Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 16 Perfusion

The Concept of Perfusion

1) What will the nurse most likely assess in a client with right heart failure?
A) Leg cramps
B) Indigestion
C) Reduced circulation to the pulmonary structures
D) Reduced urine output
Answer: C
Explanation: A) Circulation to the pulmonary structures begins with the right side of the heart.
The client with right heart failure will have reduced circulation to these structures. There is no
evidence to suggest that right heart failure will cause indigestion or reduced urine output. Not all
clients with right heart failure experience leg cramps.
B) Circulation to the pulmonary structures begins with the right side of the heart. The client with
right heart failure will have reduced circulation to these structures. There is no evidence to
suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with
right heart failure experience leg cramps.
C) Circulation to the pulmonary structures begins with the right side of the heart. The client with
right heart failure will have reduced circulation to these structures. There is no evidence to
suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with
right heart failure experience leg cramps.
D) Circulation to the pulmonary structures begins with the right side of the heart. The client with
right heart failure will have reduced circulation to these structures. There is no evidence to
suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with
right heart failure experience leg cramps.
Page Ref: 1079
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the cardiovascular system related to
perfusion.

1
Copyright © 2015 Pearson Education, Inc.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Cluster activities.
B) Instruct on deep breathing.
C) Medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider
teaching the client the importance of deep breathing to increase the amount of oxygen in the
body tissues. Clustering activities would negatively impact oxygenation. Periods of rest should
occur between activities. The client with oxygenation issues will have tachycardia. The nurse
should consider medications that would reduce instead of increase the heart rate. The client
should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow
to the heart would include Trendelenburg, which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Clustering activities would negatively impact oxygenation. Periods of rest should occur between
activities. The client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in the high-
Fowler position to improve oxygenation. Positions to increase blood flow to the heart would
include Trendelenburg, which would negatively impact oxygenation.
C) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Clustering activities would negatively impact oxygenation. Periods of rest should occur between
activities. The client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in the high-
Fowler position to improve oxygenation. Positions to increase blood flow to the heart would
include Trendelenburg, which would negatively impact oxygenation.
D) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Clustering activities would negatively impact oxygenation. Periods of rest should occur between
activities. The client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in the high-
Fowler position to improve oxygenation. Positions to increase blood flow to the heart would
include Trendelenburg, which would negatively impact oxygenation.
Page Ref: 1051
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 2. Examine the relationship between perfusion and other concepts/systems.

2
Copyright © 2015 Pearson Education, Inc.
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the
nurse expect to be indicated for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
Answer: A
Explanation: A) Treatment for cardiomyopathy includes calcium channel blockers, beta
blockers, and antiarrhythmics. Nitrates should be avoided because they increase blood pressure.
Digoxin should be avoided because it increases the force of contractions. The client should be on
a sodium and fluid restriction and not be encouraged to drink fluids.
B) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin
should be avoided because it increases the force of contractions. The client should be on a
sodium and fluid restriction and not be encouraged to drink fluids.
C) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin
should be avoided because it increases the force of contractions. The client should be on a
sodium and fluid restriction and not be encouraged to drink fluids.
D) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin
should be avoided because it increases the force of contractions. The client should be on a
sodium and fluid restriction and not be encouraged to drink fluids.
Page Ref: 1052
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 3. Identify commonly occurring alterations in perfusion and their related
therapies.

3
Copyright © 2015 Pearson Education, Inc.
4) A client is admitted with complaints of lower extremity edema and occasional shortness of
breath. Which electrocardiogram finding supports that the client is at risk for an alteration in
perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric
Answer: C
Explanation: A) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20
seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be
smooth and round. The ST segment should be isoelectric. The U wave is not normally seen.
B) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a
delay in conduction from the SA node to the ventricles. A P wave should be smooth and round.
The ST segment should be isoelectric. The U wave is not normally seen.
C) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a
delay in conduction from the SA node to the ventricles. A P wave should be smooth and round.
The ST segment should be isoelectric. The U wave is not normally seen.
D) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a
delay in conduction from the SA node to the ventricles. A P wave should be smooth and round.
The ST segment should be isoelectric. The U wave is not normally seen.
Page Ref: 1072
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's
perfusion status.

4
Copyright © 2015 Pearson Education, Inc.
5) The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease.
What should be included in this teaching?
Select all that apply.
A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake.
Answer: B, C
Explanation: A) Interventions that would help the client prevent the onset of cardiovascular
disease would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids
and wearing elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen
minutes of exercise a day may not be enough exercise to prevent the onset of cardiovascular
disease.
B) Interventions that would help the client prevent the onset of cardiovascular disease would be
to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing
elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of
exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.
C) Interventions that would help the client prevent the onset of cardiovascular disease would be
to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing
elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of
exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.
D) Interventions that would help the client prevent the onset of cardiovascular disease would be
to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing
elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of
exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.
E) Interventions that would help the client prevent the onset of cardiovascular disease would be
to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing
elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of
exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.
Page Ref: 1054
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Explain management of cardiovascular health and prevention of
cardiovascular illness.

5
Copyright © 2015 Pearson Education, Inc.
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not
sleeping well. What should the nurse suspect this client is experiencing?
A) Pancreatic disease
B) Cardiac disease
C) Normal changes of aging
D) Signs of anemia
Answer: B
Explanation: A) Many elderly women complain of vague symptoms when having a myocardial
infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would
present pain in the abdominal region. These symptoms are not considered normal changes of
aging. Anemia would present with fatigue but not with nausea or chest discomfort.
B) Many elderly women complain of vague symptoms when having a myocardial infarction
including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain
in the abdominal region. These symptoms are not considered normal changes of aging. Anemia
would present with fatigue but not with nausea or chest discomfort.
C) Many elderly women complain of vague symptoms when having a myocardial infarction
including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain
in the abdominal region. These symptoms are not considered normal changes of aging. Anemia
would present with fatigue but not with nausea or chest discomfort.
D) Many elderly women complain of vague symptoms when having a myocardial infarction
including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain
in the abdominal region. These symptoms are not considered normal changes of aging. Anemia
would present with fatigue but not with nausea or chest discomfort.
Page Ref: 1111
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in perfusion.

6
Copyright © 2015 Pearson Education, Inc.
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client
about this medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.
Answer: B
Explanation: A) Metoprolol is a beta blocker. The client should be instructed to use care when
ambulating and to change positions slowly since this medication causes orthostatic hypotension.
This medication does not cause a rapid heart rate. The client should not be instructed to increase
fluids. Protein restriction is not indicated with this medication.
B) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and
to change positions slowly since this medication causes orthostatic hypotension. This medication
does not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein
restriction is not indicated with this medication.
C) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and
to change positions slowly since this medication causes orthostatic hypotension. This medication
does not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein
restriction is not indicated with this medication.
D) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and
to change positions slowly since this medication causes orthostatic hypotension. This medication
does not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein
restriction is not indicated with this medication.
Page Ref: 1118
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in perfusion.

7
Copyright © 2015 Pearson Education, Inc.
8) The nurse instructor is teaching a group of student nurses regarding the various layers of the
heart. Which statements will the nurse include?
Select all that apply.
A) "The endocardium covers the entire heart and great vessels."
B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat."
C) "The outermost layer of the heart is the epicardium."
D) "The myocardium consists of myofibril cells."
E) "The myocardium has four layers."
Answer: C, D
Explanation: A) The heart wall consists of three layers of tissue: the epicardium, the
myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and
then folds over to form the parietal layer lining the pericardium and adheres to the heart surface.
The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells
(myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of
three layers. The myocardium is the muscular layer of the heart that contracts during each
heartbeat. The outermost layer of the heart is the epicardium.
B) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
endocardium. The epicardium covers the entire heart and great vessels, and then folds over to
form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium,
the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The
endocardium, which is the innermost layer, is a thin membrane composed of three layers. The
myocardium is the muscular layer of the heart that contracts during each heartbeat. The
outermost layer of the heart is the epicardium.
C) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
endocardium. The epicardium covers the entire heart and great vessels, and then folds over to
form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium,
the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The
endocardium, which is the innermost layer, is a thin membrane composed of three layers. The
myocardium is the muscular layer of the heart that contracts during each heartbeat. The
outermost layer of the heart is the epicardium.
D) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
endocardium. The epicardium covers the entire heart and great vessels, and then folds over to
form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium,
the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The
endocardium, which is the innermost layer, is a thin membrane composed of three layers. The
myocardium is the muscular layer of the heart that contracts during each heartbeat. The
outermost layer of the heart is the epicardium.

8
Copyright © 2015 Pearson Education, Inc.
E) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the
endocardium. The epicardium covers the entire heart and great vessels, and then folds over to
form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium,
the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The
endocardium, which is the innermost layer, is a thin membrane composed of three layers. The
myocardium is the muscular layer of the heart that contracts during each heartbeat. The
outermost layer of the heart is the epicardium.
Page Ref: 1032
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the cardiovascular system related to
perfusion.

9) A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute.
What is the client's cardiac output (CO) rounded to the nearest whole number?
Answer: 6 Liters (L)
Explanation: CO = SV × HR
85mL = 0.085 L
CO = 0.085 × 71 = 6.035 = 6L
Page Ref: 1040
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Differentiate common assessment procedures used to examine
cardiovascular health across the life span.

9
Copyright © 2015 Pearson Education, Inc.
10) A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse
will hear the client's murmur best at:
A) Right sternal border, second intercostal space.
B) Left sternal border, second intercostal space.
C) Right sternal border, third intercostal space.
D) Left sternal border, third to fifth intercostal space.
Answer: A
Explanation: A) The murmur associated with aortic stenosis is auscultated on the right sternal
border, second intercostal space.
B) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
C) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
D) The murmur associated with aortic stenosis is auscultated on the right sternal border, second
intercostal space.
Page Ref: 1039
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 4. Differentiate common assessment procedures used to examine
cardiovascular health across the life span.

11) The nurse is caring for a client with hypertension. The nurse understands that the client's
blood pressure is determined by all the following factors except:
A) Pumping action of the heart.
B) Peripheral vascular resistance.
C) Heart rate.
D) Blood volume.
Answer: C
Explanation: A) The factors which determine blood pressure include the pumping action of the
heart; peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does
not determine blood pressure.
B) The factors which determine blood pressure include the pumping action of the heart;
peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does not
determine blood pressure.
C) The factors which determine blood pressure include the pumping action of the heart;
peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does not
determine blood pressure.
D) The factors which determine blood pressure include the pumping action of the heart;
peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does not
determine blood pressure.
Page Ref: 1045
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in perfusion.

10
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.1 Cardiomyopathy

1) An older client is diagnosed with dilated cardiomyopathy. What will the nurse most likely
assess in this client?
Select all that apply.
A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Jugular vein distention
Answer: A, B, D, E
Explanation: A) Clinical manifestations of dilated cardiomyopathy include fatigue, lower
extremity edema, shortness of breath or dyspnea, and jugular vein distention. Disorders of the
heart valve, arrhythmias, and blood clots may occur with disease progression. Syncope is not a
manifestation of dilated cardiomyopathy.
B) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve,
arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation
of dilated cardiomyopathy.
C) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve,
arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation
of dilated cardiomyopathy.
D) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve,
arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation
of dilated cardiomyopathy.
E) Clinical manifestations of dilated cardiomyopathy include fatigue, lower extremity edema,
shortness of breath or dyspnea, and jugular vein distention. Disorders of the heart valve,
arrhythmias, and blood clots may occur with disease progression. Syncope is not a manifestation
of dilated cardiomyopathy.
Page Ref: 1079
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of cardiomyopathy.

11
Copyright © 2015 Pearson Education, Inc.
2) A client tells the nurse that he knows he has high blood pressure but does not want to take any
medication. Which health problem is the client at risk of developing?
A) Gastritis
B) Diabetes
C) Cardiomyopathy
D) Metabolic syndrome
Answer: C
Explanation: A) Hypertension places the client at risk for development of cardiomyopathy.
Hypertension has not been associated with metabolic syndrome, diabetes, or gastritis.
B) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has
not been associated with metabolic syndrome, diabetes, or gastritis.
C) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has
not been associated with metabolic syndrome, diabetes, or gastritis.
D) Hypertension places the client at risk for development of cardiomyopathy. Hypertension has
not been associated with metabolic syndrome, diabetes, or gastritis.
Page Ref: 1079
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors associated with cardiomyopathy.

12
Copyright © 2015 Pearson Education, Inc.
3) An older client diagnosed with cardiomyopathy reports having to rest between activities
during the day. What should the nurse realize is the reason for this client's fatigue?
A) Increased stroke volume
B) Decreased cardiac output
C) An elongated and dilated aorta
D) Increased blood pressure
Answer: B
Explanation: A) Decreased cardiac output is a result of decreased efficiency and contractibility
of the myocardium. Rest could be required after each activity that puts physiological stress on
the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac
output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the
client has high blood pressure, an elongated and dilated aorta, or increased stroke volume.
B) Decreased cardiac output is a result of decreased efficiency and contractibility of the
myocardium. Rest could be required after each activity that puts physiological stress on the heart.
Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and
this has a direct effect on the activity level that can be tolerated. It is unknown if the client has
high blood pressure, an elongated and dilated aorta, or increased stroke volume.
C) Decreased cardiac output is a result of decreased efficiency and contractibility of the
myocardium. Rest could be required after each activity that puts physiological stress on the heart.
Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and
this has a direct effect on the activity level that can be tolerated. It is unknown if the client has
high blood pressure, an elongated and dilated aorta, or increased stroke volume.
D) Decreased cardiac output is a result of decreased efficiency and contractibility of the
myocardium. Rest could be required after each activity that puts physiological stress on the heart.
Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and
this has a direct effect on the activity level that can be tolerated. It is unknown if the client has
high blood pressure, an elongated and dilated aorta, or increased stroke volume.
Page Ref: 1081
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with cardiomyopathy.

13
Copyright © 2015 Pearson Education, Inc.
4) A client admitted with the diagnosis of cardiomyopathy becomes short of breath with
ambulation and eating, and fatigued with routine care activities. The nurse would identify which
of the following nursing diagnoses as being appropriate for this client?
A) Imbalanced Nutrition: Less than Body Requirements
B) Deficient Knowledge
C) Activity Intolerance
D) Self-Care Deficit
Answer: C
Explanation: A) The client is short of breath with ambulation and eating, and fatigued with
routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client
at this time. There is not enough information to determine if the client has a knowledge deficit.
Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue
with routine care activities does not necessarily mean that the client has a Self-Care Deficit.
B) The client is short of breath with ambulation and eating, and fatigued with routine care
activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time.
There is not enough information to determine if the client has a knowledge deficit. Shortness of
breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue with routine
care activities does not necessarily mean that the client has a Self-Care Deficit.
C) The client is short of breath with ambulation and eating, and fatigued with routine care
activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time.
There is not enough information to determine if the client has a knowledge deficit. Shortness of
breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue with routine
care activities does not necessarily mean that the client has a Self-Care Deficit.
D) The client is short of breath with ambulation and eating, and fatigued with routine care
activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time.
There is not enough information to determine if the client has a knowledge deficit. Shortness of
breath with meals does not indicate that the client has Imbalanced Nutrition. Fatigue with routine
care activities does not necessarily mean that the client has a Self-Care Deficit.
Page Ref: 1080-1081
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
cardiomyopathy.

14
Copyright © 2015 Pearson Education, Inc.
5) The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with
cardiomyopathy. Which interventions should the nurse emphasize when planning this client's
care?
Select all that apply.
A) Monitor brain natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.
Answer: C, E
Explanation: A) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume
include assessing respiratory status and lung sounds every 4 hours and as needed and monitoring
intake and output. Providing oxygen and monitoring BNP level are interventions appropriate for
the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge
would be appropriate for the nursing diagnosis of Activity Intolerance.
B) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output.
Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
Decreased Cardiac Output. Providing information about activity upon discharge would be
appropriate for the nursing diagnosis of Activity Intolerance.
C) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output.
Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
Decreased Cardiac Output. Providing information about activity upon discharge would be
appropriate for the nursing diagnosis of Activity Intolerance.
D) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output.
Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
Decreased Cardiac Output. Providing information about activity upon discharge would be
appropriate for the nursing diagnosis of Activity Intolerance.
E) Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing
respiratory status and lung sounds every 4 hours and as needed and monitoring intake and output.
Providing oxygen and monitoring BNP level are interventions appropriate for the diagnosis of
Decreased Cardiac Output. Providing information about activity upon discharge would be
appropriate for the nursing diagnosis of Activity Intolerance.
Page Ref: 1082
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with cardiomyopathy and his
or her family in collaboration with other members of the healthcare team.

15
Copyright © 2015 Pearson Education, Inc.
6) A client diagnosed with cardiomyopathy is being discharged to home. What client statement
indicates discharge teaching has been effective?
A) "I will exercise as much as possible, regardless of feeling weak and short of breath."
B) "My pants getting tight around the waist, means I'm eating too much and should cut back on
food."
C) "I will eat foods containing sodium only if drinking water with them."
D) "I will see the physician to discuss implanting a cardiac defibrillator next week."
Answer: D
Explanation: A) Evidence that discharge instruction is effective for a client with
cardiomyopathy would be the statement "I will see the physician to discuss implanting a cardiac
defibrillator next week," as sudden cardiac death can occur with this medical diagnosis. The
other client statements would indicate that discharge teaching was not effective and the client
needs additional instruction and follow-up.
B) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
statement "I will see the physician to discuss implanting a cardiac defibrillator next week," as
sudden cardiac death can occur with this medical diagnosis. The other client statements would
indicate that discharge teaching was not effective and the client needs additional instruction and
follow-up.
C) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
statement "I will see the physician to discuss implanting a cardiac defibrillator next week," as
sudden cardiac death can occur with this medical diagnosis. The other client statements would
indicate that discharge teaching was not effective and the client needs additional instruction and
follow-up.
D) Evidence that discharge instruction is effective for a client with cardiomyopathy would be the
statement "I will see the physician to discuss implanting a cardiac defibrillator next week," as
sudden cardiac death can occur with this medical diagnosis. The other client statements would
indicate that discharge teaching was not effective and the client needs additional instruction and
follow-up.
Page Ref: 1081
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with cardiomyopathy.

16
Copyright © 2015 Pearson Education, Inc.
7) The nurse is preparing teaching for a client with hypertrophic cardiomyopathy. For which
medication classification should the nurse prepare to instruct this client?
A) Digitalis
B) Vasodilators
C) Nitrates
D) Beta blocker
Answer: D
Explanation: A) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal
episodes associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are
contraindicated for the client with hypertrophic cardiomyopathy.
B) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes
associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are
contraindicated for the client with hypertrophic cardiomyopathy.
C) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes
associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are
contraindicated for the client with hypertrophic cardiomyopathy.
D) Beta blockers are the drugs of choice to reduce anginal symptoms and syncopal episodes
associated with hypertrophic cardiomyopathy. Vasodilators, digitalis, and nitrates are
contraindicated for the client with hypertrophic cardiomyopathy.
Page Ref: 1080
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with cardiomyopathy.

17
Copyright © 2015 Pearson Education, Inc.
8) A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8
hours. What should the nurse do to assist this client?
A) Assist the client to ambulate.
B) This is a normal urine output and the client does not need anything.
C) Notify the physician, as the client could be dehydrated.
D) Measure abdominal girth as a true assessment of the client's fluid status.
Answer: C
Explanation: A) The nurse should notify the physician, because a urine output of 300 cc in 8
hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral
edema. This is not a normal urine output. The nurse should not assist the client out of bed to
ambulate at this time. Daily weights are an objective measurement of fluid volume and not
abdominal girth.
B) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than
30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not a
normal urine output. The nurse should not assist the client out of bed to ambulate at this time.
Daily weights are an objective measurement of fluid volume and not abdominal girth.
C) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than
30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not a
normal urine output. The nurse should not assist the client out of bed to ambulate at this time.
Daily weights are an objective measurement of fluid volume and not abdominal girth.
D) The nurse should notify the physician, because a urine output of 300 cc in 8 hours is less than
30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not a
normal urine output. The nurse should not assist the client out of bed to ambulate at this time.
Daily weights are an objective measurement of fluid volume and not abdominal girth.
Page Ref: 1082
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with cardiomyopathy and his
or her family in collaboration with other members of the healthcare team.

