings may be normal.
Depending on the client's age, the findings may be normal is not the statement that describes the cause of this finding. This statement is a vague and dismissive response that does not address the underlying problem of peripheral vascular disease. The findings are not normal for any age group and require further assessment and intervention.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nursing 200 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Decreased hair is most likely a hereditary condition and nail changes are related to fungus is not the statement that describes the cause of this finding. This statement is not based on evidence and does not explain the relationship between peripheral vascular disease and the observed changes in the legs and feet.
Choice B reason: A blood clot may be forming and the client needs immediate intervention is not the statement that describes the cause of this finding. This statement is an alarmist and inaccurate interpretation of the finding. A blood clot would cause more acute and severe symptoms, such as pain, swelling, redness, and warmth in the affected area.
Choice C reason: Decreased oxygen to the tissues causes changes in hair growth and nail texture is the statement that describes the cause of this finding. This statement is based on the pathophysiology of peripheral vascular disease, which is a chronic condition that reduces the blood flow to the extremities due to atherosclerosis or inflammation of the blood vessels. The reduced blood flow leads to tissue ischemia and necrosis, which can manifest as hair loss, thickening and yellowing of the nails, skin ulcers, and gangrene.
Choice D reason: Depending on the client's age, the findings may be normal is not the statement that describes the cause of this finding. This statement is a vague and dismissive response that does not address the underlying problem of peripheral vascular disease. The findings are not normal for any age group and require further assessment and intervention.
Similar Questions
A client who has chronic stable angina is being discharged. Which statement by the client indicates an understanding of the discharge teaching?
A. I should not experience chest pain since I am on aspirin therapy.
I should not experience chest pain since I am on aspirin therapy is not a statement that indicates an understanding of the discharge teaching. This statement is false and misleading, as aspirin therapy does not prevent or relieve angina, but only reduces the risk of blood clots and heart attacks. The client should be instructed to take nitroglycerin as prescribed for chest pain and to seek medical attention if the pain persists or worsens.
B. The chest pain is caused by a spasm in my heart.
The chest pain is caused by a spasm in my heart is not a statement that indicates an understanding of the discharge teaching. This statement is inaccurate and incomplete, as chest pain can have different causes and mechanisms. The client should be educated about the types and triggers of angina, such as stable, unstable, or variant angina, and how they are related to the reduced blood flow and oxygen supply to the heart muscle.
C. Each time I have chest pain, my heart is damaged more.
Each time I have chest pain, my heart is damaged more is not a statement that indicates an understanding of the discharge teaching. This statement is exaggerated and pessimistic, as chest pain does not necessarily imply permanent or irreversible damage to the heart. The client should be encouraged to adopt a positive and proactive attitude and to follow the recommended lifestyle modifications and medications to prevent or minimize angina episodes and complications.
D. I should hire someone to shovel snow in the winter.
I should hire someone to shovel snow in the winter is a statement that indicates an understanding of the discharge teaching. This statement is sensible and realistic, as shoveling snow is a strenuous and cold activity that can trigger or exacerbate angina. The client should be advised to avoid or limit physical exertion, especially in extreme temperatures, and to pace themselves and rest as needed.
The nurse has provided discharge teaching to a client prescribed nitroglycerin SL. Which statement, made by the client, indicates that the teaching has been effective? I will:
A. throw away any tablets that fizzle under my tongue, it means they are ineffective.
B. keep my bottle of nitroglycerin at home in the medicine cabinet.
C. call 911 if I get chest pain that doesn't go away after one tablet and I will take another tablet.
D. remove the tablets from the bottle and keep them in a plastic bag in my handbag.
Full Explanation
Choice A reason: Throwing away any tablets that fizzle under my tongue, it means they are ineffective is not a statement that indicates an understanding of the discharge teaching. This statement is incorrect and dangerous, as fizzling or tingling is a normal sensation that indicates that the tablet is working. The client should not discard or waste the medication, but keep it in a dark, dry, and cool place.
Choice B reason: Keeping my bottle of nitroglycerin at home in the medicine cabinet is not a statement that indicates an understanding of the discharge teaching. This statement is impractical and risky, as the client may need the medication when they are away from home. The client should always carry the medication with them and have it readily available in case of chest pain.
Choice C reason: Calling 911 if I get chest pain that doesn't go away after one tablet and I will take another tablet is a statement that indicates an understanding of the discharge teaching. This statement is correct and safe, as it follows the standard protocol for using nitroglycerin SL for angina. The client should take one tablet under the tongue at the onset of chest pain, wait five minutes, and repeat if the pain persists. If the pain is not relieved after three tablets, the client should seek emergency medical attention.
Choice D reason: Removing the tablets from the bottle and keeping them in a plastic bag in my handbag is not a statement that indicates an understanding of the discharge teaching. This statement is inappropriate and harmful, as it exposes the medication to light, moisture, and heat, which can reduce its potency and effectiveness. The client should keep the tablets in their original container and close it tightly after each use.
A patient has recently started ferrous sulfate 500 mg by mouth two times per day for anemia. Which of the following data would indicate to the nurse that the therapy is successful?
A. International normalized ratio 1.3 seconds
The international normalized ratio (INR) is a measure of the blood's ability to clot. It is not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of INR is 0.8 to 1.2 seconds.
B. Hemoglobin 14 g/dL
Hemoglobin is the protein in red blood cells that carries oxygen. It is the main indicator of anemia and the response to iron therapy. The normal range of hemoglobin for adults is 12 to 18 g/dL. A hemoglobin level of 14 g/dL suggests that the patient's anemia has improved with ferrous sulfate therapy.
C. Serum iron 150 mcg/dL
Serum iron is the amount of iron in the blood. It is not a reliable indicator of anemia or iron therapy, as it can fluctuate with dietary intake, infection, inflammation, and other factors. The normal range of serum iron for adults is 50 to 170 mcg/dL.
D. Platelet count 250,000/mm3
Platelet count is the number of platelets in the blood. Platelets are involved in blood clotting and wound healing. They are not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of platelet count for adults is 150,000 to 450,000/mm3.
Full Explanation
Choice A reason: The international normalized ratio (INR) is a measure of the blood's ability to clot. It is not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of INR is 0.8 to 1.2 seconds.
Choice B reason: Hemoglobin is the protein in red blood cells that carries oxygen. It is the main indicator of anemia and the response to iron therapy. The normal range of hemoglobin for adults is 12 to 18 g/dL. A hemoglobin level of 14 g/dL suggests that the patient's anemia has improved with ferrous sulfate therapy.
Choice C reason: Serum iron is the amount of iron in the blood. It is not a reliable indicator of anemia or iron therapy, as it can fluctuate with dietary intake, infection, inflammation, and other factors. The normal range of serum iron for adults is 50 to 170 mcg/dL.
Choice D reason: Platelet count is the number of platelets in the blood. Platelets are involved in blood clotting and wound healing. They are not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of platelet count for adults is 150,000 to 450,000/mm3.