MULTIPLE CHOICE

1.Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis?

1.Limit diet to contain less than 40?t 2.Restrict exercise

3.           Stop smoking

4.           Avoid prescription medications ANS: 3

To reduce the risk for arteriosclerosis, the nurse should instruct the client to stop smoking. The diet should be limited to less than 30% of fat. Exercise should be encouraged. Prescription medications are often prescribed for clients with symptoms of arteriosclerosis.

2.           The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than:

1.3 seconds.

2.4 seconds.

3.5 seconds.

4.6 seconds.

ANS: 3

Elderly patients have a greater capillary refill time due to aging. Capillary refill greater than 5 seconds is significant. Capillary refill in non-elderly clients should be 3 seconds. Capillary refill in a non-elderly client of 4 seconds would be an abnormal finding. Capillary refill of 6 seconds for all clients is an abnormal assessment finding.

3.           When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include?

1.Eat more meat and eggs. 2.Consume less meat and eggs.

4.Limit fruits. ANS: 2

Cholesterol is located in animal sources, so decreasing meat and eggs will lower cholesterol levels. The client should not be instructed to eat more meat and eggs. Vegetables and fruits do not impact the cholesterol level.

4.A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client?

1.Respiratory distress 2.Skin breakdown 3.Decreased urine output 4.Bruising and bleeding

ANS: 4

A client who is prescribed blood-thinning medication is at a greater risk of bleeding and bruising. Anticoagulant therapy does not increase a clients risk for developing respiratory distress, skin breakdown, or decreased urine output.

5.The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?

1.           Pleural rub

2.           Hyperactive bowel sounds 3.Crackles

4.Bruit ANS: 4

The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be heard when assessing the abdomen.

6.A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

2.Cardiac arrhythmias 3.Aneurysm rupture 4.Loss of bowel sounds

ANS: 3