18
Copyright © 2015 Pearson Education, Inc.
9) A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the
disease. The nurse will include all except:
A) Dilated.
B) Restrictive.
C) Hypotrophic.
D) Arrythmogenic right ventricular.
Answer: C
Explanation: A) The types of cardiomyopathy include dilated, restrictive, hypertrophic,
arrythmogenic right ventricular, and unclassified.
B) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
ventricular, and unclassified.
C) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
ventricular, and unclassified.
D) The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right
ventricular, and unclassified.
Page Ref: 1078
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of cardiomyopathy.

19
Copyright © 2015 Pearson Education, Inc.
10) A client with cardiomyopathy is experiencing tachycardia. Which medication order does the
client's nurse anticipate?
A) ACE Inhibitor
B) Angiotensin II receptor blocker
C) Beta blocker
D) Cardiac glycoside
Answer: C
Explanation: A) A client with cardiomyopathy experiencing tachycardia may take a beta blocker
to lower the heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood
pressure in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure
and do not assist in lowering the heart rate in a client with cardiomyopathy.
B) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the
heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure in a
client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not
assist in lowering the heart rate in a client with cardiomyopathy.
C) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the
heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure in a
client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not
assist in lowering the heart rate in a client with cardiomyopathy.
D) A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the
heart rate. ACE inhibitors and angiotensin II blockers are used to decrease blood pressure in a
client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not
assist in lowering the heart rate in a client with cardiomyopathy.
Page Ref: 1080
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with cardiomyopathy.

20
Copyright © 2015 Pearson Education, Inc.
11) A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity
Intolerance. The nurse plans all interventions except:
A) Spacing out nursing activities so client fatigue is lessened.
B) Assisting with client ADLs as necessary.
C) Using passive and active range-of-motion (ROM) exercises as tolerated.
D) Consulting with a physical therapist on an activity plan.
Answer: A
Explanation: A) The client who is experiencing activity intolerance should have nursing
interventions implemented that encourage and preserve client energy. Assisting the client with
ADLs, utilizing ROM exercises, and consulting with physical therapy are all interventions which
support this nursing diagnosis. The nurse should cluster nursing activities, not space them out, in
order to conserve client energy.
B) The client who is experiencing activity intolerance should have nursing interventions
implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing
ROM exercises, and consulting with physical therapy are all interventions which support this
nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to
conserve client energy.
C) The client who is experiencing activity intolerance should have nursing interventions
implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing
ROM exercises, and consulting with physical therapy are all interventions which support this
nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to
conserve client energy.
D) The client who is experiencing activity intolerance should have nursing interventions
implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing
ROM exercises, and consulting with physical therapy are all interventions which support this
nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to
conserve client energy.
Page Ref: 1082
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
cardiomyopathy.

21
Copyright © 2015 Pearson Education, Inc.
12) A nurse is educating a client with cardiomyopathy about diet choices which are appropriate
for the client's condition. The nurse will include all statements except:
A) "It is important to monitor your sodium intake."
B) "Increasing your dietary protein helps with cardiac cell repair."
C) "Here is a list of high-fat, high-cholesterol foods to avoid."
D) "I have notified the dietitian regarding your condition in order to provide you with more
information."
Answer: B
Explanation: A) Diet is an important part of long-term management of heart failure. It also
contributes to reducing fluid retention. The nurse will instruct the client with cardiomyopathy to
monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to
increase protein is not appropriate and is not shown effective in managing cardiomyopathy.
Consulting with the dietitian is appropriate with this client.
B) Diet is an important part of long-term management of heart failure. It also contributes to
reducing fluid retention. The nurse will instruct the client with cardiomyopathy to monitor
sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase
protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting
with the dietitian is appropriate with this client.
C) Diet is an important part of long-term management of heart failure. It also contributes to
reducing fluid retention. The nurse will instruct the client with cardiomyopathy to monitor
sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase
protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting
with the dietitian is appropriate with this client.
D) Diet is an important part of long-term management of heart failure. It also contributes to
reducing fluid retention. The nurse will instruct the client with cardiomyopathy to monitor
sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase
protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting
with the dietitian is appropriate with this client.
Page Ref: 1082
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with cardiomyopathy and his
or her family in collaboration with other members of the healthcare team.

22
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.2 Congenital Heart Defects

1) The mother of a baby born with a congenital heart defect is upset, as no one else in the family
has been born with this condition. About what should the nurse ask the mother during the
assessment?
A) Use of alcohol during the pregnancy
B) Maternal father's history of diabetes
C) Father's exposure to toxins in the work environment
D) History of hypertension
Answer: A
Explanation: A) Most congenital heart defects occur during the first 8 weeks of pregnancy and
are a combination of environmental and genetic factors. Fetal exposure to alcohol is one of the
greatest factors for the development of these defects. A history of hypertension will not cause a
fetus to develop a congenital heart defect. The father's exposure to toxins in the work
environment is not known to cause congenital heart defects of children. The maternal father's
history of diabetes also is not known to cause congenital heart defects in children.
B) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a
combination of environmental and genetic factors. Fetal exposure to alcohol is one of the
greatest factors for the development of these defects. A history of hypertension will not cause a
fetus to develop a congenital heart defect. The father's exposure to toxins in the work
environment is not known to cause congenital heart defects of children. The maternal father's
history of diabetes also is not known to cause congenital heart defects in children.
C) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a
combination of environmental and genetic factors. Fetal exposure to alcohol is one of the
greatest factors for the development of these defects. A history of hypertension will not cause a
fetus to develop a congenital heart defect. The father's exposure to toxins in the work
environment is not known to cause congenital heart defects of children. The maternal father's
history of diabetes also is not known to cause congenital heart defects in children.
D) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a
combination of environmental and genetic factors. Fetal exposure to alcohol is one of the
greatest factors for the development of these defects. A history of hypertension will not cause a
fetus to develop a congenital heart defect. The father's exposure to toxins in the work
environment is not known to cause congenital heart defects of children. The maternal father's
history of diabetes also is not known to cause congenital heart defects in children.
Page Ref: 1089
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors associated with congenital heart defects.

23
Copyright © 2015 Pearson Education, Inc.
2) The nurse is analyzing data collected after assessing a child with a congenital heart defect that
decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client?
A) Risk for Infection related to engorged pulmonary vasculature
B) Interrupted Family Processes
C) Decreased Cardiac Output
D) Excess Fluid Volume
Answer: C
Explanation: A) Nursing diagnoses for clients with congenital heart defects that decrease
pulmonary blood flow include Decreased Cardiac Output, Risk for Infection related to unfiltered
bacteria in the blood, Caregiver Role Strain, Activity Intolerance, and Delayed Growth and
Development. Excess Fluid Volume, Risk for Infection related to engorged pulmonary
vasculature, and Interrupted Family Processes are nursing diagnoses seen in the care of a client
with a congenital heart defect that increases pulmonary blood flow.
B) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood
flow include Decreased Cardiac Output, Risk for Infection related to unfiltered bacteria in the
blood, Caregiver Role Strain, Activity Intolerance, and Delayed Growth and Development.
Excess Fluid Volume, Risk for Infection related to engorged pulmonary vasculature, and
Interrupted Family Processes are nursing diagnoses seen in the care of a client with a congenital
heart defect that increases pulmonary blood flow.
C) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood
flow include Decreased Cardiac Output, Risk for Infection related to unfiltered bacteria in the
blood, Caregiver Role Strain, Activity Intolerance, and Delayed Growth and Development.
Excess Fluid Volume, Risk for Infection related to engorged pulmonary vasculature, and
Interrupted Family Processes are nursing diagnoses seen in the care of a client with a congenital
heart defect that increases pulmonary blood flow.
D) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood
flow include Decreased Cardiac Output, Risk for Infection related to unfiltered bacteria in the
blood, Caregiver Role Strain, Activity Intolerance, and Delayed Growth and Development.
Excess Fluid Volume, Risk for Infection related to engorged pulmonary vasculature, and
Interrupted Family Processes are nursing diagnoses seen in the care of a client with a congenital
heart defect that increases pulmonary blood flow.
Page Ref: 1101
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
congenital heart defects.

24
Copyright © 2015 Pearson Education, Inc.
3) The nurse is planning care for a pediatric client recovering from surgery to repair a congenital
heart defect. Which intervention should the nurse include to support the client's fluid status?
A) Encourage fluids.
B) Limit fluids.
C) Monitor output.
D) Maintain intravenous therapy until day before discharge.
Answer: A
Explanation: A) The child should be encouraged to begin oral fluids and nutrition when
permitted. Although oral fluids are rarely limited, intake and output should be carefully assessed.
Fluids and antibiotics should be provided as ordered until the child's oral intake is normal. Once
normal, the line can be converted to a heparin or saline lock. Both intake and output should be
monitored.
B) The child should be encouraged to begin oral fluids and nutrition when permitted. Although
oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and
antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the
line can be converted to a heparin or saline lock. Both intake and output should be monitored.
C) The child should be encouraged to begin oral fluids and nutrition when permitted. Although
oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and
antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the
line can be converted to a heparin or saline lock. Both intake and output should be monitored.
D) The child should be encouraged to begin oral fluids and nutrition when permitted. Although
oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and
antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the
line can be converted to a heparin or saline lock. Both intake and output should be monitored.
Page Ref: 1102
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with a congenital heart defect
and his or her family in collaboration with other members of the healthcare team.

25
Copyright © 2015 Pearson Education, Inc.
4) The nurse provides discharge instructions to the parents of a child recovering from surgery to
repair a congenital heart defect. What statement indicates that teaching provided to these parents
has been effective?
A) "Our child should be restricted in play and activity for at least 6 months."
B) "Our child will need to take antibiotics prior to having dental surgery."
C) "Fluids should be restricted to maximize lung function."
D) "Our child should not return to normal activities for at least 2 years."
Answer: B
Explanation: A) Since the child is at risk for infective endocarditis, prophylactic antibiotics are
indicated for invasive procedures. The child should not be restricted in play and activities for at
least 6 months. The child should not restrict fluids. The parents should be encouraged to have the
child live a normal life and not be restricted for 2 years.
B) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
invasive procedures. The child should not be restricted in play and activities for at least 6
months. The child should not restrict fluids. The parents should be encouraged to have the child
live a normal life and not be restricted for 2 years.
C) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
invasive procedures. The child should not be restricted in play and activities for at least 6
months. The child should not restrict fluids. The parents should be encouraged to have the child
live a normal life and not be restricted for 2 years.
D) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for
invasive procedures. The child should not be restricted in play and activities for at least 6
months. The child should not restrict fluids. The parents should be encouraged to have the child
live a normal life and not be restricted for 2 years.
Page Ref: 1103
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with a congenital heart
defect.

26
Copyright © 2015 Pearson Education, Inc.
5) The nurse is caring for an infant diagnosed with patent ductus arteriosus. Which medication
should the nurse plan to provide this client?
A) Indomethacin
B) NSAIDS
C) Antidepressant
D) Insulin
Answer: A
Explanation: A) Intravenous indomethacin often stimulates the closure of the ductus arteriosus
in premature infants. The infant will most likely not be prescribed an NSAID or an
antidepressant. The infant would be prescribed insulin if diabetes were diagnosed.
B) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
infants. The infant will most likely not be prescribed an NSAID or an antidepressant. The infant
would be prescribed insulin if diabetes were diagnosed.
C) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
infants. The infant will most likely not be prescribed an NSAID or an antidepressant. The infant
would be prescribed insulin if diabetes were diagnosed.
D) Intravenous indomethacin often stimulates the closure of the ductus arteriosus in premature
infants. The infant will most likely not be prescribed an NSAID or an antidepressant. The infant
would be prescribed insulin if diabetes were diagnosed.
Page Ref: 1084
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with a congenital heart defects.

27
Copyright © 2015 Pearson Education, Inc.
6) A baby will be having surgery to correct a congenital heart defect. On which topic should the
parents be instructed regarding the care of the child before surgery?
A) Restricting immunizations until after the surgery
B) Preventing exposure to infection
C) Implementing no particular precautions
D) Restricting fluids
Answer: B
Explanation: A) Preoperative care of a baby having surgery to correct a congenital heart defect
should include prevention from infection with good hand washing. There are precautions that the
parents should take to ensure the child is in optimal health prior to the surgery. Fluids are not to
be restricted but encouraged. Immunizations should be continued.
B) Preoperative care of a baby having surgery to correct a congenital heart defect should include
prevention from infection with good hand washing. There are precautions that the parents should
take to ensure the child is in optimal health prior to the surgery. Fluids are not to be restricted but
encouraged. Immunizations should be continued.
C) Preoperative care of a baby having surgery to correct a congenital heart defect should include
prevention from infection with good hand washing. There are precautions that the parents should
take to ensure the child is in optimal health prior to the surgery. Fluids are not to be restricted but
encouraged. Immunizations should be continued.
D) Preoperative care of a baby having surgery to correct a congenital heart defect should include
prevention from infection with good hand washing. There are precautions that the parents should
take to ensure the child is in optimal health prior to the surgery. Fluids are not to be restricted but
encouraged. Immunizations should be continued.
Page Ref: 1102
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with a congenital heart defect
and his or her family in collaboration with other members of the healthcare team.

28
Copyright © 2015 Pearson Education, Inc.
7) The nurse is assessing a toddler diagnosed with tetralogy of Fallot. Which assessment findings
should the nurse determine as being consistent with this child's diagnosis?
Select all that apply.
A) Palpable thrill in the pulmonic area
B) Nail clubbing
C) Cough
D) Apneic periods
E) Knee e-chest position
Answer: A, B, E
Explanation: A) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic
area, clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the
child will perform to decrease the return of systemic venous blood to the heart. A cough and
apneic periods are not manifestations of this congenital heart defect.
B) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of
the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform
to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not
manifestations of this congenital heart defect.
C) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of
the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform
to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not
manifestations of this congenital heart defect.
D) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing
of the fingers due to reduce oxygenation, and the knee-chest position, which the child will
perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods
are not manifestations of this congenital heart defect.
E) Manifestations of tetralogy of Fallot include a palpable thrill in the pulmonic area, clubbing of
the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform
to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not
manifestations of this congenital heart defect.
Page Ref: 1088
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of congenital heart defects.

29
Copyright © 2015 Pearson Education, Inc.
8) A nurse working in the Neonatal Intensive Care Unit (NICU) is caring for a preterm infant
with a congenital heart defect. The nurse knows that these conditions are categorized by:
A) Severity of defect.
B) Pathophysiology and hemodynamics of defect.
C) Location of defect.
D) Age when defect diagnosed.
Answer: B
Explanation: A) Congenital heart defects are categorized by their pathophysiology and
hemodynamics.
B) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
C) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
D) Congenital heart defects are categorized by their pathophysiology and hemodynamics.
Page Ref: 1077
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of congenital heart defects.

30
Copyright © 2015 Pearson Education, Inc.
9) A nurse working in Labor and Delivery is assessing a term newborn for congenital heart
defects. The nurse understands that manifestations of an atrial septal defect (ASD) may include:
A) Pulmonary artery hypotension and congestive heart failure.
B) Midsystolic murmur at lower right sternal border, due to increased blood flow across the
tricuspid valve.
C) Mitral valve regurgitation with cleft on mitral valve.
D) S1 heart tone may be split due to forceful left ventricular contraction.
Answer: C, D
Explanation: A) An atrial septal defect (ASD) occurs when there is an opening in the atrial
septum permitting left-to-right shunting of blood. Midsystolic murmur may be auscultated at the
lower left sternal border, due to increased blood flow across the tricuspid valve. Mitral valve
regurgitation may occur with a cleft on the mitral valve. S1 heart tones may be split due to
forceful right ventricular contraction. Finally, pulmonary artery hypertension and congestive
heart failure may occur.
B) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting
left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal
border, due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may
occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular
contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.
C) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting
left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal
border, due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may
occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular
contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.
D) An atrial septal defect (ASD) occurs when there is an opening in the atrial septum permitting
left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal
border, due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may
occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular
contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.
Page Ref: 1084-1085
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of congenital heart defects.

31
Copyright © 2015 Pearson Education, Inc.
10) A nurse is educating the parents of a child born with tetralogy of Fallot. Which statement
will the nurse include regarding this defect?
A) "Increased pulmonary blood flow causes symptoms with this disease."
B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal
defect, and an overriding aorta."
C) "Your child has a decreased amount of red blood cells because of this disease."
D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal
defect, and an overriding aorta."
Answer: D
Explanation: A) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right
ventricular hypertrophy, ventricular septal defect, and an overriding aorta. This disease is also
characterized by decreased pulmonary blood flow, and polycythemia (increased red blood cells
due to hypoxia).
B) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased
pulmonary blood flow, and polycythemia (increased red blood cells due to hypoxia).
C) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased
pulmonary blood flow, and polycythemia (increased red blood cells due to hypoxia).
D) Tetralogy of Fallot consists of four defects—pulmonic stenosis, right ventricular hypertrophy,
ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased
pulmonary blood flow, and polycythemia (increased red blood cells due to hypoxia).
Page Ref: 1088
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with congenital heart defects.

32
Copyright © 2015 Pearson Education, Inc.
11) A physician caring for a client with hypoplastic left heart syndrome has provided the client's
family with information regarding the surgical repair necessary for this condition. The client's
nurse knows that this procedure is named the:
A) Glenn procedure.
B) Jatene procedure.
C) Fontan procedure.
D) Damus-Kaye-Stansel procedure.
Answer: A
Explanation: A) The Glenn procedure is used to surgically repair hypoplastic left heart
syndrome. The Jatene procedure and the Damus-Kaye-Stansel procedure surgically repairs the
Transportation of Great Arteries. The Fontan procedure surgically repairs tricuspid atresia,
pulmonary atresia, and hypoplastic left heart syndrome.
B) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
procedure and the Damus-Kaye-Stansel procedure surgically repairs the Transportation of Great
Arteries. The Fontan procedure surgically repairs tricuspid atresia, pulmonary atresia, and
hypoplastic left heart syndrome.
C) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
procedure and the Damus-Kaye-Stansel procedure surgically repairs the Transportation of Great
Arteries. The Fontan procedure surgically repairs tricuspid atresia, pulmonary atresia, and
hypoplastic left heart syndrome.
D) The Glenn procedure is used to surgically repair hypoplastic left heart syndrome. The Jatene
procedure and the Damus-Kaye-Stansel procedure surgically repairs the Transportation of Great
Arteries. The Fontan procedure surgically repairs tricuspid atresia, pulmonary atresia, and
hypoplastic left heart syndrome.
Page Ref: 1099
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 6. Plan evidence-based care for an individual with a congenital heart defect
and his or her family in collaboration with other members of the healthcare team.

33
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.3 Coronary Artery Disease

1) A client with angina complains that the pain is prolonged and severe, and occurs at the same
time each day while at rest. There are no precipitating factors to the pain. How should the nurse
describe this type of angina pain?
A) Non-anginal pain
B) Atypical angina (Prinzmetal angina)
C) Unstable angina
D) Stable angina
Answer: B
Explanation: A) Atypical or Prinzmetal angina often occurs at the same time each day and
typically at rest. Stable angina is induced by exercise and is relieved by rest or nitroglycerin.
Unstable angina is not relieved by rest or nitroglycerin and is less predictable. The client has
been diagnosed with angina, and, therefore, the pain the client is experiencing is angina.
B) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest.
Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is
not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with
angina, and, therefore, the pain the client is experiencing is angina.
C) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest.
Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is
not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with
angina, and, therefore, the pain the client is experiencing is angina.
D) Atypical or Prinzmetal angina often occurs at the same time each day and typically at rest.
Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina is
not relieved by rest or nitroglycerin and is less predictable. The client has been diagnosed with
angina, and, therefore, the pain the client is experiencing is angina.
Page Ref: 1107
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of coronary artery disease.

34
Copyright © 2015 Pearson Education, Inc.
2) A client with a history of myocardial infarctions tells the nurse that he has been smoking for
35 years and it does not matter now if he stops. What should the nurse respond to this client?
A) "Your risk of continued coronary heart disease will decrease by half when you stop."
B) "It will enhance the effects of your medications."
C) "It will reduce your risk of lung cancer."
D) "It will decrease any complications you might develop."
Answer: A
Explanation: A) Smoking cessation reduces the risk for coronary heart disease by 50% no matter
how long the person has smoked. It will reduce lung cancer, decrease complications, and
possibly enhance medication effects, but the primary focus for this client is the effect on
coronary heart disease.
B) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance
medication effects, but the primary focus for this client is the effect on coronary heart disease.
C) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance
medication effects, but the primary focus for this client is the effect on coronary heart disease.
D) Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the
person has smoked. It will reduce lung cancer, decrease complications, and possibly enhance
medication effects, but the primary focus for this client is the effect on coronary heart disease.
Page Ref: 1110
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors associated with coronary artery disease.

35
Copyright © 2015 Pearson Education, Inc.
3) The nurse is preparing preoperative teaching for an older client scheduled for a ventricular
assist device. What should the nurse include in these instructions?
A) Need to stay on bed rest for a week or more
B) Cardiac pain postoperatively is to be expected.
C) Risk for postoperative infection
D) Expect to be ambulating the evening of surgery.
Answer: C
Explanation: A) Clients with VAD are at considerable risk for infection; strict aseptic technique
is used with all invasive catheters and dressing changes. The client may or may not be on bed
rest for a week or more after the surgery. The client, however, will most likely not be ambulating
the evening of the surgery. Cardiac pain postoperatively is not to be expected and could indicate
a myocardial infarction.
B) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with
all invasive catheters and dressing changes. The client may or may not be on bed rest for a week
or more after the surgery. The client, however, will most likely not be ambulating the evening of
the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial
infarction.
C) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with
all invasive catheters and dressing changes. The client may or may not be on bed rest for a week
or more after the surgery. The client, however, will most likely not be ambulating the evening of
the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial
infarction.
D) Clients with VAD are at considerable risk for infection; strict aseptic technique is used with
all invasive catheters and dressing changes. The client may or may not be on bed rest for a week
or more after the surgery. The client, however, will most likely not be ambulating the evening of
the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial
infarction.
Page Ref: 1123
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with coronary artery disease.

36
Copyright © 2015 Pearson Education, Inc.
4) A client, admitted with irregular chest pain and shortness of breath, complains of fatigue with
activity. The client's body mass index (BMI) is 30.5. Which nursing diagnosis would be a
priority for the client at this time?
A) Ineffective Coping
B) Fear
C) Imbalanced Nutrition: More than Body Requirements.
D) Fluid Volume Deficit
Answer: C
Explanation: A) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest
pain and shortness of breath, and complains of fatigue with activity. The priority nursing
diagnosis for the client at this time would be Imbalanced Nutrition: More than Body
Requirements. Fear and Ineffective Coping would be applicable to the client diagnosed with an
acute myocardial infarction. There is no evidence that the client has Fluid Volume Deficit.
B) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and
shortness of breath, and complains of fatigue with activity. The priority nursing diagnosis for the
client at this time would be Imbalanced Nutrition: More than Body Requirements. Fear and
Ineffective Coping would be applicable to the client diagnosed with an acute myocardial
infarction. There is no evidence that the client has Fluid Volume Deficit.
C) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and
shortness of breath, and complains of fatigue with activity. The priority nursing diagnosis for the
client at this time would be Imbalanced Nutrition: More than Body Requirements. Fear and
Ineffective Coping would be applicable to the client diagnosed with an acute myocardial
infarction. There is no evidence that the client has Fluid Volume Deficit.
D) The client with a BMI of 30.5 is obese. In addition, the client has irregular chest pain and
shortness of breath, and complains of fatigue with activity. The priority nursing diagnosis for the
client at this time would be Imbalanced Nutrition: More than Body Requirements. Fear and
Ineffective Coping would be applicable to the client diagnosed with an acute myocardial
infarction. There is no evidence that the client has Fluid Volume Deficit.
Page Ref: 1124
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
coronary artery disease.

37
Copyright © 2015 Pearson Education, Inc.
5) The nurse is instructing an older client about atorvastatin (Lipitor) to treat elevated
cholesterol. What side effects should the nurse advise the client to report to the healthcare
provider?
A) Headaches
B) Muscle pain and weakness
C) Bruising and excessive bleeding
D) Shortness of breath
Answer: B
Explanation: A) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver
inflammation, elevated enzymes, and muscle pain and weakness. Clients are to be advised to
report these symptoms while on these medications. The other symptoms are unrelated to statin
drugs.
B) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms
while on these medications. The other symptoms are unrelated to statin drugs.
C) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms
while on these medications. The other symptoms are unrelated to statin drugs.
D) Side effects of statin drugs, such as atorvastatin (Lipitor), include liver inflammation, elevated
enzymes, and muscle pain and weakness. Clients are to be advised to report these symptoms
while on these medications. The other symptoms are unrelated to statin drugs.
Page Ref: 1118
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with coronary artery disease
and his or her family in collaboration with other members of the healthcare team.

38
Copyright © 2015 Pearson Education, Inc.
6) The nurse is providing care to a client who has experienced several episodes of angina. What
is the primary outcome for this client?
A) The client will experience relief of chest pain with therapeutic lifestyle changes.
B) The client will experience relief of chest pain with aspirin therapy.
C) The client will experience relief of chest pain with nitrate therapy.
D) The client will experience relief of chest pain with anticoagulant therapy.
Answer: C
Explanation: A) A primary goal in the treatment of angina is to reduce the intensity and
frequency of angina episodes. Rapid-acting organic nitrates are the drugs of choice for
terminating an acute angina episode. Anticoagulant therapy is used to prevent additional thrombi
from forming post-myocardial infarction; it will not relieve angina pain. Therapeutic lifestyle
changes are significant if the client is to maintain a healthy heart, but they will not relieve chest
pain; this is accomplished with medications. Aspirin therapy following an acute myocardial
infarction dramatically reduces mortality due to its antiplatelet function; it will not relieve angina
pain.
B) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina
episode. Anticoagulant therapy is used to prevent additional thrombi from forming post-
myocardial infarction; it will not relieve angina pain. Therapeutic lifestyle changes are
significant if the client is to maintain a healthy heart, but they will not relieve chest pain; this is
accomplished with medications. Aspirin therapy following an acute myocardial infarction
dramatically reduces mortality due to its antiplatelet function; it will not relieve angina pain.
C) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina
episode. Anticoagulant therapy is used to prevent additional thrombi from forming post-
myocardial infarction; it will not relieve angina pain. Therapeutic lifestyle changes are
significant if the client is to maintain a healthy heart, but they will not relieve chest pain; this is
accomplished with medications. Aspirin therapy following an acute myocardial infarction
dramatically reduces mortality due to its antiplatelet function; it will not relieve angina pain.
D) A primary goal in the treatment of angina is to reduce the intensity and frequency of angina
episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina
episode. Anticoagulant therapy is used to prevent additional thrombi from forming post-
myocardial infarction; it will not relieve angina pain. Therapeutic lifestyle changes are
significant if the client is to maintain a healthy heart, but they will not relieve chest pain; this is
accomplished with medications. Aspirin therapy following an acute myocardial infarction
dramatically reduces mortality due to its antiplatelet function; it will not relieve angina pain.
Page Ref: 1124
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 7. Evaluate expected outcomes for an individual with coronary artery
disease.

39
Copyright © 2015 Pearson Education, Inc.
7) A client recovering from an acute myocardial infarction is prescribed aspirin. What should the
nurse instruct the client about this medication?
Select all that apply.
A) Report any itching after seven days of taking.
B) Check with your healthcare provider before taking herbal remedies.
C) Take at a different time of day than warfarin.
D) Report bleeding or bruising to the healthcare provider.
E) Do not skip any scheduled appointments to have blood drawn for labs.
Answer: B, D
Explanation: A) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or
grapeseed extract can increase the effect of the aspirin. Aspirin inhibits platelet aggregation and
clot formation. Bleeding and bruising can occur, and should be reported to the healthcare
provider. Itching is not a common side effect of aspirin therapy. Aspirin and Coumadin are not to
be taken concurrently. No lab appointments will be made just for aspirin therapy.
B) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation.
Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not
a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently.
No lab appointments will be made just for aspirin therapy.
C) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation.
Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not
a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently.
No lab appointments will be made just for aspirin therapy.
D) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation.
Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not
a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently.
No lab appointments will be made just for aspirin therapy.
E) Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can
increase the effect of the aspirin. Aspirin inhibits platelet aggregation and clot formation.
Bleeding and bruising can occur, and should be reported to the healthcare provider. Itching is not
a common side effect of aspirin therapy. Aspirin and Coumadin are not to be taken concurrently.
No lab appointments will be made just for aspirin therapy.
Page Ref: 1120
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with coronary artery disease.

40
Copyright © 2015 Pearson Education, Inc.
8) A client with angina is experiencing acute chest pain. What actions would the nurse
implement at this time?
Select all that apply.
A) Administer antianxiety medication as prescribed.
B) Coach in non-pharmacological pain management techniques.
C) Keep on bed rest.
D) Administer morphine sulfate 2 mg intravenous push as prescribed.
E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.
Answer: C, D, E
Explanation: A) Interventions for the client experiencing acute chest pain include administering
oxygen as prescribed, keeping on bed rest, and administering morphine sulfate as prescribed.
Non-pharmacologic pain management techniques are not appropriate for an episode of acute
chest pain. Antianxiety medications are not effective in acute chest pain.
B) Interventions for the client experiencing acute chest pain include administering oxygen as
prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
pharmacologic pain management techniques are not appropriate for an episode of acute chest
pain. Antianxiety medications are not effective in acute chest pain.
C) Interventions for the client experiencing acute chest pain include administering oxygen as
prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
pharmacologic pain management techniques are not appropriate for an episode of acute chest
pain. Antianxiety medications are not effective in acute chest pain.
D) Interventions for the client experiencing acute chest pain include administering oxygen as
prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
pharmacologic pain management techniques are not appropriate for an episode of acute chest
pain. Antianxiety medications are not effective in acute chest pain.
E) Interventions for the client experiencing acute chest pain include administering oxygen as
prescribed, keeping on bed rest, and administering morphine sulfate as prescribed. Non-
pharmacologic pain management techniques are not appropriate for an episode of acute chest
pain. Antianxiety medications are not effective in acute chest pain.
Page Ref: 1126
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with coronary artery disease
and his or her family in collaboration with other members of the healthcare team.

41
Copyright © 2015 Pearson Education, Inc.
9) A nurse is providing discharge education to a client who has been diagnosed with angina.
Which statement would the nurse exclude from teaching?
A) "Stable angina is the most common form of angina."
B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise."
C) "Unstable angina occurs with increasing frequency, severity, and duration."
D) "Clients with unstable angina are at risk for a heart attack."
Answer: B
Explanation: A) Angina results from ischemia and can be a one-time event or a chronic
condition. There are three types of angina: stable, unstable, and Prinzmetal. Stable angina is the
most common form of angina and is relieved with rest and nitrate medications. Unstable angina
occurs with increasing frequency, severity, and duration. Clients with unstable angina are at risk
for a heart attack, or myocardial infarction.
B) Angina results from ischemia and can be a one-time event or a chronic condition. There are
three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form
of angina and is relieved with rest and nitrate medications. Unstable angina occurs with
increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart
attack, or myocardial infarction.
C) Angina results from ischemia and can be a one-time event or a chronic condition. There are
three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form
of angina and is relieved with rest and nitrate medications. Unstable angina occurs with
increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart
attack, or myocardial infarction.
D) Angina results from ischemia and can be a one-time event or a chronic condition. There are
three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form
of angina and is relieved with rest and nitrate medications. Unstable angina occurs with
increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart
attack, or myocardial infarction.
Page Ref: 1107
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with coronary artery disease.

42
Copyright © 2015 Pearson Education, Inc.
10) A nurse is caring for a client who has been successfully resuscitated after a myocardial
infarction. The client has now developed an arrhythmia. The nurse understands that the causes of
this arrhythmia are all of the following except:
A) Tissue alkalosis.
B) Cellular acidosis.
C) Electrolyte imbalance.
D) Hypoxia.
Answer: A
Explanation: A) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse
conduction and myocardial contractility. The risk for dysrhythmias increases, and myocardial
contractility decreases, reducing stroke volume, cardiac output, blood pressure, and tissue
perfusion.
B) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and
myocardial contractility. The risk for dysrhythmias increases, and myocardial contractility
decreases, reducing stroke volume, cardiac output, blood pressure, and tissue perfusion.
C) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and
myocardial contractility. The risk for dysrhythmias increases, and myocardial contractility
decreases, reducing stroke volume, cardiac output, blood pressure, and tissue perfusion.
D) Cellular acidosis, electrolyte imbalances, and hypoxia affect impulse conduction and
myocardial contractility. The risk for dysrhythmias increases, and myocardial contractility
decreases, reducing stroke volume, cardiac output, blood pressure, and tissue perfusion.
Page Ref: 1090
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of coronary artery disease.

43
Copyright © 2015 Pearson Education, Inc.
11) A nurse is caring for a client suspected of a cocaine-induced myocardial infarction. Cocaine
may cause a myocardial infarction because the drug:
A) Significantly increases the serum triglyceride level, leading to the development of an
atheroma.
B) Alters the body's clotting mechanisms, leading to thrombus formation.
C) Increases sympathetic nervous system stimulation, increasing blood pressure and
vasoconstriction.
D) Alters electrolyte balance, leading to arrhythmias.
Answer: C
Explanation: A) Acute myocardial infarction may also develop as a result of cocaine
intoxication. Cocaine increases sympathetic nervous system activity by both increasing the
release of catecholamines from central and peripheral stores and interfering with the reuptake of
catecholamines. This increased catecholamine concentration stimulates the heart rate and
increases its contractility, increases the automaticity of cardiac tissues and the risk of
dysrhythmias, and causes vasoconstriction and hypertension. The other answers do not occur
with cocaine intoxication.
B) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine
increases sympathetic nervous system activity by both increasing the release of catecholamines
from central and peripheral stores and interfering with the reuptake of catecholamines. This
increased catecholamine concentration stimulates the heart rate and increases its contractility,
increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes
vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.
C) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine
increases sympathetic nervous system activity by both increasing the release of catecholamines
from central and peripheral stores and interfering with the reuptake of catecholamines. This
increased catecholamine concentration stimulates the heart rate and increases its contractility,
increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes
vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.
D) Acute myocardial infarction may also develop as a result of cocaine intoxication. Cocaine
increases sympathetic nervous system activity by both increasing the release of catecholamines
from central and peripheral stores and interfering with the reuptake of catecholamines. This
increased catecholamine concentration stimulates the heart rate and increases its contractility,
increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes
vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.
Page Ref: 1108
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors associated with coronary artery disease.

44
Copyright © 2015 Pearson Education, Inc.
12) A community care nurse is providing education to a group of adults regarding myocardial
infarction (MI). When discussing ways to decrease the number of MI-related deaths, the nurse
will include all of the following statements except:
A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR) techniques."
B) "Be sure to take a baby aspirin every day to help prevent an MI."
C) "Increase your knowledge of cardiac health and cardiac-related disease."
D) "Seek immediate medical attention when you suspect an MI."
Answer: B
Explanation: A) When educating clients regarding ways to decrease the number of MI-related
deaths, the nurse will stress the importance of prevention. Learning about cardiac health and
cardiac disease, as well as learning CPR, is appropriate. Clients should be taught to seek
immediate medical attention when they suspect an MI. However, instructing all clients to take a
baby aspirin every day to help prevent an MI is inappropriate, as not all clients should take this
medication.
B) When educating clients regarding ways to decrease the number of MI-related deaths, the
nurse will stress the importance of prevention. Learning about cardiac health and cardiac disease,
as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical
attention when they suspect an MI. However, instructing all clients to take a baby aspirin every
day to help prevent an MI is inappropriate, as not all clients should take this medication.
C) When educating clients regarding ways to decrease the number of MI-related deaths, the
nurse will stress the importance of prevention. Learning about cardiac health and cardiac disease,
as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical
attention when they suspect an MI. However, instructing all clients to take a baby aspirin every
day to help prevent an MI is inappropriate, as not all clients should take this medication.
D) When educating clients regarding ways to decrease the number of MI-related deaths, the
nurse will stress the importance of prevention. Learning about cardiac health and cardiac disease,
as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical
attention when they suspect an MI. However, instructing all clients to take a baby aspirin every
day to help prevent an MI is inappropriate, as not all clients should take this medication.
Page Ref: 1118
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with coronary artery disease.

45
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.4 Deep Venous Thrombosis

1) The nurse is completing an assessment on a newly admitted client. What assessment finding
would suggest to the nurse that a client is experiencing a deep venous thrombosis?
A) Shortness of breath after activity
B) Two-plus palpable pedal pulses
C) Swelling in one leg with pitting edema
D) Bilateral calf tenderness after walking up a flight of stairs
Answer: C
Explanation: A) Manifestations of deep venous thrombosis include swelling in one leg with
pitting edema because the clot is obstructing the venous return from the leg. Bilateral calf
tenderness may be a normal reaction to the exercise of climbing stairs. Shortness of breath that
subsides after activity and two-plus palpable pulses are not manifestations of deep venous
thrombosis.
B) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema
because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a
normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity
and two-plus palpable pulses are not manifestations of deep venous thrombosis.
C) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema
because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a
normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity
and two-plus palpable pulses are not manifestations of deep venous thrombosis.
D) Manifestations of deep venous thrombosis include swelling in one leg with pitting edema
because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a
normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity
and two-plus palpable pulses are not manifestations of deep venous thrombosis.
Page Ref: 1131
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of deep venous thrombosis.

46
Copyright © 2015 Pearson Education, Inc.
2) The nurse is planning care for a group of clients. Which client should the nurse realize has the
greatest risk for developing deep venous thrombosis?
A) The client recovering from laparoscopic gallbladder surgery
B) The client admitted with new-onset type II diabetes mellitus
C) The client admitted with community-acquired pneumonia
D) The client recovering from knee replacement surgery
Answer: D
Explanation: A) Up to 60% of clients recovering from total knee replacement surgery can
develop a deep venous thrombosis. This is because of the procedure and prolonged immobility
after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted
with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder
surgery would be at a lower risk for deep venous thrombosis because prolonged immobility will
not occur.
B) Up to 60% of clients recovering from total knee replacement surgery can develop a deep
venous thrombosis. This is because of the procedure and prolonged immobility after surgery.
The client admitted with new-onset type II diabetes mellitus, the client admitted with
community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery
would be at a lower risk for deep venous thrombosis because prolonged immobility will not
occur.
C) Up to 60% of clients recovering from total knee replacement surgery can develop a deep
venous thrombosis. This is because of the procedure and prolonged immobility after surgery.
The client admitted with new-onset type II diabetes mellitus, the client admitted with
community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery
would be at a lower risk for deep venous thrombosis because prolonged immobility will not
occur.
D) Up to 60% of clients recovering from total knee replacement surgery can develop a deep
venous thrombosis. This is because of the procedure and prolonged immobility after surgery.
The client admitted with new-onset type II diabetes mellitus, the client admitted with
community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery
would be at a lower risk for deep venous thrombosis because prolonged immobility will not
occur.
Page Ref: 1131
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 2. Identify risk factors associated with deep venous thrombosis.

47
Copyright © 2015 Pearson Education, Inc.
3) A client recovering from a cesarean section is afebrile but is experiencing tenderness,
localized heat, and redness of the left leg. What would be the best intervention for the client at
this time?
A) Encourage to ambulate freely.
B) Provide aspirin 650 mg by mouth.
C) Place on bed rest.
D) Provide Methergine IM.
Answer: C
Explanation: A) These symptoms indicate the presence of superficial thrombophlebitis. The
treatment involves bed rest and elevation of the affected limb, analgesics, and the use of elastic
support hose. Ambulation would increase the inflammation. Aspirin does have anticoagulant
properties but may not be the medication of choice at this time. Methergine is given only for
postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.
B) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves
bed rest and elevation of the affected limb, analgesics, and the use of elastic support hose.
Ambulation would increase the inflammation. Aspirin does have anticoagulant properties but
may not be the medication of choice at this time. Methergine is given only for postpartum
hemorrhage and would cause vasoconstriction of an already inflamed vessel.
C) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves
bed rest and elevation of the affected limb, analgesics, and the use of elastic support hose.
Ambulation would increase the inflammation. Aspirin does have anticoagulant properties but
may not be the medication of choice at this time. Methergine is given only for postpartum
hemorrhage and would cause vasoconstriction of an already inflamed vessel.
D) These symptoms indicate the presence of superficial thrombophlebitis. The treatment
involves bed rest and elevation of the affected limb, analgesics, and the use of elastic support
hose. Ambulation would increase the inflammation. Aspirin does have anticoagulant properties
but may not be the medication of choice at this time. Methergine is given only for postpartum
hemorrhage and would cause vasoconstriction of an already inflamed vessel.
Page Ref: 1130
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with deep venous thrombosis.

48
Copyright © 2015 Pearson Education, Inc.
4) The nurse is planning care for a client with deep venous thrombosis. Which nursing diagnosis
would be a priority for this client?
A) Risk for Infection related to obstructed venous return
B) Excess Fluid Volume related to tissue edema
C) Ineffective Tissue Perfusion related to obstructed venous return
D) Disturbed Sleep Pattern related to tissue hypoxia
Answer: C
Explanation: A) Ineffective Tissue Perfusion related to obstructed venous return is the correct
diagnosis because it identifies the underlying cause. Excess Fluid Volume related to tissue edema
and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify
the underlying cause. Risk for Infection related to obstructed venous return would be a priority if
complications of infection were present, however this is not the case.
B) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis
because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and
Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the
underlying cause. Risk for Infection related to obstructed venous return would be a priority if
complications of infection were present, however this is not the case.
C) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis
because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and
Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the
underlying cause. Risk for Infection related to obstructed venous return would be a priority if
complications of infection were present, however this is not the case.
D) Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis
because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and
Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the
underlying cause. Risk for Infection related to obstructed venous return would be a priority if
complications of infection were present, however this is not the case.
Page Ref: 1135
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
deep venous thrombosis.

49
Copyright © 2015 Pearson Education, Inc.
5) The nurse is providing discharge instructions to a postpartum client recovering from deep
venous thrombosis. What should these instructions include?
Select all that apply.
A) Avoid crossing the legs.
B) Avoid long car trips.
C) Avoid prolonged standing or sitting.
D) Take frequent walks.
E) Take a daily aspirin dose of 650 mg.
Answer: A, C, D
Explanation: A) The client should be instructed to avoid crossing the legs because it increases
pressure on the veins of the lower extremities. The client should be instructed also to avoid
prolonged standing or sitting, which contributes to venous stasis. The client should also be
instructed to take frequent walks to promote venous return. The client should not be instructed to
take a daily aspirin, because it will increase anticoagulant activity and could interact with other
medication prescribed for the treatment of the deep venous thrombosis. The client does not need
to be instructed to avoid long car trips but rather to take frequent breaks during long car trips.
B) The client should be instructed to avoid crossing the legs because it increases pressure on the
veins of the lower extremities. The client should be instructed also to avoid prolonged standing
or sitting, which contributes to venous stasis. The client should also be instructed to take frequent
walks to promote venous return. The client should not be instructed to take a daily aspirin,
because it will increase anticoagulant activity and could interact with other medication
prescribed for the treatment of the deep venous thrombosis. The client does not need to be
instructed to avoid long car trips but rather to take frequent breaks during long car trips.
C) The client should be instructed to avoid crossing the legs because it increases pressure on the
veins of the lower extremities. The client should be instructed also to avoid prolonged standing
or sitting, which contributes to venous stasis. The client should also be instructed to take frequent
walks to promote venous return. The client should not be instructed to take a daily aspirin,
because it will increase anticoagulant activity and could interact with other medication
prescribed for the treatment of the deep venous thrombosis. The client does not need to be
instructed to avoid long car trips but rather to take frequent breaks during long car trips.
D) The client should be instructed to avoid crossing the legs because it increases pressure on the
veins of the lower extremities. The client should be instructed also to avoid prolonged standing
or sitting, which contributes to venous stasis. The client should also be instructed to take frequent
walks to promote venous return. The client should not be instructed to take a daily aspirin,
because it will increase anticoagulant activity and could interact with other medication
prescribed for the treatment of the deep venous thrombosis. The client does not need to be
instructed to avoid long car trips but rather to take frequent breaks during long car trips.

50
Copyright © 2015 Pearson Education, Inc.
E) The client should be instructed to avoid crossing the legs because it increases pressure on the
veins of the lower extremities. The client should be instructed also to avoid prolonged standing
or sitting, which contributes to venous stasis. The client should also be instructed to take frequent
walks to promote venous return. The client should not be instructed to take a daily aspirin,
because it will increase anticoagulant activity and could interact with other medication
prescribed for the treatment of the deep venous thrombosis. The client does not need to be
instructed to avoid long car trips but rather to take frequent breaks during long car trips.
Page Ref: 1135
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with deep venous thrombosis
and his or her family in collaboration with other members of the healthcare team.

6) A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What does
the nurse identify as the priority outcome for this client?
A) The client will not disturb the intravenous infusion.
B) The client will comply with dietary restrictions.
C) The client will not experience bleeding.
D) The client will keep the right leg elevated on two pillows.
Answer: C
Explanation: A) An absence of bleeding is a priority outcome for any client receiving
anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not
directly correlate with heparin. Dietary restrictions are important but not as high a priority as an
absence of bleeding. Elevation of the affected extremity is important but not as high a priority as
an absence of bleeding.
B) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with
heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding.
Elevation of the affected extremity is important but not as high a priority as an absence of
bleeding.
C) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with
heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding.
Elevation of the affected extremity is important but not as high a priority as an absence of
bleeding.
D) An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy.
Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with
heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding.
Elevation of the affected extremity is important but not as high a priority as an absence of
bleeding.
Page Ref: 1135
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 7. Evaluate expected outcomes for an individual with deep venous
thrombosis.
51
Copyright © 2015 Pearson Education, Inc.
7) A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain
and shortness of breath. Suspecting a pulmonary embolism, what action should the nurse
perform first?
A) Assess pulse, respirations, and blood pressure.
B) Apply oxygen and elevate the head of the bed.
C) Reassure the client and notify family members.
D) Increase the rate of heparin infusion.
Answer: B
Explanation: A) Applying oxygen and elevating the head of the bed will promote ventilation and
gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation.
Increasing the rate of heparin infusion cannot be done by the nurse without an order from a
healthcare provider. Reassuring the client and notifying family members are not priorities,
although these measures can decrease the client's anxiety; the priority is to begin oxygen therapy
and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse,
respiration, and blood pressure will be performed following the initiation of oxygen therapy and
bed elevation.
B) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange
in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate
of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
Reassuring the client and notifying family members are not priorities, although these measures
can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of
the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure
will be performed following the initiation of oxygen therapy and bed elevation.
C) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange
in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate
of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
Reassuring the client and notifying family members are not priorities, although these measures
can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of
the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure
will be performed following the initiation of oxygen therapy and bed elevation.
D) Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange
in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate
of heparin infusion cannot be done by the nurse without an order from a healthcare provider.
Reassuring the client and notifying family members are not priorities, although these measures
can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of
the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure
will be performed following the initiation of oxygen therapy and bed elevation.
Page Ref: 1133
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with deep venous thrombosis.

52
Copyright © 2015 Pearson Education, Inc.
8) A client being treated for a deep venous thrombosis is experiencing pain. What can the nurse
do to assist this client?
Select all that apply.
A) Apply an egg-crate mattress on the bed.
B) Maintain bed rest as ordered.
C) Apply warm moist heat to the area four times a day.
D) Encourage position changes every 2 hours.
E) Measure calf and thigh diameter daily.
Answer: B, C, E
Explanation: A) Interventions to address pain include applying warm moist heat to the area four
times a day, maintaining bed rest as ordered, and measuring calf and thigh diameter daily.
Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours
would be appropriate for the client experiencing Ineffective Tissue Perfusion.
B) Interventions to address pain include applying warm moist heat to the area four times a day,
maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-
crate mattress on the bed and encouraging position changes every 2 hours would be appropriate
for the client experiencing Ineffective Tissue Perfusion.
C) Interventions to address pain include applying warm moist heat to the area four times a day,
maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-
crate mattress on the bed and encouraging position changes every 2 hours would be appropriate
for the client experiencing Ineffective Tissue Perfusion.
D) Interventions to address pain include applying warm moist heat to the area four times a day,
maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-
crate mattress on the bed and encouraging position changes every 2 hours would be appropriate
for the client experiencing Ineffective Tissue Perfusion.
E) Interventions to address pain include applying warm moist heat to the area four times a day,
maintaining bed rest as ordered, and measuring calf and thigh diameter daily. Applying an egg-
crate mattress on the bed and encouraging position changes every 2 hours would be appropriate
for the client experiencing Ineffective Tissue Perfusion.
Page Ref: 1135
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with deep venous thrombosis
and his or her family in collaboration with other members of the healthcare team.

53
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.5 Disseminated Intravascular Coagulation

1) A client is admitted to the Intensive Care Unit with disseminated intravascular coagulation.
What will the nurse most likely assess in this client?
Select all that apply.
A) Tachycardia
B) Increased blood glucose level
C) Decreased breath sounds
D) Confusion
E) Thick, tenacious bronchial secretions
Answer: A, C, D
Explanation: A) Clinical manifestations of disseminated intravascular coagulation include
decreased breath sounds, tachycardia, and confusion. Increased blood glucose and thick
bronchial secretions are not associated with this health problem.
B) Clinical manifestations of disseminated intravascular coagulation include decreased breath
sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are
not associated with this health problem.
C) Clinical manifestations of disseminated intravascular coagulation include decreased breath
sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are
not associated with this health problem.
D) Clinical manifestations of disseminated intravascular coagulation include decreased breath
sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are
not associated with this health problem.
E) Clinical manifestations of disseminated intravascular coagulation include decreased breath
sounds, tachycardia, and confusion. Increased blood glucose and thick bronchial secretions are
not associated with this health problem.
Page Ref: 1140
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of disseminated intravascular coagulation.

54
Copyright © 2015 Pearson Education, Inc.
2) The nurse is planning an educational program to instruct clients on disseminating
intravascular coagulation (DIC). What should the nurse include as risk factors for this health
problem?
Select all that apply.
A) Multiparity
B) Abruptio placentae
C) Preterm labor
D) Prolonged retention of a fetus after demise
E) Diabetes mellitus
Answer: B, D
Explanation: A) Abruptio placentae leave intrauterine arteries open and bleeding. This results in
release of thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating
fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This
triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII,
and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of
thromboplastin that triggers DIC.
B) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating
fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This
triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII,
and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of
thromboplastin that triggers DIC.
C) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating
fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This
triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII,
and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of
thromboplastin that triggers DIC.
D) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating
fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This
triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII,
and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of
thromboplastin that triggers DIC.

55
Copyright © 2015 Pearson Education, Inc.
E) Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of
thromboplastin into the maternal blood supply and triggers the development of DIC. In
prolonged retention of the fetus after demise, thromboplastin is released from the degenerating
fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This
triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII,
and result in DIC. Diabetes, multiparity, and preterm labor do not cause the same release of
thromboplastin that triggers DIC.
Page Ref: 1139
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Planning
Learning Outcome: 2. Identify risk factors associated with disseminated intravascular
coagulation.

3) The nurse is caring for a child with disseminated intravascular coagulation (DIC).What will
the nurse include as a priority intervention for this client?
A) Frequent ambulation
B) Maintenance of skin integrity
C) Preparation for radiograph procedures
D) Monitoring of fluid restriction
Answer: B
Explanation: A) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC
should be placed on bed rest. Fluids need to be monitored but will not be restricted. DIC is not
diagnosed with radiograph examination but by serum lab studies.
B) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be
placed on bed rest. Fluids need to be monitored but will not be restricted. DIC is not diagnosed
with radiograph examination but by serum lab studies.
C) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be
placed on bed rest. Fluids need to be monitored but will not be restricted. DIC is not diagnosed
with radiograph examination but by serum lab studies.
D) Impairment of skin integrity can lead to bleeding in DIC. The child with DIC should be
placed on bed rest. Fluids need to be monitored but will not be restricted. DIC is not diagnosed
with radiograph examination but by serum lab studies.
Page Ref: 1140
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with disseminated intravascular coagulation.

56
Copyright © 2015 Pearson Education, Inc.
4) A client with disseminated intravascular coagulation (DIC) is anxious and has decreased
oxygen saturation. Which nursing diagnosis is the most appropriate for the client at this time?
A) Pain
B) Impaired Gas Exchange
C) Ineffective Tissue Perfusion
D) Anxiety
Answer: B
Explanation: A) The decrease in oxygen saturation is causing an impairment in the client's gas
exchange. Anxiety could contribute to the client's impaired gas exchange but is not the primary
problem to address. Decreased oxygen saturation and anxiety would not be addressed with the
diagnoses of Ineffective Tissue Perfusion and Pain.
B) The decrease in oxygen saturation is causing an impairment in the client's gas exchange.
Anxiety could contribute to the client's impaired gas exchange but is not the primary problem to
address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of
Ineffective Tissue Perfusion and Pain.
C) The decrease in oxygen saturation is causing an impairment in the client's gas exchange.
Anxiety could contribute to the client's impaired gas exchange but is not the primary problem to
address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of
Ineffective Tissue Perfusion and Pain.
D) The decrease in oxygen saturation is causing an impairment in the client's gas exchange.
Anxiety could contribute to the client's impaired gas exchange but is not the primary problem to
address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of
Ineffective Tissue Perfusion and Pain.
Page Ref: 1140
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
disseminated intravascular coagulation.

57
Copyright © 2015 Pearson Education, Inc.
5) The nurse has identified Ineffective Tissue Perfusion as a diagnosis for a client with
disseminated intravascular coagulation. What intervention would be appropriate for the client?
A) Carefully repositioning the client every 2 hours
B) Administering oxygen
C) Monitoring oxygen saturation
D) Encouraging deep breathing and coughing
Answer: A
Explanation: A) The intervention appropriate for the client experiencing ineffective tissue
perfusion is to carefully reposition the client every 2 hours because position changes facilitate
circulation and tissue perfusion. The other interventions would be appropriate if the client were
experiencing impaired gas exchange.
B) The intervention appropriate for the client experiencing ineffective tissue perfusion is to
carefully reposition the client every 2 hours because position changes facilitate circulation and
tissue perfusion. The other interventions would be appropriate if the client were experiencing
impaired gas exchange.
C) The intervention appropriate for the client experiencing ineffective tissue perfusion is to
carefully reposition the client every 2 hours because position changes facilitate circulation and
tissue perfusion. The other interventions would be appropriate if the client were experiencing
impaired gas exchange.
D) The intervention appropriate for the client experiencing ineffective tissue perfusion is to
carefully reposition the client every 2 hours because position changes facilitate circulation and
tissue perfusion. The other interventions would be appropriate if the client were experiencing
impaired gas exchange.
Page Ref: 1140
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with disseminated
intravascular coagulation and his or her family in collaboration with other members of the
healthcare team.

58
Copyright © 2015 Pearson Education, Inc.
6) The nurse is evaluating care provided to a client with disseminated intravascular coagulation.
Which observation indicates care has been successful for this client?
A) Heart rate 110 beats per minute
B) Oxygen saturation level 86%
C) Urine output 20 cc per hour
D) No evidence of bleeding
Answer: D
Explanation: A) Care provided to a client with disseminated intravascular coagulation is
successful when there is no further bleeding. Oxygen saturation of 86% is evidence that
treatment is needed. Heart rate of 110 beats per minute is evidence that treatment is needed.
Urine output of 20 cc per hour is below normal limits and would indicate the need for further
treatment.
B) Care provided to a client with disseminated intravascular coagulation is successful when there
is no further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate
of 110 beats per minute is evidence that treatment is needed. Urine output of 20 cc per hour is
below normal limits and would indicate the need for further treatment.
C) Care provided to a client with disseminated intravascular coagulation is successful when there
is no further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate
of 110 beats per minute is evidence that treatment is needed. Urine output of 20 cc per hour is
below normal limits and would indicate the need for further treatment.
D) Care provided to a client with disseminated intravascular coagulation is successful when there
is no further bleeding. Oxygen saturation of 86% is evidence that treatment is needed. Heart rate
of 110 beats per minute is evidence that treatment is needed. Urine output of 20 cc per hour is
below normal limits and would indicate the need for further treatment.
Page Ref: 1143
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with disseminated
intravascular coagulation.

59
Copyright © 2015 Pearson Education, Inc.
7) A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding
through the gastrointestinal tract. What will the nurse expect to provide for the client?
A) Aspirin
B) Coumadin
C) Fresh frozen plasma and platelets
D) Heparin
Answer: C
Explanation: A) When bleeding is the major manifestation of DIC, fresh frozen plasma and
platelet concentrates are given to restore clotting factors and platelets. Heparin may be
administered if bleeding is not controlled by plasma and platelets and if the client has
manifestations of thrombotic problems. Coumadin and aspirin are not indicated in the treatment
of DIC.
B) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet
concentrates are given to restore clotting factors and platelets. Heparin may be administered if
bleeding is not controlled by plasma and platelets and if the client has manifestations of
thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
C) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet
concentrates are given to restore clotting factors and platelets. Heparin may be administered if
bleeding is not controlled by plasma and platelets and if the client has manifestations of
thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
D) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet
concentrates are given to restore clotting factors and platelets. Heparin may be administered if
bleeding is not controlled by plasma and platelets and if the client has manifestations of
thrombotic problems. Coumadin and aspirin are not indicated in the treatment of DIC.
Page Ref: 1140
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with disseminated intravascular coagulation.

60
Copyright © 2015 Pearson Education, Inc.
8) A client with disseminated intravascular coagulation is experiencing joint pain. Which nursing
intervention should the nurse use to help the client at this time?
A) Splints
B) Cool compresses
C) Heat
D) Ice
Answer: B
Explanation: A) Joint pain associated with disseminated intravascular coagulation can be
reduced by applying cool compresses to the affected joints to reduce the transmission of pain
impulses. Heat will encourage bleeding and should not be applied to this client. Splints may
hinder joint mobility and are not indicated for the care of this client. Ice should not be applied
but rather cool compresses.
B) Joint pain associated with disseminated intravascular coagulation can be reduced by applying
cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will
encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and
are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
C) Joint pain associated with disseminated intravascular coagulation can be reduced by applying
cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will
encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and
are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
D) Joint pain associated with disseminated intravascular coagulation can be reduced by applying
cool compresses to the affected joints to reduce the transmission of pain impulses. Heat will
encourage bleeding and should not be applied to this client. Splints may hinder joint mobility and
are not indicated for the care of this client. Ice should not be applied but rather cool compresses.
Page Ref: 1142
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with disseminated
intravascular coagulation and his or her family in collaboration with other members of the
healthcare team.

61
Copyright © 2015 Pearson Education, Inc.
9) A nurse caring for a client with disseminated intravascular coagulation (DIC) is reviewing the
client's diagnostic tests. Which test result is common in DIC?
A) Decreased prothrombin time
B) Increased platelet count
C) Decreased fibrinogen level
D) Decreased partial thromboplastin time
Answer: C
Explanation: A) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk
for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the
depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting
factors.
B) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for
hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the
depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting
factors.
C) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for
hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the
depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting
factors.
D) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for
hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the
depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting
factors.
Page Ref: 1140
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with disseminated intravascular coagulation.

62
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in labor and delivery is caring for a client with suspected DIC. The nurse is
aware that DIC most often occurs in which pregnancy complication?
A) Gestational diabetes
B) Polyhydramnios
C) Placental abruption
D) Placenta previa
Answer: C
Explanation: A) Acute DIC can occur in pregnant clients, most often with pregnancies
complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and
septic abortion.
B) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
C) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
D) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by
preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion.
Page Ref: 1139
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with disseminated intravascular coagulation.

63
Copyright © 2015 Pearson Education, Inc.
11) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of
Ineffective Tissue Perfusion. Which nursing action does not support this diagnosis?
A) Monitor the client's level of consciousness and mental status.
B) Elevate the client's knees on the bed or with a pillow.
C) Minimize the use of tape on the client's skin.
D) Assess extremity pulses, warmth, and capillary refill.
Answer: B
Explanation: A) Thrombi and emboli forming throughout the microcirculation in DIC affect the
perfusion of multiple organs and tissues. The nurse should monitor the client's level of
consciousness and mental status due to the risk of cerebral emboli. Minimizing the use of tape on
the client's skin ensures protecting the integrity of the client's skin. The nurse will assess
extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired
perfusion. The nurse should not elevate the client's knees on the bed or with a pillow because this
may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the
risk for thrombosis.
B) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
multiple organs and tissues. The nurse should monitor the client's level of consciousness and
mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin
ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses,
warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The
nurse should not elevate the client's knees on the bed or with a pillow because this may impair
arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for
thrombosis.
C) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
multiple organs and tissues. The nurse should monitor the client's level of consciousness and
mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin
ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses,
warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The
nurse should not elevate the client's knees on the bed or with a pillow because this may impair
arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for
thrombosis.
D) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of
multiple organs and tissues. The nurse should monitor the client's level of consciousness and
mental status due to the risk of cerebral emboli. Minimizing the use of tape on the client's skin
ensures protecting the integrity of the client's skin. The nurse will assess extremity pulses,
warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. The
nurse should not elevate the client's knees on the bed or with a pillow because this may impair
arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for
thrombosis.
Page Ref: 1142
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
disseminated intravascular coagulation.

64
Copyright © 2015 Pearson Education, Inc.
12) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of
Impaired Gas Exchange. Which nursing action does not support this diagnosis?
A) Place client in low-Fowler position to improve gas exchange.
B) Monitor the client's oxygen saturation continuously.
C) Maintain bed rest.
D) Encourage deep breathing and coughing.
Answer: A
Explanation: A) Micro clots in the pulmonary vasculature are likely to interfere with gas
exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler
position to improve gas exchange. Monitoring the client's oxygen saturation continuously,
maintaining bed rest, and encouraging deep breathing and coughing are all interventions the
nurse should implement.
B) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client
with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas
exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and
encouraging deep breathing and coughing are all interventions the nurse should implement.
C) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client
with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas
exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and
encouraging deep breathing and coughing are all interventions the nurse should implement.
D) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the
client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve
gas exchange. Monitoring the client's oxygen saturation continuously, maintaining bed rest, and
encouraging deep breathing and coughing are all interventions the nurse should implement.
Page Ref: 1142
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
disseminated intravascular coagulation.

65
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.6 Heart Failure

1) During hospitalization for congestive heart failure, a client awakens during the night
frightened and short of breath. What is this client most likely experiencing?
A) Cardiomyopathy
B) Paroxysmal nocturnal dyspnea
C) High-output failure
D) Multisystem heart failure
Answer: B
Explanation: A) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated
during the day is reabsorbed into the circulation at night. This causes fluid overload and
pulmonary congestion. The client awakens at night short of breath and frightened. The client is
not experiencing multisystem heart failure, cardiomyopathy, or high-output failure.
B) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day
is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion.
The client awakens at night short of breath and frightened. The client is not experiencing
multisystem heart failure, cardiomyopathy, or high-output failure.
C) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day
is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion.
The client awakens at night short of breath and frightened. The client is not experiencing
multisystem heart failure, cardiomyopathy, or high-output failure.
D) Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day
is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion.
The client awakens at night short of breath and frightened. The client is not experiencing
multisystem heart failure, cardiomyopathy, or high-output failure.
Page Ref: 1149
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of heart failure.

66
Copyright © 2015 Pearson Education, Inc.
2) The nurse is planning care for several clients. Which client has the greatest risk of developing
heart failure?
A) A 69-year-old African-American male with hypertension
B) A 50-year-old African-American female who smokes
C) A 75-year-old Caucasian male who is overweight
D) A 52-year-old Caucasian female with asthma
Answer: A
Explanation: A) Age, race, and hypertension lead to an increased risk for developing heart
failure. Race and smoking are risk factors, but being female and younger decreases the overall
risk. Age and obesity are risk factors, but not as much as age, being African-American, and
having hypertension. Asthma is not considered a significant risk factor in the development of
heart failure.
B) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
smoking are risk factors, but being female and younger decreases the overall risk. Age and
obesity are risk factors, but not as much as age, being African-American, and having
hypertension. Asthma is not considered a significant risk factor in the development of heart
failure.
C) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
smoking are risk factors, but being female and younger decreases the overall risk. Age and
obesity are risk factors, but not as much as age, being African-American, and having
hypertension. Asthma is not considered a significant risk factor in the development of heart
failure.
D) Age, race, and hypertension lead to an increased risk for developing heart failure. Race and
smoking are risk factors, but being female and younger decreases the overall risk. Age and
obesity are risk factors, but not as much as age, being African-American, and having
hypertension. Asthma is not considered a significant risk factor in the development of heart
failure.
Page Ref: 1148
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors associated with heart failure.

67
Copyright © 2015 Pearson Education, Inc.
3) The nurse is caring for a child with heart failure. What will the nurse most likely assess in this
child?
Select all that apply.
A) Shortness of breath
B) Weight loss
C) Bradycardia
D) Tachycardia
E) Increased blood pressure
Answer: A, D
Explanation: A) Tachycardia is a sign of CHF because the heart attempts to improve cardiac
output by beating faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a
serious sign and can indicate impending cardiac arrest, but is not a typical assessment finding in
a client with CHF. Blood pressure does not increase in CHF, and the weight, instead of
decreasing, increases because of retention of fluids.
B) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and
can indicate impending cardiac arrest, but is not a typical assessment finding in a client with
CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases
because of retention of fluids.
C) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and
can indicate impending cardiac arrest, but is not a typical assessment finding in a client with
CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases
because of retention of fluids.
D) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and
can indicate impending cardiac arrest, but is not a typical assessment finding in a client with
CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases
because of retention of fluids.
E) Tachycardia is a sign of CHF because the heart attempts to improve cardiac output by beating
faster. Shortness of breath is caused by pulmonary congestion. Bradycardia is a serious sign and
can indicate impending cardiac arrest, but is not a typical assessment finding in a client with
CHF. Blood pressure does not increase in CHF, and the weight, instead of decreasing, increases
because of retention of fluids.
Page Ref: 1148
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with heart failure.

68
Copyright © 2015 Pearson Education, Inc.
4) During an assessment, a client with congestive heart failure and severe shortness of breath
tells the nurse about not having enough money to purchase medications. What nursing diagnosis
is of the greatest initial importance when planning care?
A) Excess Fluid Volume related to shortness of breath
B) Ineffective Family Management of Therapeutic Regime related to inability to purchase
medications
C) Fatigue related to shortness of breath
D) Activity Intolerance related to shortness of breath
Answer: A
Explanation: A) The client is experiencing acute shortness of breath because of the excess fluid.
Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance
and Fatigue will improve once the Excess Fluid Volume is addressed. Ineffective Family
Management of Therapeutic Regime related to inability to purchase medications should be
addressed after the client's physiological problems are resolved.
B) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue
will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of
Therapeutic Regime related to inability to purchase medications should be addressed after the
client's physiological problems are resolved.
C) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue
will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of
Therapeutic Regime related to inability to purchase medications should be addressed after the
client's physiological problems are resolved.
D) The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid
Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance and Fatigue
will improve once the Excess Fluid Volume is addressed. Ineffective Family Management of
Therapeutic Regime related to inability to purchase medications should be addressed after the
client's physiological problems are resolved.
Page Ref: 1158
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
heart failure.

69
Copyright © 2015 Pearson Education, Inc.
5) The nurse is planning care for an infant with congestive heart failure. What should the nurse
include in this child's care?
A) Give larger feedings less often to conserve energy.
B) Organize activities to allow for uninterrupted sleep.
C) Monitor respirations during active periods.
D) Force fluids appropriate for age.
Answer: B
Explanation: A) It is important to allow for uninterrupted sleep in order to decrease metabolic
demands on the heart. Fluids should be restricted to those that are high in calories and low in
volume in order to avoid overloading the lungs with fluid. Respirations are difficult to monitor
during active periods, making this an unrealistic goal. Small-volume, high-calorie feedings
should be given.
B) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
heart. Fluids should be restricted to those that are high in calories and low in volume in order to
avoid overloading the lungs with fluid. Respirations are difficult to monitor during active
periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
C) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
heart. Fluids should be restricted to those that are high in calories and low in volume in order to
avoid overloading the lungs with fluid. Respirations are difficult to monitor during active
periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
D) It is important to allow for uninterrupted sleep in order to decrease metabolic demands on the
heart. Fluids should be restricted to those that are high in calories and low in volume in order to
avoid overloading the lungs with fluid. Respirations are difficult to monitor during active
periods, making this an unrealistic goal. Small-volume, high-calorie feedings should be given.
Page Ref: 1215
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with heart failure and his or
her family in collaboration with other members of the healthcare team.

70
Copyright © 2015 Pearson Education, Inc.
6) The nurse is assessing a client being treated for congestive heart failure. What physical
findings would indicate that the client's condition is not improving?
Select all that apply.
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6°F (37°C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus
Answer: A, D
Explanation: A) Wheezing heard when assessing breath sounds is indicative of abnormal breath
sounds, which are characteristic in congestive heart failure. These sounds would indicate that the
client's condition is not improving. A urine output of less than 30 ml/hour should be reported to
the healthcare provider and is an indication of a worsening of congestive heart failure. A
temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are
all normal findings.
B) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which
are characteristic in congestive heart failure. These sounds would indicate that the client's
condition is not improving. A urine output of less than 30 ml/hour should be reported to the
healthcare provider and is an indication of a worsening of congestive heart failure. A temperature
reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal
findings.
C) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which
are characteristic in congestive heart failure. These sounds would indicate that the client's
condition is not improving. A urine output of less than 30 ml/hour should be reported to the
healthcare provider and is an indication of a worsening of congestive heart failure. A temperature
reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal
findings.
D) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which
are characteristic in congestive heart failure. These sounds would indicate that the client's
condition is not improving. A urine output of less than 30 ml/hour should be reported to the
healthcare provider and is an indication of a worsening of congestive heart failure. A temperature
reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal
findings.
E) Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which
are characteristic in congestive heart failure. These sounds would indicate that the client's
condition is not improving. A urine output of less than 30 ml/hour should be reported to the
healthcare provider and is an indication of a worsening of congestive heart failure. A temperature
reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal
findings.
Page Ref: 1148
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with heart failure.

71
Copyright © 2015 Pearson Education, Inc.
7) A client is prescribed enalapril (Vasotec) for treatment of heart failure. What assessment
finding should cause the nurse concern following the initial administration of this drug?
A) Serious rash
B) Ototoxicity
C) Low blood pressure
D) Irregular pulse
Answer: C
Explanation: A) Severe hypotension can occur after the initial administration of enalapril
(Vasotec). Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a
serious rash, and an irregular pulse are adverse effects of beta blockers.
B) Severe hypotension can occur after the initial administration of enalapril (Vasotec).
Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and
an irregular pulse are adverse effects of beta blockers.
C) Severe hypotension can occur after the initial administration of enalapril (Vasotec).
Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and
an irregular pulse are adverse effects of beta blockers.
D) Severe hypotension can occur after the initial administration of enalapril (Vasotec).
Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and
an irregular pulse are adverse effects of beta blockers.
Page Ref: 1154
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with heart failure.

72
Copyright © 2015 Pearson Education, Inc.
8) The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position
would the client find the most comfortable?
A) Seated in a recliner with 2-3 pillows under feet
B) Lying on the left side with the head of the bed elevated 30°
C) Seated in a recliner with 2-3 pillows under head
D) Lying on either side with the head of the bed elevated 30°
Answer: A
Explanation: A) The client with left-sided cardiac failure could develop orthopnea. This is a
result of the pulmonary congestion and decreased cardiac output. Being in an upright position
will ease the work of breathing. Side-lying positions will not help alleviate or prevent the
development of orthopnea. Propping the lower legs up while in a sitting position can help
decrease dependent edema, but 2-3 pillows are not needed for sleep.
B) The client with left-sided cardiac failure could develop orthopnea. This is a result of the
pulmonary congestion and decreased cardiac output. Being in an upright position will ease the
work of breathing. Side-lying positions will not help alleviate or prevent the development of
orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent
edema, but 2-3 pillows are not needed for sleep.
C) The client with left-sided cardiac failure could develop orthopnea. This is a result of the
pulmonary congestion and decreased cardiac output. Being in an upright position will ease the
work of breathing. Side-lying positions will not help alleviate or prevent the development of
orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent
edema, but 2-3 pillows are not needed for sleep.
D) The client with left-sided cardiac failure could develop orthopnea. This is a result of the
pulmonary congestion and decreased cardiac output. Being in an upright position will ease the
work of breathing. Side-lying positions will not help alleviate or prevent the development of
orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent
edema, but 2-3 pillows are not needed for sleep.
Page Ref: 1148
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with heart failure and his or
her family in collaboration with other members of the healthcare team.

73
Copyright © 2015 Pearson Education, Inc.
9) A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition.
Which condition would be excluded from the client's cause of heart failure?
A) Massive pulmonary embolus
B) Hyperthyroidism
C) Rheumatic fever
D) Volume overload
Answer: C
Explanation: A) Heart failure is caused by either impaired myocardial function, increased
cardiac workload, or acute non-cardiac conditions. Acute non-cardiac conditions include massive
pulmonary embolus, hyperthyroidism, and volume overload. Rheumatic fever is a condition that
causes impaired myocardial function.
B) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus,
hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired
myocardial function.
C) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus,
hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired
myocardial function.
D) Heart failure is caused by either impaired myocardial function, increased cardiac workload, or
acute non-cardiac conditions. Acute non-cardiac conditions include massive pulmonary embolus,
hyperthyroidism, and volume overload. Rheumatic fever is a condition that causes impaired
myocardial function.
Page Ref: 1145
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of heart failure.

74
Copyright © 2015 Pearson Education, Inc.
10) A nurse caring for clients with heart failure must be aware of the compensatory mechanisms
activated in heart failure. Which physiology is not associated with the neuroendocrine
compensatory mechanism?
A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate.
B) Decreased CO stimulates the sympathetic nervous system and catecholamine release.
C) Decreased CO and decreased renal perfusion stimulate the renin-angiotensin system.
D) Antidiuretic hormone is released from posterior pituitary.
Answer: A
Explanation: A) When the heart begins to fail, mechanisms are activated to compensate for the
impaired function and maintain the cardiac output. The primary compensatory mechanisms are
as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to
hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine
response.
B) When the heart begins to fail, mechanisms are activated to compensate for the impaired
function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to
hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine
response.
C) When the heart begins to fail, mechanisms are activated to compensate for the impaired
function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to
hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine
response.
D) When the heart begins to fail, mechanisms are activated to compensate for the impaired
function and maintain the cardiac output. The primary compensatory mechanisms are as follows:
1. The Frank-Starling mechanism
2. Neuroendocrine responses, including activation of the SNS and the renin-angiotensin system
3. Myocardial hypertrophy
The Frank-Starling mechanism is when increased cardiac workload causes myocardial muscle to
hypertrophy and ventricles to dilate. All other choices are characteristics of the neuroendocrine
response.
Page Ref: 1145
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of heart failure.
75
Copyright © 2015 Pearson Education, Inc.
11) A client with heart failure is admitted to the hospital for the placement of an implantable
defibrillator. The client appears comfortable at rest but displays dyspnea with ADLs. In which
stage of heart failure does the nurse classify this client?
A) I
B) II
C) III
D) IV
Answer: C
Explanation: A) This client is in Stage III heart failure, or moderate heart failure. In this stage,
the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also
in this stage, surgical intervention includes implantation of a defibrillator.
B) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
comfortable at rest but displays dyspnea with less than normal physical activity. Also in this
stage, surgical intervention includes implantation of a defibrillator.
C) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
comfortable at rest but displays dyspnea with less than normal physical activity. Also in this
stage, surgical intervention includes implantation of a defibrillator.
D) This client is in Stage III heart failure, or moderate heart failure. In this stage, the client is
comfortable at rest but displays dyspnea with less than normal physical activity. Also in this
stage, surgical intervention includes implantation of a defibrillator.
Page Ref: 1149
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with heart failure.

76
Copyright © 2015 Pearson Education, Inc.
12) A client diagnosed with systolic heart failure is admitted to the Intensive Care Unit (ICU).
The nurse assigned to this client understands that systolic heart failure:
A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood
into the arterial system.
B) Results when the heart cannot completely relax in diastole, disrupting normal filling.
C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload.
D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes
and impaired relaxation of the heart muscle.
Answer: A
Explanation: A) Heart failure is commonly classified as either systolic or diastolic heart failure,
based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to
contract adequately to eject a sufficient volume of blood into the arterial system. All other
choices are true of diastolic heart failure, not systolic.
B) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately
to eject a sufficient volume of blood into the arterial system. All other choices are true of
diastolic heart failure, not systolic.
C) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately
to eject a sufficient volume of blood into the arterial system. All other choices are true of
diastolic heart failure, not systolic.
D) Heart failure is commonly classified as either systolic or diastolic heart failure, based on the
underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately
to eject a sufficient volume of blood into the arterial system. All other choices are true of
diastolic heart failure, not systolic.
Page Ref: 1148
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with heart failure.

77
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.7 Hypertension

1) A client reports morning headache that extends into the neck and goes away as the day wears
on. What should the nurse suspect this client is describing?
A) A symptom of hypertension
B) A sinus headache
C) A migraine headache
D) Spinal stenosis
Answer: A
Explanation: A) When symptoms of hypertension do appear, they are usually vague. Headache,
generally in the back of the head and neck, may be present on awakening, subsiding during the
day. The client is not describing a migraine or sinus headache. There is not enough information
to determine whether the client has spinal stenosis.
B) When symptoms of hypertension do appear, they are usually vague. Headache, generally in
the back of the head and neck, may be present on awakening, subsiding during the day. The
client is not describing a migraine or sinus headache. There is not enough information to
determine whether the client has spinal stenosis.
C) When symptoms of hypertension do appear, they are usually vague. Headache, generally in
the back of the head and neck, may be present on awakening, subsiding during the day. The
client is not describing a migraine or sinus headache. There is not enough information to
determine whether the client has spinal stenosis.
D) When symptoms of hypertension do appear, they are usually vague. Headache, generally in
the back of the head and neck, may be present on awakening, subsiding during the day. The
client is not describing a migraine or sinus headache. There is not enough information to
determine whether the client has spinal stenosis.
Page Ref: 1167
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of hypertension.

78
Copyright © 2015 Pearson Education, Inc.
2) The nurse teaches a client about lifestyle modifications to help manage hypertension. Which
client statement indicates teaching has been effective?
A) "I won't be able to run in marathons anymore."
B) "I know I need to give up my cigarettes and alcohol."
C) "I need to get started on my medications right away."
D) "My father had hypertension, did nothing, and lived to be 90 years old."
Answer: B
Explanation: A) Limiting intake of alcohol and discontinuing tobacco products are important
nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications
may eliminate the need for pharmacotherapy, so the client may not have to take medication right
away. Increasing physical activity is an important lifestyle modification for controlling
hypertension. The fact that the client's father had hypertension and lived to be 90 years old does
not mean that the client will have the same experience; the client is in denial.
B) Limiting intake of alcohol and discontinuing tobacco products are important
nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications
may eliminate the need for pharmacotherapy, so the client may not have to take medication right
away. Increasing physical activity is an important lifestyle modification for controlling
hypertension. The fact that the client's father had hypertension and lived to be 90 years old does
not mean that the client will have the same experience; the client is in denial.
C) Limiting intake of alcohol and discontinuing tobacco products are important
nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications
may eliminate the need for pharmacotherapy, so the client may not have to take medication right
away. Increasing physical activity is an important lifestyle modification for controlling
hypertension. The fact that the client's father had hypertension and lived to be 90 years old does
not mean that the client will have the same experience; the client is in denial.
D) Limiting intake of alcohol and discontinuing tobacco products are important
nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications
may eliminate the need for pharmacotherapy, so the client may not have to take medication right
away. Increasing physical activity is an important lifestyle modification for controlling
hypertension. The fact that the client's father had hypertension and lived to be 90 years old does
not mean that the client will have the same experience; the client is in denial.
Page Ref: 1167
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 2. Identify risk factors and prevention methods associated with
hypertension.

79
Copyright © 2015 Pearson Education, Inc.
3) A client has a nighttime cough related to taking enalapril (Vasotec). What is the best nursing
intervention to promote rest in this client?
A) Have the client sit up at an 80° angle in a comfortable chair at night.
B) Have the client sleep on 2 or 3 pillows at night.
C) Contact the physician for an order for a cough-suppressant medication.
D) Contact the physician for an order for a sedative-hypnotic medication.
Answer: B
Explanation: A) The client should sleep with the head elevated if a cough becomes troublesome
when in supine position. A cough induced by an angiotensin-converting enzyme inhibitor will
not be relieved by cough medication. Sitting up at an 80° angle would be effective but would be
too uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep,
but it does nothing to address the client's cough.
B) The client should sleep with the head elevated if a cough becomes troublesome when in
supine position. A cough induced by an angiotensin-converting enzyme inhibitor will not be
relieved by cough medication. Sitting up at an 80° angle would be effective but would be too
uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it
does nothing to address the client's cough.
C) The client should sleep with the head elevated if a cough becomes troublesome when in
supine position. A cough induced by an angiotensin-converting enzyme inhibitor will not be
relieved by cough medication. Sitting up at an 80° angle would be effective but would be too
uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it
does nothing to address the client's cough.
D) The client should sleep with the head elevated if a cough becomes troublesome when in
supine position. A cough induced by an angiotensin-converting enzyme inhibitor will not be
relieved by cough medication. Sitting up at an 80° angle would be effective but would be too
uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it
does nothing to address the client's cough.
Page Ref: 1154
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with hypertension.

80
Copyright © 2015 Pearson Education, Inc.
4) The nursing diagnosis Noncompliance related to unknown factors is established for a client
with hypertension who admits to occasionally taking prescribed antihypertensive medications.
Which behavior should the nurse demonstrate when discussing reasons for noncompliance with
this client?
A) Indifference
B) Nonjudgmental
C) Direct
D) Confrontational
Answer: B
Explanation: A) The nurse who listens to the client openly and nonjudgmentally will both
validate the client's self-esteem and communicate the idea of partnership in the treatment plan for
the client. Employing a confrontational attitude is unlikely to elicit a positive response from the
client regarding the reason for noncompliance. If the nurse issues a directive by telling the client
what to do without listening nonjudgmentally to the problems encountered when taking
medications, the client is not likely change his behavior. The nurse who adopts an attitude of
indifference is communicating a lack of caring, which will decrease the client's sense of self-
esteem.
B) The nurse who listens to the client openly and nonjudgmentally will both validate the client's
self-esteem and communicate the idea of partnership in the treatment plan for the client.
Employing a confrontational attitude is unlikely to elicit a positive response from the client
regarding the reason for noncompliance. If the nurse issues a directive by telling the client what
to do without listening nonjudgmentally to the problems encountered when taking medications,
the client is not likely change his behavior. The nurse who adopts an attitude of indifference is
communicating a lack of caring, which will decrease the client's sense of self-esteem.
C) The nurse who listens to the client openly and nonjudgmentally will both validate the client's
self-esteem and communicate the idea of partnership in the treatment plan for the client.
Employing a confrontational attitude is unlikely to elicit a positive response from the client
regarding the reason for noncompliance. If the nurse issues a directive by telling the client what
to do without listening nonjudgmentally to the problems encountered when taking medications,
the client is not likely change his behavior. The nurse who adopts an attitude of indifference is
communicating a lack of caring, which will decrease the client's sense of self-esteem.
D) The nurse who listens to the client openly and nonjudgmentally will both validate the client's
self-esteem and communicate the idea of partnership in the treatment plan for the client.
Employing a confrontational attitude is unlikely to elicit a positive response from the client
regarding the reason for noncompliance. If the nurse issues a directive by telling the client what
to do without listening nonjudgmentally to the problems encountered when taking medications,
the client is not likely change his behavior. The nurse who adopts an attitude of indifference is
communicating a lack of caring, which will decrease the client's sense of self-esteem.
Page Ref: 1173
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for individuals with
hypertension.

81
Copyright © 2015 Pearson Education, Inc.
5) An older client receiving medication for hypertension had a recent fall at home. What should
the nurse include in this client's plan of care?
A) Monitor serum sodium levels.
B) Assess postural blood pressures.
C) Monitor serum creatinine levels.
D) Monitor blood pressure every 2 hours.
Answer: B
Explanation: A) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension
is more likely to occur. Also, clients treated for hypertension could have an increase in
sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent
orthostatic hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical
client. Sodium intake and creatinine levels assess renal function.
B) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely
to occur. Also, clients treated for hypertension could have an increase in sensitivity to the
medications. Postural blood pressure assessment allows the nurse to prevent orthostatic
hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client.
Sodium intake and creatinine levels assess renal function.
C) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely
to occur. Also, clients treated for hypertension could have an increase in sensitivity to the
medications. Postural blood pressure assessment allows the nurse to prevent orthostatic
hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client.
Sodium intake and creatinine levels assess renal function.
D) Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely
to occur. Also, clients treated for hypertension could have an increase in sensitivity to the
medications. Postural blood pressure assessment allows the nurse to prevent orthostatic
hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client.
Sodium intake and creatinine levels assess renal function.
Page Ref: 1166
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with hypertension and his or
her family in collaboration with other members of the healthcare team.

82
Copyright © 2015 Pearson Education, Inc.
6) The nurse instructs a client about the medication nifedipine (Procardia) for hypertension.
Which client statement indicates that additional teaching is needed?
A) "This medication will cause my ankles to swell, which is normal."
B) "I need to drink 6-8 glasses of water each day."
C) "I will call my doctor if I gain weight or become short of breath."
D) "I need to eat foods high in fiber when taking this medication."
Answer: A
Explanation: A) Swelling in the feet or ankles when taking this medication should be reported to
the healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water
each day and increasing fiber in the diet are appropriate interventions cited by the client. The
client should notify the healthcare provider with weight gain or shortness of breath.
B) Swelling in the feet or ankles when taking this medication should be reported to the
healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water
each day and increasing fiber in the diet are appropriate interventions cited by the client. The
client should notify the healthcare provider with weight gain or shortness of breath.
C) Swelling in the feet or ankles when taking this medication should be reported to the
healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water
each day and increasing fiber in the diet are appropriate interventions cited by the client. The
client should notify the healthcare provider with weight gain or shortness of breath.
D) Swelling in the feet or ankles when taking this medication should be reported to the
healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water
each day and increasing fiber in the diet are appropriate interventions cited by the client. The
client should notify the healthcare provider with weight gain or shortness of breath.
Page Ref: 1171
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with hypertension.

83
Copyright © 2015 Pearson Education, Inc.
7) The home care nurse assesses an older client's blood pressure as being 150/100 mmHg. When
reviewing medications, the client reports taking the blood pressure medication only when feeling
tense. What should the nurse instruct this client to do?
A) Continue to take medication when feeling tense.
B) Take the blood pressure medication as prescribed regardless of feeling tense.
C) Take the blood pressure medication at twice the prescribed dosage for 1 day and then resume
the daily schedule.
D) Contact the physician for an increase in blood pressure medication.
Answer: B
Explanation: A) Clients sometimes mistakenly take blood pressure medication only on an as-
needed basis. This is incorrect; the client should take the medication as prescribed on a daily
basis. The dosage prescribed may be appropriate if taken daily; therefore, it would not need to be
increased. To advise the client to increase the medication without a physician consultation would
be out of the scope of nursing practice.
B) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis.
This is incorrect; the client should take the medication as prescribed on a daily basis. The dosage
prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To
advise the client to increase the medication without a physician consultation would be out of the
scope of nursing practice.
C) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis.
This is incorrect; the client should take the medication as prescribed on a daily basis. The dosage
prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To
advise the client to increase the medication without a physician consultation would be out of the
scope of nursing practice.
D) Clients sometimes mistakenly take blood pressure medication only on an as-needed basis.
This is incorrect; the client should take the medication as prescribed on a daily basis. The dosage
prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To
advise the client to increase the medication without a physician consultation would be out of the
scope of nursing practice.
Page Ref: 1174
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with hypertension and his or
her family in collaboration with other members of the healthcare team.

84
Copyright © 2015 Pearson Education, Inc.
8) A client is admitted to determine the cause of secondary hypertension. Which diagnostic tests
should the nurse suspect the client will be prescribed and need teaching?
Select all that apply.
A) Cerebral angiogram
B) Intravenous pyelogram
C) Renal angiogram
D) Cardiac catheterization
E) Myelogram
Answer: B, C
Explanation: A) When secondary hypertension is suspected, diagnostic tests include an
intravenous pyelogram and renal ultrasound to determine if the renal system is the cause of the
hypertension. Cerebral angiogram, cardiac catheterization, and myelogram are not diagnostic
tests to determine the cause for secondary hypertension.
B) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram
and renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral
angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the
cause for secondary hypertension.
C) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram
and renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral
angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the
cause for secondary hypertension.
D) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram
and renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral
angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the
cause for secondary hypertension.
E) When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram
and renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral
angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the
cause for secondary hypertension.
Page Ref: 1168
Cognitive Level: Creating
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with hypertension.

85
Copyright © 2015 Pearson Education, Inc.
9) A client has a blood pressure of 142/92. The nurse recognizes this as:
A) Normal.
B) Hypertension Stage I.
C) Prehypertension.
D) Hypertension Stage II.
Answer: B
Explanation: A) Blood pressure values in the adult are classified as either normal (<120/<80
mmHg), prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or
hypertension stage II (> or =160/> or =100).
B) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II
(> or =160/> or =100).
C) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II
(> or =160/> or =100).
D) Blood pressure values in the adult are classified as either normal (<120/<80 mmHg),
prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II
(> or =160/> or =100).
Page Ref: 1169
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with hypertension.

86
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in the Intensive Care Unit (ICU) is caring for a client in a hypertensive
emergency due to acute nephritis. The nurse understands that the client's renal system affects
blood pressure by:
A) Releasing the catecholamines epinephrine and norepinephrine.
B) Stimulating the release of renin.
C) Stimulating the release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).
D) Synthesizing and releasing adrenomedullin.
Answer: B
Explanation: A) A drop in renal perfusion stimulates renin release. Renin converts
angiotensinogen to angiotensin I, which is then converted to angiotensin II in the lungs. ANP and
BNP are released from the atrial cells, not the renal system. The catecholamines epinephrine and
norepinephrine are released from the adrenal cortex, not from the kidneys.
B) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to
angiotensin I, which is then converted to angiotensin II in the lungs. ANP and BNP are released
from the atrial cells, not the renal system. The catecholamines epinephrine and norepinephrine
are released from the adrenal cortex, not from the kidneys.
C) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to
angiotensin I, which is then converted to angiotensin II in the lungs. ANP and BNP are released
from the atrial cells, not the renal system. The catecholamines epinephrine and norepinephrine
are released from the adrenal cortex, not from the kidneys.
D) A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to
angiotensin I, which is then converted to angiotensin II in the lungs. ANP and BNP are released
from the atrial cells, not the renal system. The catecholamines epinephrine and norepinephrine
are released from the adrenal cortex, not from the kidneys.
Page Ref: 1163-1164
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of hypertension.

87
Copyright © 2015 Pearson Education, Inc.
11) A nurse is caring for a pregnant client who is hypertensive. What additional symptom likely
indicates this client has early preeclampsia?
A) Persistent headache
B) Excessive protein in the urine
C) Right-sided abdominal pain
D) Severe epigastric pain
Answer: B
Explanation: A) Early signs of preeclampsia include high blood pressure and evidence of protein
in the urine. Later symptoms include persistent headache and right-sided abdominal pain. Severe
epigastric pain is a symptom of HELLP syndrome.
B) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine.
Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric
pain is a symptom of HELLP syndrome.
C) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine.
Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric
pain is a symptom of HELLP syndrome.
D) Early signs of preeclampsia include high blood pressure and evidence of protein in the urine.
Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric
pain is a symptom of HELLP syndrome.
Page Ref: 1166
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with hypertension.

88
Copyright © 2015 Pearson Education, Inc.
12) A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition.
The nurse caring for this client understands that the mechanism of action for this medication is:
A) Prevents conversion of angiotensin I to angiotensin II.
B) Prevents beta-receptor stimulation in the heart.
C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac
cells.
D) Blocks alpha-receptors in the vascular smooth muscle.
Answer: D
Explanation: A) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-
receptors in the vascular smooth muscle. ACE inhibitor medications prevent conversion of
angiotensin I to angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the
heart. Calcium channel blockers inhibit the flow of calcium ions across the cell membrane of
vascular tissue and cardiac cells.
B) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the
vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to
angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium
channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and
cardiac cells.
C) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the
vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to
angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium
channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and
cardiac cells.
D) Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the
vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to
angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium
channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and
cardiac cells.
Page Ref: 1171
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with hypertension.

89
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.8 Life-Threatening Dysrhythmias

1) During a blood pressure screening, an older client tells the nurse about chest fluttering while
doing yard work. The client reports no other symptoms and the frequency is intermittent. How
should the nurse interpret this client's finding?
A) Exercise intolerance
B) Nonspecific cardiac changes with aging
C) Underlying illness that requires a medical evaluation
D) Hypothyroidism
Answer: C
Explanation: A) New-onset atrial fibrillation and other arrhythmias may signal the onset of a
serious underlying illness that requires further medical evaluation. Chest fluttering can be a sign
of hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes.
Exercise intolerance would include shortness of breath, which the client does not report.
B) New-onset atrial fibrillation and other arrhythmias may signal the onset of a serious
underlying illness that requires further medical evaluation. Chest fluttering can be a sign of
hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes. Exercise
intolerance would include shortness of breath, which the client does not report.
C) New-onset atrial fibrillation and other arrhythmias may signal the onset of a serious
underlying illness that requires further medical evaluation. Chest fluttering can be a sign of
hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes. Exercise
intolerance would include shortness of breath, which the client does not report.
D) New-onset atrial fibrillation and other arrhythmias may signal the onset of a serious
underlying illness that requires further medical evaluation. Chest fluttering can be a sign of
hyperthyroidism, not hypothyroidism. These symptoms are not normal cardiac changes. Exercise
intolerance would include shortness of breath, which the client does not report.
Page Ref: 1182
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of life-threatening dysrhythmias.

90
Copyright © 2015 Pearson Education, Inc.
2) The nurse is assessing an older client with a cardiac dysrhythmia. What finding would the
nurse identify as contributing to this client's dysrhythmia?
A) Drinks caffeinated coffee in the morning and for lunch.
B) Does not smoke or ingest any alcohol.
C) Plays golf three times a week and gardens daily.
D) Takes antihypertensive medication as prescribed.
Answer: A
Explanation: A) Aging affects the heart and the cardiac conduction system, increasing the
incidence of dysrhythmias and conduction defects. Caffeine increases the risk of ectopic beats
and rapid heart rates. Antihypertensive medications are not associated with cardiac
dysrhythmias. Engaging in routine physical activity will not cause dysrhythmias or conduction
defects. The client is a non-smoker and does not ingest alcohol, both of which would contribute
to cardiac dysrhythmias.
B) Aging affects the heart and the cardiac conduction system, increasing the incidence of
dysrhythmias and conduction defects. Caffeine increases the risk of ectopic beats and rapid heart
rates. Antihypertensive medications are not associated with cardiac dysrhythmias. Engaging in
routine physical activity will not cause dysrhythmias or conduction defects. The client is a non-
smoker and does not ingest alcohol, both of which would contribute to cardiac dysrhythmias.
C) Aging affects the heart and the cardiac conduction system, increasing the incidence of
dysrhythmias and conduction defects. Caffeine increases the risk of ectopic beats and rapid heart
rates. Antihypertensive medications are not associated with cardiac dysrhythmias. Engaging in
routine physical activity will not cause dysrhythmias or conduction defects. The client is a non-
smoker and does not ingest alcohol, both of which would contribute to cardiac dysrhythmias.
D) Aging affects the heart and the cardiac conduction system, increasing the incidence of
dysrhythmias and conduction defects. Caffeine increases the risk of ectopic beats and rapid heart
rates. Antihypertensive medications are not associated with cardiac dysrhythmias. Engaging in
routine physical activity will not cause dysrhythmias or conduction defects. The client is a non-
smoker and does not ingest alcohol, both of which would contribute to cardiac dysrhythmias.
Page Ref: 1179
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with life-
threatening dysrhythmias.

91
Copyright © 2015 Pearson Education, Inc.
3) A 35-year-old female client is experiencing paroxysmal supraventricular tachycardia. What
should the nurse prepare to do to assist this client?
Select all that apply.
A) Massage the carotid arteries.
B) Prepare for cardioversion.
C) Begin anticoagulation therapy.
D) Administer intravenous adenosine.
E) Administer a beta blocker.
Answer: A, B, D, E
Explanation: A) Management of paroxysmal supraventricular tachycardia includes carotid sinus
massage, adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not
a part of the management for this dysrhythmia.
B) Management of paroxysmal supraventricular tachycardia includes carotid sinus massage,
adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a part of
the management for this dysrhythmia.
C) Management of paroxysmal supraventricular tachycardia includes carotid sinus massage,
adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a part of
the management for this dysrhythmia.
D) Management of paroxysmal supraventricular tachycardia includes carotid sinus massage,
adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a part of
the management for this dysrhythmia.
E) Management of paroxysmal supraventricular tachycardia includes carotid sinus massage,
adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a part of
the management for this dysrhythmia.
Page Ref: 1192
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with life-threatening dysrhythmias.

92
Copyright © 2015 Pearson Education, Inc.
4) A client admitted with a cardiac dysrhythmia reports being easily fatigued and frustrated with
the inability to perform normal daily activities. Which nursing diagnosis should the nurse select
to address this client's issue?
A) Excess Fluid Volume
B) Activity Intolerance
C) Depression
D) Situational Low Self-Esteem
Answer: B
Explanation: A) The client is experiencing fatigue and frustration with the inability to perform
normal daily activities. The nursing diagnosis to address this client's issue would be Activity
Intolerance. There is no evidence that the client is experiencing excess fluid volume. The client
may or may not be experiencing depression. The client may develop situational low self-esteem
if the diagnosis of Activity Intolerance is not addressed.
B) The client is experiencing fatigue and frustration with the inability to perform normal daily
activities. The nursing diagnosis to address this client's issue would be Activity Intolerance.
There is no evidence that the client is experiencing excess fluid volume. The client may or may
not be experiencing depression. The client may develop situational low self-esteem if the
diagnosis of Activity Intolerance is not addressed.
C) The client is experiencing fatigue and frustration with the inability to perform normal daily
activities. The nursing diagnosis to address this client's issue would be Activity Intolerance.
There is no evidence that the client is experiencing excess fluid volume. The client may or may
not be experiencing depression. The client may develop situational low self-esteem if the
diagnosis of Activity Intolerance is not addressed.
D) The client is experiencing fatigue and frustration with the inability to perform normal daily
activities. The nursing diagnosis to address this client's issue would be Activity Intolerance.
There is no evidence that the client is experiencing excess fluid volume. The client may or may
not be experiencing depression. The client may develop situational low self-esteem if the
diagnosis of Activity Intolerance is not addressed.
Page Ref: 1195
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
life-threatening dysrhythmias.

93
Copyright © 2015 Pearson Education, Inc.
5) The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action
would be the most appropriate for this client?
A) Restrict fluids.
B) Encourage bed rest.
C) Monitor serum electrolyte levels.
D) Instruct in a low-fat diet.
Answer: C
Explanation: A) The nurse should monitor serum electrolyte levels because electrolyte
imbalances affect cardiac depolarization and repolarization, and may cause dysrhythmias. More
information is needed before determining whether the client needs to be on bed rest. There is no
evidence to suggest the client needs to have fluids restricted. There is no evidence to suggest the
client needs instruction on a low-fat diet.
B) The nurse should monitor serum electrolyte levels because electrolyte imbalances affect
cardiac depolarization and repolarization, and may cause dysrhythmias. More information is
needed before determining whether the client needs to be on bed rest. There is no evidence to
suggest the client needs to have fluids restricted. There is no evidence to suggest the client needs
instruction on a low-fat diet.
C) The nurse should monitor serum electrolyte levels because electrolyte imbalances affect
cardiac depolarization and repolarization, and may cause dysrhythmias. More information is
needed before determining whether the client needs to be on bed rest. There is no evidence to
suggest the client needs to have fluids restricted. There is no evidence to suggest the client needs
instruction on a low-fat diet.
D) The nurse should monitor serum electrolyte levels because electrolyte imbalances affect
cardiac depolarization and repolarization, and may cause dysrhythmias. More information is
needed before determining whether the client needs to be on bed rest. There is no evidence to
suggest the client needs to have fluids restricted. There is no evidence to suggest the client needs
instruction on a low-fat diet.
Page Ref: 1195
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with a life-threatening
dysrhythmias and his or her family in collaboration with other members of the healthcare team.

94
Copyright © 2015 Pearson Education, Inc.
6) A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia.
Which outcome indicates the client is adhering to the provided medication instruction?
A) The client will monitor the pulse and not take the medication if the pulse is less than 60.
B) The client will take the medication as directed, even when feeling well.
C) The client will take the medication on an empty stomach.
D) The client will take the medication with food.
Answer: B
Explanation: A) It is very important for clients to understand that medication must be taken as
directed, even if the client is feeling well. Procainamide hydrochloride (Pronestyl) can be taken
on an empty stomach. The beta-adrenergic blocking drugs cause bradycardia, not Group 1A
cardiac antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide
hydrochloride (Pronestyl) can be taken with food.
B) It is very important for clients to understand that medication must be taken as directed, even if
the client is feeling well. Procainamide hydrochloride (Pronestyl) can be taken on an empty
stomach. The beta-adrenergic blocking drugs cause bradycardia, not Group 1A cardiac
antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide hydrochloride
(Pronestyl) can be taken with food.
C) It is very important for clients to understand that medication must be taken as directed, even if
the client is feeling well. Procainamide hydrochloride (Pronestyl) can be taken on an empty
stomach. The beta-adrenergic blocking drugs cause bradycardia, not Group 1A cardiac
antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide hydrochloride
(Pronestyl) can be taken with food.
D) It is very important for clients to understand that medication must be taken as directed, even if
the client is feeling well. Procainamide hydrochloride (Pronestyl) can be taken on an empty
stomach. The beta-adrenergic blocking drugs cause bradycardia, not Group 1A cardiac
antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide hydrochloride
(Pronestyl) can be taken with food.
Page Ref: 1189
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with a life-threatening
dysrhythmia.

95
Copyright © 2015 Pearson Education, Inc.
7) A client is scheduled for permanent pacemaker instruction. What instruction will this client
need?
A) Dizziness is to be expected.
B) There are no special precautions.
C) Wear a tight-fitting shirt to help hold the pacemaker in place.
D) Use battery-powered equipment.
Answer: D
Explanation: A) The client should be instructed to use electrical equipment with a grounded
plug and avoid using adapters or extension cords. Battery-powered equipment should be used
instead. There are special precautions for the client to be aware of with a permanent pacemaker.
The client should wear loose-fitting clothing. Dizziness is not to be expected and should be
reported to the healthcare provider.
B) The client should be instructed to use electrical equipment with a grounded plug and avoid
using adapters or extension cords. Battery-powered equipment should be used instead. There are
special precautions for the client to be aware of with a permanent pacemaker. The client should
wear loose-fitting clothing. Dizziness is not to be expected and should be reported to the
healthcare provider.
C) The client should be instructed to use electrical equipment with a grounded plug and avoid
using adapters or extension cords. Battery-powered equipment should be used instead. There are
special precautions for the client to be aware of with a permanent pacemaker. The client should
wear loose-fitting clothing. Dizziness is not to be expected and should be reported to the
healthcare provider.
D) The client should be instructed to use electrical equipment with a grounded plug and avoid
using adapters or extension cords. Battery-powered equipment should be used instead. There are
special precautions for the client to be aware of with a permanent pacemaker. The client should
wear loose-fitting clothing. Dizziness is not to be expected and should be reported to the
healthcare provider.
Page Ref: 1191
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with a life-threatening dysrhythmia.

96
Copyright © 2015 Pearson Education, Inc.
8) A client with sepsis has a temperature of 40°Celsius. Which potentially life-threatening
dysrhythmia is most likely to occur in this client?
A) Bradyarrhythmia
B) Tachyarrhythmia
C) Wolff-Parkinson-White dysrhythmia
D) Long QT dysrhythmia
Answer: B
Explanation: A) This client is febrile and at risk for developing a tachyarrhythmia. Fever does
not cause bradyarrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are
caused by genetic cardiac problems.
B) This client is febrile and at risk for developing a tachyarrhythmia. Fever does not cause
bradyarrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are caused by
genetic cardiac problems.
C) This client is febrile and at risk for developing a tachyarrhythmia. Fever does not cause
bradyarrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are caused by
genetic cardiac problems.
D) This client is febrile and at risk for developing a tachyarrhythmia. Fever does not cause
bradyarrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are caused by
genetic cardiac problems.
Page Ref: 1179
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of life-threatening dysrhythmias.

97
Copyright © 2015 Pearson Education, Inc.
9) A nurse caring for a client in the in the ICU notes that the client's cardiac rhythm indicates a
ventricular tachycardia dysrhythmia. Which rhythm is classified as supraventricular?
A) Sinus tachycardia
B) Atrial flutter
C) Junctional escape
D) Torsades de Pointes
Answer: B
Explanation: A) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is
sinus dysrhythmia, atrial flutter is a supraventricular dysrhythmia, and junctional escape is a
junctional dysrhythmia.
B) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus
dysrhythmia, atrial flutter is a supraventricular dysrhythmia, and junctional escape is a junctional
dysrhythmia.
C) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus
dysrhythmia, atrial flutter is a supraventricular dysrhythmia, and junctional escape is a junctional
dysrhythmia.
D) Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia is sinus
dysrhythmia, atrial flutter is a supraventricular dysrhythmia, and junctional escape is a junctional
dysrhythmia.
Page Ref: 1185
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with life-threatening dysrhythmias.

98
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in the Emergency Department is participating in the resuscitation of a client
experiencing sudden cardiac death. After 5 cycles of CPR, the nurse evaluates the client's cardiac
rhythm as asystole. What is the next action by the nurse?
A) Administer epinephrine.
B) Immediately defibrillate the client.
C) Assess the cardiac monitor electrodes.
D) Assess the client's pulse.
Answer: D
Explanation: A) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should
assess the client's pulse. All other choices are incorrect actions by the nurse.
B) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the client's
pulse. All other choices are incorrect actions by the nurse.
C) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the client's
pulse. All other choices are incorrect actions by the nurse.
D) According to AHA CPR guidelines, after 5 rounds of CPR, the nurse should assess the
client's pulse. All other choices are incorrect actions by the nurse.
Page Ref: 1193
Cognitive Level: Understanding
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with a life-threatening dysrhythmia.

99
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.9 Peripheral Vascular Disease

1) A client admitted with chronic venous insufficiency has an infected wound of the left lower
extremity. What will the nurse find when assessing this wound?
Select all that apply.
A) Pulses absent in the extremity with the wound
B) Wound that is pink with skin warm
C) Ulceration that is pale in color
D) Skin surrounding ulcer that is cool to the touch
E) Surrounding skin brown in color
Answer: B, E
Explanation: A) Manifestations of a venous status ulcer would be a pink wound with warm skin
and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and
absent pulses is manifestations of arterial ulcers.
B) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is
manifestations of arterial ulcers.
C) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is
manifestations of arterial ulcers.
D) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is
manifestations of arterial ulcers.
E) Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of
hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is
manifestations of arterial ulcers.
Page Ref: 1200
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of peripheral vascular disease.

100
Copyright © 2015 Pearson Education, Inc.
2) A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette
smoking, and works as a contractor. What should the nurse instruct the client about the
diagnosis?
A) Nicotine is a vasoconstrictor.
B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease.
C) Nicotine primarily affects coronary arteries and the lungs.
D) The client's occupation is a major risk factor.
Answer: A
Explanation: A) The vasoconstrictive properties of nicotine will worsen the client's peripheral
vascular disease (PVD) by further decreasing peripheral blood flow. One of the most important
parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk
factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however,
the nurse should focus on smoking cessation as a first priority with this client.
B) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
(PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment
is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD.
Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus
on smoking cessation as a first priority with this client.
C) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
(PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment
is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD.
Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus
on smoking cessation as a first priority with this client.
D) The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease
(PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment
is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD.
Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus
on smoking cessation as a first priority with this client.
Page Ref: 1201
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with peripheral
vascular disease.

101
Copyright © 2015 Pearson Education, Inc.
3) The nurse is planning care for an older client with chronic venous insufficiency. What should
the nurse plan to teach this client?
A) Keep the legs dependent as much as possible and elevate only when asleep.
B) Wear elastic hose as prescribed.
C) Standing will prevent the progression of the disease.
D) Cross legs only at the knees.
Answer: B
Explanation: A) Care and treatment of a client with peripheral vascular disease includes
instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse
should instruct the client to avoid sitting or standing for long periods of time. The legs should be
elevated during rest and when asleep. Crossing the legs should be avoided.
B) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client
to avoid sitting or standing for long periods of time. The legs should be elevated during rest and
when asleep. Crossing the legs should be avoided.
C) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client
to avoid sitting or standing for long periods of time. The legs should be elevated during rest and
when asleep. Crossing the legs should be avoided.
D) Care and treatment of a client with peripheral vascular disease includes instruction. The nurse
should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client
to avoid sitting or standing for long periods of time. The legs should be elevated during rest and
when asleep. Crossing the legs should be avoided.
Page Ref: 1202-1203
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with peripheral vascular disease.

102
Copyright © 2015 Pearson Education, Inc.
4) The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased
arterial flow to extremities as appropriate for a client. What should the nurse instruct the client to
do to improve blood flow?
A) Cross the legs at the knees when seated.
B) Use a heating pad to increase warmth.
C) Elevate the feet while reclining.
D) Position with the extremities dependent.
Answer: D
Explanation: A) Positioning with the extremities dependent is correct because gravity promotes
arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the
knees when seated is not recommended because this position compresses partially obstructed
arteries and impairs blood flow. Elevating the feet while reclining is not recommended because
elevating the feet works against gravity and will further impede blood flow. Using a heating pad
to increase warmth is not recommended because external heating devices could increase the risk
of burns in a client with impaired circulation and decreased sensation.
B) Positioning with the extremities dependent is correct because gravity promotes arterial flow to
the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated
is not recommended because this position compresses partially obstructed arteries and impairs
blood flow. Elevating the feet while reclining is not recommended because elevating the feet
works against gravity and will further impede blood flow. Using a heating pad to increase
warmth is not recommended because external heating devices could increase the risk of burns in
a client with impaired circulation and decreased sensation.
C) Positioning with the extremities dependent is correct because gravity promotes arterial flow to
the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated
is not recommended because this position compresses partially obstructed arteries and impairs
blood flow. Elevating the feet while reclining is not recommended because elevating the feet
works against gravity and will further impede blood flow. Using a heating pad to increase
warmth is not recommended because external heating devices could increase the risk of burns in
a client with impaired circulation and decreased sensation.
D) Positioning with the extremities dependent is correct because gravity promotes arterial flow
to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when
seated is not recommended because this position compresses partially obstructed arteries and
impairs blood flow. Elevating the feet while reclining is not recommended because elevating the
feet works against gravity and will further impede blood flow. Using a heating pad to increase
warmth is not recommended because external heating devices could increase the risk of burns in
a client with impaired circulation and decreased sensation.
Page Ref: 1203
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
peripheral vascular disease.

103
Copyright © 2015 Pearson Education, Inc.
5) The nurse is planning care for a client with peripheral vascular disease who is at risk for
Impaired Skin Integrity. What would be included in this client's plan of care?
A) Restrict fluids.
B) Keep the skin clean and dry, and moisturize areas of dryness.
C) Encourage bed rest with legs elevated on pillows.
D) Consult a dietitian for low-protein diet.
Answer: B
Explanation: A) The client with peripheral vascular disease who is at risk for impaired skin
integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to
prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be
indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor.
Bed rest with legs elevated on pillows could increase the client's pain and would not help with
preventing skin breakdown.
B) The client with peripheral vascular disease who is at risk for impaired skin integrity should
have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin
breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for
this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with
legs elevated on pillows could increase the client's pain and would not help with preventing skin
breakdown.
C) The client with peripheral vascular disease who is at risk for impaired skin integrity should
have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin
breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for
this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with
legs elevated on pillows could increase the client's pain and would not help with preventing skin
breakdown.
D) The client with peripheral vascular disease who is at risk for impaired skin integrity should
have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin
breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for
this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with
legs elevated on pillows could increase the client's pain and would not help with preventing skin
breakdown.
Page Ref: 1203
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with peripheral vascular
disease and his or her family in collaboration with other members of the healthcare team.

104
Copyright © 2015 Pearson Education, Inc.
6) The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which
client observation indicates teaching has been effective?
A) Sitting in a chair with a pillow behind knees
B) Washing the lower extremities with mild soap, drying the legs, and applying a light
moisturizer
C) Sitting in a chair with left leg crossed over the right
D) Smoking a pipe instead of cigarettes
Answer: B
Explanation: A) The client who is observed washing the legs with mild soap, drying the legs,
and applying a moisturizer is putting into practice the instruction regarding peripheral vascular
disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate
further instruction was needed. The client smoking a pipe instead of cigarettes needs additional
instruction regarding the hazards of tobacco.
B) The client who is observed washing the legs with mild soap, drying the legs, and applying a
moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting
in a chair with legs crossed or with a pillow behind the knees would indicate further instruction
was needed. The client smoking a pipe instead of cigarettes needs additional instruction
regarding the hazards of tobacco.
C) The client who is observed washing the legs with mild soap, drying the legs, and applying a
moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting
in a chair with legs crossed or with a pillow behind the knees would indicate further instruction
was needed. The client smoking a pipe instead of cigarettes needs additional instruction
regarding the hazards of tobacco.
D) The client who is observed washing the legs with mild soap, drying the legs, and applying a
moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting
in a chair with legs crossed or with a pillow behind the knees would indicate further instruction
was needed. The client smoking a pipe instead of cigarettes needs additional instruction
regarding the hazards of tobacco.
Page Ref: 1203
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with peripheral vascular
disease.

105
Copyright © 2015 Pearson Education, Inc.
7) A client with peripheral vascular disease asks the nurse what types of exercise would improve
the client's condition and overall health. About what should the nurse instruct this client?
A) Bicycling
B) Weight lifting
C) Yoga
D) Jogging
Answer: C
Explanation: A) Yoga is considered a complementary therapy used to reduce stress and improve
circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's
diagnosis of peripheral vascular disease.
B) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of
peripheral vascular disease.
C) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of
peripheral vascular disease.
D) Yoga is considered a complementary therapy used to reduce stress and improve circulation.
Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of
peripheral vascular disease.
Page Ref: 1201
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with peripheral vascular disease.

106
Copyright © 2015 Pearson Education, Inc.
8) A client with peripheral vascular disease is experiencing pain. What can the nurse do to assist
this client?
A) Elevate legs in bed with pillows under the knees.
B) Keep the extremities warm with blankets.
C) Encourage to ambulate and stand on legs 4 times each day.
D) Apply cool compresses to the extremities.
Answer: B
Explanation: A) The nurse should help keep the client's extremities warm with blankets, as heat
promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more
pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too
aggressive. Pillows should not be placed under the knees.
B) The nurse should help keep the client's extremities warm with blankets, as heat promotes
vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain.
Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive.
Pillows should not be placed under the knees.
C) The nurse should help keep the client's extremities warm with blankets, as heat promotes
vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain.
Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive.
Pillows should not be placed under the knees.
D) The nurse should help keep the client's extremities warm with blankets, as heat promotes
vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain.
Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive.
Pillows should not be placed under the knees.
Page Ref: 1202
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with peripheral vascular
disease and his or her family in collaboration with other members of the healthcare team.

107
Copyright © 2015 Pearson Education, Inc.
9) A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication.
The nurse caring for this client understands that intermittent claudication:
A) Causes pain that occurs during periods of inactivity.
B) Causes pain that increases when the legs are elevated and decreases when the legs are
dependent.
C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a
predictable level of activity.
D) Is often described as a burning sensation in the lower legs.
Answer: C
Explanation: A) Intermittent claudication is a cramping or aching pain in the calves of the legs,
the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often
accompanied by weakness and is relieved by rest.
B) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and
the buttocks that occurs with a predictable level of activity. The pain is often accompanied by
weakness and is relieved by rest.
C) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and
the buttocks that occurs with a predictable level of activity. The pain is often accompanied by
weakness and is relieved by rest.
D) Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and
the buttocks that occurs with a predictable level of activity. The pain is often accompanied by
weakness and is relieved by rest.
Page Ref: 1199
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of peripheral vascular disease.

108
Copyright © 2015 Pearson Education, Inc.
10) A client is admitted to the hospital in order to have surgical intervention due to peripheral
vascular disease (PVD). Which procedure is the likely intervention?
A) Stent placement
B) Endarterectomy
C) Percutaneous transluminal angioplasty
D) Atherectomy
Answer: B
Explanation: A) Surgical intervention for PVD includes endarterectomy and bypass grafts. All
other choices are non-surgical interventions for PVD.
B) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices
are non-surgical interventions for PVD.
C) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices
are non-surgical interventions for PVD.
D) Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices
are non-surgical interventions for PVD.
Page Ref: 1201
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with peripheral vascular disease.

11) A nurse is caring for a client with venous stasis whose lower extremities have a brown
pigmentation appearance. Which is this pigmentation appearance best attributed to?
A) The necrosis of subcutaneous fat due to tissue hypoxia
B) Breakdown of red blood cells in the congested tissues
C) The inflammatory and immune response from congested circulation
D) Skin atrophy caused by lack of circulation
Answer: B
Explanation: A) Breakdown of red blood cells in the congested tissues causes brown skin
pigmentation. While the other choices may occur with PVD, they are not responsible for the
cause of brown pigmentation to the skin.
B) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While
the other choices may occur with PVD, they are not responsible for the cause of brown
pigmentation to the skin.
C) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While
the other choices may occur with PVD, they are not responsible for the cause of brown
pigmentation to the skin.
D) Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While
the other choices may occur with PVD, they are not responsible for the cause of brown
pigmentation to the skin.
Page Ref: 1200
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of peripheral vascular disease.

109
Copyright © 2015 Pearson Education, Inc.
12) A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement
will the nurse include when providing client education regarding this therapy?
A) "A nurse will change this dressing every 2 days."
B) "It is important that you maintain strict bed rest."
C) "The dressing will be applied to the entire length of your leg."
D) "The dressing I am applying is semi-rigid."
Answer: D
Explanation: A) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The
dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a
client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers
the lower leg and part of the thigh but not the entire leg.
B) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be
ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower
leg and part of the thigh but not the entire leg.
C) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be
ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower
leg and part of the thigh but not the entire leg.
D) The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be
changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be
ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower
leg and part of the thigh but not the entire leg.
Page Ref: 1200
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with peripheral vascular disease.

110
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.10 Hypertensive Disorders in Pregnancy

1) The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would
require immediate intervention by the nurse?
A) Blood pressure of 142/92
B) Pulse of 92 beats per minute
C) Respiratory rate of 24 per minute
D) Weight gain of 16 oz per week
Answer: A
Explanation: A) A pregnant client's blood pressure should not be greater than 140/90, and if it is
elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's
heart and respiratory rates will increase slightly as a result of an increased circulatory volume
and a decrease in intrathoracic space. Weight gain should average a pound per week in the
second and third trimesters.
B) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it
could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and
respiratory rates will increase slightly as a result of an increased circulatory volume and a
decrease in intrathoracic space. Weight gain should average a pound per week in the second and
third trimesters.
C) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it
could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and
respiratory rates will increase slightly as a result of an increased circulatory volume and a
decrease in intrathoracic space. Weight gain should average a pound per week in the second and
third trimesters.
D) A pregnant client's blood pressure should not be greater than 140/90, and if it is elevated, it
could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and
respiratory rates will increase slightly as a result of an increased circulatory volume and a
decrease in intrathoracic space. Weight gain should average a pound per week in the second and
third trimesters.
Page Ref: 1205
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of pregnancy-induced hypertension.

111
Copyright © 2015 Pearson Education, Inc.
2) The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse
recognize as increasing this client's risk for the development of eclampsia?
A) Treatment for vitamin D deficiency
B) Surgery for ruptured appendix 1 year prior
C) Fibrocystic breast disease
D) Obesity
Answer: D
Explanation: A) Risk factors for the development of eclampsia include obesity. The other
choices will not predispose the client to developing eclampsia.
B) Risk factors for the development of eclampsia include obesity. The other choices will not
predispose the client to developing eclampsia.
C) Risk factors for the development of eclampsia include obesity. The other choices will not
predispose the client to developing eclampsia.
D) Risk factors for the development of eclampsia include obesity. The other choices will not
predispose the client to developing eclampsia.
Page Ref: 1205
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with pregnancy-
induced hypertension.

112
Copyright © 2015 Pearson Education, Inc.
3) The nurse identifies assessment findings for an African-American client with preeclampsia.
Blood pressure is 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein
1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding
would indicate worsening of the condition?
A) Blood pressure 158/100
B) Platelet count 150,000
C) Urinary output 20 mL/hour
D) Reflexes 2+
Answer: C
Explanation: A) The decrease in urine output is an indication of decrease in glomerular filtration
rate, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-
threatening is the urine output change. The blood pressure increase is not significant. The
reflexes are normal at 2+. The platelet count is normal, though it is at the lower end.
B) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is
the urine output change. The blood pressure increase is not significant. The reflexes are normal
at 2+. The platelet count is normal, though it is at the lower end.
C) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is
the urine output change. The blood pressure increase is not significant. The reflexes are normal
at 2+. The platelet count is normal, though it is at the lower end.
D) The decrease in urine output is an indication of decrease in glomerular filtration rate, which
indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is
the urine output change. The blood pressure increase is not significant. The reflexes are normal
at 2+. The platelet count is normal, though it is at the lower end.
Page Ref: 1222
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
individuals with pregnancy-induced hypertension.

113
Copyright © 2015 Pearson Education, Inc.
4) During a routine prenatal visit, a client who is 24 weeks pregnant has an increased blood
pressure. The nurse identifies which nursing diagnosis as appropriate for the client at this time?
A) Fluid Volume Excess
B) Anxiety
C) Excess Fluid Volume
D) Ineffective Coping
Answer: A
Explanation: A) The rise in blood pressure could be caused by fluid retention as seen in
preeclampsia. The client would be at risk for fluid volume excess. Not enough information is
provided to determine if the client is experiencing fluid volume overload. There is no
information to support ineffective coping or anxiety in the client.
B) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The
client would be at risk for fluid volume excess. Not enough information is provided to determine
if the client is experiencing fluid volume overload. There is no information to support ineffective
coping or anxiety in the client.
C) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The
client would be at risk for fluid volume excess. Not enough information is provided to determine
if the client is experiencing fluid volume overload. There is no information to support ineffective
coping or anxiety in the client.
D) The rise in blood pressure could be caused by fluid retention as seen in preeclampsia. The
client would be at risk for fluid volume excess. Not enough information is provided to determine
if the client is experiencing fluid volume overload. There is no information to support ineffective
coping or anxiety in the client.
Page Ref: 1215
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
pregnancy-induced hypertension.

114
Copyright © 2015 Pearson Education, Inc.
5) The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with
preeclampsia. What should the nurse include in this client's plan of care?
A) Suggest family and friends phone frequently.
B) Place in a semiprivate room.
C) Provide stimulation with television and visitors.
D) Limit phone calls and visitors.
Answer: D
Explanation: A) The client with preeclampsia who is at risk for injury needs to be placed in a
private room near the nurses' station. The room should be a quiet, with phone calls and visitors
limited. The semiprivate room might provide too much stimulation. Television and visitors
should be limited to reduce stimulation. Frequent phone calls would provide too much
stimulation and should be limited.
B) The client with preeclampsia who is at risk for injury needs to be placed in a private room
near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The
semiprivate room might provide too much stimulation. Television and visitors should be limited
to reduce stimulation. Frequent phone calls would provide too much stimulation and should be
limited.
C) The client with preeclampsia who is at risk for injury needs to be placed in a private room
near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The
semiprivate room might provide too much stimulation. Television and visitors should be limited
to reduce stimulation. Frequent phone calls would provide too much stimulation and should be
limited.
D) The client with preeclampsia who is at risk for injury needs to be placed in a private room
near the nurses' station. The room should be a quiet, with phone calls and visitors limited. The
semiprivate room might provide too much stimulation. Television and visitors should be limited
to reduce stimulation. Frequent phone calls would provide too much stimulation and should be
limited.
Page Ref: 1208
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with pregnancy-induced
hypertension and his or her family in collaboration with other members of the healthcare team.

115
Copyright © 2015 Pearson Education, Inc.
6) The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with
preeclampsia. Which statement indicates that the client requires additional teaching?
A) "My urine may become darker and smaller in amount each day."
B) "I should call the doctor if I develop a headache or blurred vision."
C) "Pain in the top of my abdomen is a sign my condition is worsening."
D) "Lying on my left side as much as possible is good for the baby."
Answer: A
Explanation: A) Oliguria is a complication of preeclampsia caused by renal involvement and is a
sign that the condition is worsening. It is not an expected outcome and should be reported to the
physician. Headache and blurred vision or other visual disturbances are an indication of
worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes
uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia.
Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and
should be reported to the physician.
B) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
condition is worsening. It is not an expected outcome and should be reported to the physician.
Headache and blurred vision or other visual disturbances are an indication of worsening
preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine
and renal blood flow, and therefore is the optimal position for a client with preeclampsia.
Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and
should be reported to the physician.
C) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
condition is worsening. It is not an expected outcome and should be reported to the physician.
Headache and blurred vision or other visual disturbances are an indication of worsening
preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine
and renal blood flow, and therefore is the optimal position for a client with preeclampsia.
Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and
should be reported to the physician.
D) Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the
condition is worsening. It is not an expected outcome and should be reported to the physician.
Headache and blurred vision or other visual disturbances are an indication of worsening
preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine
and renal blood flow, and therefore is the optimal position for a client with preeclampsia.
Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and
should be reported to the physician.
Page Ref: 1206
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with pregnancy-induced
hypertension.

116
Copyright © 2015 Pearson Education, Inc.
7) A pregnant client with preeclampsia delivers the fetus. What care will the client need within
the first 48 hours after delivery?
Select all that apply.
A) Antihypertensives as prescribed
B) Frequent assessment of serum electrolytes
C) Oxygen 2 liters nasal cannula as prescribed
D) Seizure precautions
E) Vital sign assessment every 4 hours
Answer: A, D, E
Explanation: A) Even though the client with preeclampsia usually improves rapidly after giving
birth, seizures can still occur during the first 48 hours postpartum. The client may also continue
to receive antihypertensives as prescribed. Nursing management during the postpartal period also
includes vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be
assessed and not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
B) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures
can still occur during the first 48 hours postpartum. The client may also continue to receive
antihypertensives as prescribed. Nursing management during the postpartal period also includes
vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and
not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
C) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures
can still occur during the first 48 hours postpartum. The client may also continue to receive
antihypertensives as prescribed. Nursing management during the postpartal period also includes
vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and
not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
D) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures
can still occur during the first 48 hours postpartum. The client may also continue to receive
antihypertensives as prescribed. Nursing management during the postpartal period also includes
vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and
not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
E) Even though the client with preeclampsia usually improves rapidly after giving birth, seizures
can still occur during the first 48 hours postpartum. The client may also continue to receive
antihypertensives as prescribed. Nursing management during the postpartal period also includes
vital sign assessment every 4 hours for 48 hours. The client's hematocrit should be assessed and
not necessarily serum electrolytes. Oxygen is not usually indicated after delivery.
Page Ref: 1206
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pregnancy-induced hypertension.

117
Copyright © 2015 Pearson Education, Inc.
8) A client with preeclampsia begins to seize. What should the nurse should do to protect the
client and fetus from injury?
A) Elevate the client's legs.
B) Place the client on the left side and protect the airway.
C) Place the client in the supine position.
D) Elevate the head of the bed.
Answer: B
Explanation: A) The client should be placed on the side to aid in circulation to the placenta. The
airway needs to be maintained to ensure oxygenation throughout the seizure. The client should
not be placed in the supine position. The head of the bed should not be elevated. The client's legs
should not be elevated.
B) The client should be placed on the side to aid in circulation to the placenta. The airway needs
to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in
the supine position. The head of the bed should not be elevated. The client's legs should not be
elevated.
C) The client should be placed on the side to aid in circulation to the placenta. The airway needs
to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in
the supine position. The head of the bed should not be elevated. The client's legs should not be
elevated.
D) The client should be placed on the side to aid in circulation to the placenta. The airway needs
to be maintained to ensure oxygenation throughout the seizure. The client should not be placed in
the supine position. The head of the bed should not be elevated. The client's legs should not be
elevated.
Page Ref: 1208
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with pregnancy-induced
hypertension and his or her family in collaboration with other members of the healthcare team.

118
Copyright © 2015 Pearson Education, Inc.
9) A nurse working in Labor and Delivery is teaching a group of pregnant clients regarding
seizures associated with eclampsia. The nurse will include which statement?
A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation
of the muscles."
B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity."
C) "Seizures are rare in eclampsia, but they occur sometimes."
D) "Seizures do not occur in preeclampsia."
Answer: D
Explanation: A) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has
a seizure, so seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is
evidenced by muscular contraction and rigidity. The clonic phase of a grand mal seizure is
evidenced by alternate contraction and relaxation of the muscles.
B) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by
muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by
alternate contraction and relaxation of the muscles.
C) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by
muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by
alternate contraction and relaxation of the muscles.
D) Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so
seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by
muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by
alternate contraction and relaxation of the muscles.
Page Ref: 1208
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care for
individuals with pregnancy-induced hypertension.

119
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in Labor and Delivery is caring for a client with preeclampsia. Which
clinical manifestation is the nurse most likely to find in this client?
A) Increased nitric oxide production
B) Decreased serum sodium
C) Decreased blood urea nitrogen (BUN)
D) Increased serum creatinine
Answer: D
Explanation: A) Preeclampsia decreases renal perfusion, causing an increase in both serum
creatinine and blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide
production and the retention of serum sodium.
B) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and
blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide production and
the retention of serum sodium.
C) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and
blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide production and
the retention of serum sodium.
D) Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and
blood urea nitrogen (BUN). Preeclampsia also causes a decrease in nitric oxide production and
the retention of serum sodium.
Page Ref: 1206
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pregnancy-induced hypertension.

120
Copyright © 2015 Pearson Education, Inc.
11) A pregnant client is diagnosed with HELLP syndrome. The client's nurse understands that
which clinical finding is not a manifestation of this condition?
A) Elevated liver enzymes
B) Hemolysis
C) Elevated lipid panel
D) Decreased platelet count
Answer: C
Explanation: A) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)
is thought to be related to severe preeclampsia. Elevated lipid panel is not a characteristic of
HELLP syndrome.
B) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be
related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.
C) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be
related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.
D) HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to
be related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP
syndrome.
Page Ref: 1205
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pregnancy-induced hypertension.

121
Copyright © 2015 Pearson Education, Inc.
12) Which clinical consideration should the nurse implement for the client in labor who has been
diagnosed with preeclampsia?
A) Place the client in the room closest to the nurse's station, even if it is a shared room.
B) Place the client in left lateral position when the client feels the urge to push.
C) Monitor client's fetus intermittently while client is in first stage of labor.
D) Encourage the client to be alone in the room without family in order to maintain a quiet
environment.
Answer: B
Explanation: A) A laboring client with preeclampsia is at risk for the development of eclampsia
with subsequent seizures. The nurse should place the client in left lateral position when the client
feels the urge to push because this position improves circulation to the placenta and fetus. If
possible, the nurse should place the client in a private room to promote a non-stimulating
environment. However, the client should always have support with her, not be alone during
labor. The nurse will monitor the client's fetus continuously during labor.
B) A laboring client with preeclampsia is at risk for the development of eclampsia with
subsequent seizures. The nurse should place the client in left lateral position when the client feels
the urge to push because this position improves circulation to the placenta and fetus. If possible,
the nurse should place the client in a private room to promote a non-stimulating environment.
However, the client should always have support with her, not be alone during labor. The nurse
will monitor the client's fetus continuously during labor.
C) A laboring client with preeclampsia is at risk for the development of eclampsia with
subsequent seizures. The nurse should place the client in left lateral position when the client feels
the urge to push because this position improves circulation to the placenta and fetus. If possible,
the nurse should place the client in a private room to promote a non-stimulating environment.
However, the client should always have support with her, not be alone during labor. The nurse
will monitor the client's fetus continuously during labor.
D) A laboring client with preeclampsia is at risk for the development of eclampsia with
subsequent seizures. The nurse should place the client in left lateral position when the client feels
the urge to push because this position improves circulation to the placenta and fetus. If possible,
the nurse should place the client in a private room to promote a non-stimulating environment.
However, the client should always have support with her, not be alone during labor. The nurse
will monitor the client's fetus continuously during labor.
Page Ref: 1206
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with pregnancy-induced
hypertension and her family in collaboration with other members of the healthcare team.

122
Copyright © 2015 Pearson Education, Inc.
13) A nurse working in Labor and Delivery cares for clients with preeclampsia. The nurse
understands that the exact cause of this condition is not known; however, research suggests:
A) It is a disorder of placental dysfunction.
B) It is a disorder of fetal liver compromise.
C) It is a disorder of maternal hyporesponsiveness to vasoactive peptides.
D) It is a disorder of excess trophoblast invasion within the placenta.
Answer: A
Explanation: A) The exact cause of preeclampsia is unknown. However, it has been identified as
a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with
associated vasospasm.
B) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
placental dysfunction leading to a syndrome of endothelial dysfunction with associated
vasospasm.
C) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
placental dysfunction leading to a syndrome of endothelial dysfunction with associated
vasospasm.
D) The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of
placental dysfunction leading to a syndrome of endothelial dysfunction with associated
vasospasm.
Page Ref: 1205
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of pregnancy-induced hypertension.

123
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.11 Pulmonary Embolism

1) The nurse caring for a client recovering from an abdominal hysterectomy suspects the client is
experiencing a pulmonary embolism. What did the nurse assess in this client?
A) Nausea
B) Decreased urine output
C) Dyspnea and shortness of breath
D) Activity intolerance
Answer: C
Explanation: A) Manifestations of a pulmonary embolism include dyspnea, shortness of breath,
pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-
grade fever. Decreased urine output, activity intolerance and nausea are not clinical
manifestations of a pulmonary embolism.
B) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever.
Decreased urine output, activity intolerance and nausea are not clinical manifestations of a
pulmonary embolism.
C) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever.
Decreased urine output, activity intolerance and nausea are not clinical manifestations of a
pulmonary embolism.
D) Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest
pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever.
Decreased urine output, activity intolerance and nausea are not clinical manifestations of a
pulmonary embolism.
Page Ref: 1212
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of pulmonary embolism.

124
Copyright © 2015 Pearson Education, Inc.
2) The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus
formation. What assessment information caused the nurse to come to this conclusion?
A) Body mass index (BMI) 35.8
B) Former cigarette smoker
C) Blood pressure 132/88 mmHg
D) Age 45 years
Answer: A
Explanation: A) Risk factors for the development of thrombus formation that could lead to a
pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure,
and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the
client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status
as a former smoker, and blood pressure would not have as significant an impact on the
development of a thrombus as the client's weight.
B) Risk factors for the development of thrombus formation that could lead to a pulmonary
embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and
advancing age. The BMI of 35.8 falls into the category of obese, which would increase the
client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status
as a former smoker, and blood pressure would not have as significant an impact on the
development of a thrombus as the client's weight.
C) Risk factors for the development of thrombus formation that could lead to a pulmonary
embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and
advancing age. The BMI of 35.8 falls into the category of obese, which would increase the
client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status
as a former smoker, and blood pressure would not have as significant an impact on the
development of a thrombus as the client's weight.
D) Risk factors for the development of thrombus formation that could lead to a pulmonary
embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and
advancing age. The BMI of 35.8 falls into the category of obese, which would increase the
client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status
as a former smoker, and blood pressure would not have as significant an impact on the
development of a thrombus as the client's weight.
Page Ref: 1212
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with pulmonary
embolism.

125
Copyright © 2015 Pearson Education, Inc.
3) The nurse is providing discharge instructions to an older client who is going home after
having a total knee replacement. What teaching will the nurse include to prevent the
development of a thrombosis or pulmonary embolism?
Select all that apply.
A) Place pillows under the knees when in bed.
B) Use compression stockings.
C) Limit ambulation.
D) Limit fluids.
E) Continue with leg exercises.
Answer: B, E
Explanation: A) A client being discharged after having orthopedic surgery is at increased risk
for pulmonary embolism. The nurse should instruct the client to continue with leg exercises and
use compression stockings to reduce the risk of deep vein thrombosis formation. The client
should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated
unless another physiological condition exists that would necessitate a fluid restriction.
B) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
embolism. The nurse should instruct the client to continue with leg exercises and use
compression stockings to reduce the risk of deep vein thrombosis formation. The client should be
encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless
another physiological condition exists that would necessitate a fluid restriction.
C) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
embolism. The nurse should instruct the client to continue with leg exercises and use
compression stockings to reduce the risk of deep vein thrombosis formation. The client should be
encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless
another physiological condition exists that would necessitate a fluid restriction.
D) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
embolism. The nurse should instruct the client to continue with leg exercises and use
compression stockings to reduce the risk of deep vein thrombosis formation. The client should be
encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless
another physiological condition exists that would necessitate a fluid restriction.
E) A client being discharged after having orthopedic surgery is at increased risk for pulmonary
embolism. The nurse should instruct the client to continue with leg exercises and use
compression stockings to reduce the risk of deep vein thrombosis formation. The client should be
encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless
another physiological condition exists that would necessitate a fluid restriction.
Page Ref: 1214
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with pulmonary embolism.

126
Copyright © 2015 Pearson Education, Inc.
4) A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation
level and dyspnea. The nurse would identify which diagnosis as a priority for this client?
A) Ineffective Tissue Perfusion
B) Anxiety
C) Impaired Gas Exchange
D) Impaired Physical Mobility
Answer: C
Explanation: A) A reduction in arterial oxygen saturation level and dyspnea indicate the client is
experiencing impaired gas exchange. This would be the priority for the client at this time. The
client may have ineffective tissue perfusion; however, this is not the priority. The client may be
experiencing anxiety; however, this is not the priority at this time either. There is not enough
information to determine whether the client is at risk for impaired mobility.
B) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
impaired gas exchange. This would be the priority for the client at this time. The client may have
ineffective tissue perfusion; however, this is not the priority. The client may be experiencing
anxiety; however, this is not the priority at this time either. There is not enough information to
determine whether the client is at risk for impaired mobility.
C) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
impaired gas exchange. This would be the priority for the client at this time. The client may have
ineffective tissue perfusion; however, this is not the priority. The client may be experiencing
anxiety; however, this is not the priority at this time either. There is not enough information to
determine whether the client is at risk for impaired mobility.
D) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing
impaired gas exchange. This would be the priority for the client at this time. The client may have
ineffective tissue perfusion; however, this is not the priority. The client may be experiencing
anxiety; however, this is not the priority at this time either. There is not enough information to
determine whether the client is at risk for impaired mobility.
Page Ref: 1215
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
pulmonary embolism.

127
Copyright © 2015 Pearson Education, Inc.
5) The nurse is planning care for a client with a pulmonary embolism. Which intervention would
assist with the client's decrease in cardiac output?
A) Provide oxygen.
B) Keep protamine sulfate at the bedside.
C) Monitor pulmonary arterial pressures.
D) Assess for bleeding.
Answer: C
Explanation: A) The client with a pulmonary embolism and decreased cardiac output is at risk
for developing right heart failure. The nurse should monitor pulmonary arterial pressures.
Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the
client with ineffective protection. Oxygen would be appropriate for the client with impaired gas
exchange.
B) The client with a pulmonary embolism and decreased cardiac output is at risk for developing
right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for
bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with
ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.
C) The client with a pulmonary embolism and decreased cardiac output is at risk for developing
right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for
bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with
ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.
D) The client with a pulmonary embolism and decreased cardiac output is at risk for developing
right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for
bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with
ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.
Page Ref: 1215
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with pulmonary embolism and
his or her family in collaboration with other members of the healthcare team.

128
Copyright © 2015 Pearson Education, Inc.
6) The nurse has instructed a client recovering from a pulmonary embolism on long-term
anticoagulant therapy. Which client statement indicates that instruction has been effective?
A) "I will expect bloody sputum when I brush my teeth."
B) "I need to use a soft toothbrush and an electric razor, and avoid injuries."
C) "I need to eat a well-balanced diet with green salads."
D) "I can expect to be bruised, since this is normal."
Answer: B
Explanation: A) Instruction on anticoagulant therapy should include the need to avoid injury,
use a soft toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-
Alert bracelet that identifies anticoagulant therapy. The client should avoid green salads because
of the vitamin K content. The statements about bruising being normal and expecting bloody
sputum mean the client is in need of additional instruction on anticoagulant therapy.
B) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft
toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert
bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the
vitamin K content. The statements about bruising being normal and expecting bloody sputum
mean the client is in need of additional instruction on anticoagulant therapy.
C) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft
toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert
bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the
vitamin K content. The statements about bruising being normal and expecting bloody sputum
mean the client is in need of additional instruction on anticoagulant therapy.
D) Instruction on anticoagulant therapy should include the need to avoid injury, use a soft
toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert
bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the
vitamin K content. The statements about bruising being normal and expecting bloody sputum
mean the client is in need of additional instruction on anticoagulant therapy.
Page Ref: 1215
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with pulmonary embolism.

129
Copyright © 2015 Pearson Education, Inc.
7) A client scheduled for surgery is being instructed in leg exercises and the pneumatic
compression device. For the prevention of which postoperative complication are these
instructions being provided?
A) Infection
B) Delayed wound healing
C) Contractures
D) Deep vein thrombosis
Answer: D
Explanation: A) The best care for a pulmonary embolism is prevention. Since surgical clients
have an increased risk of developing a pulmonary embolism postoperatively, instructions should
include ways to encourage movement, such as leg exercises, and the need for pneumatic
compression devices to maintain lower extremity circulation and prevent the development of a
deep vein thrombosis. Exercises and pneumatic compression devices do not prevent infection,
encourage wound healing, or prevent contractures.
B) The best care for a pulmonary embolism is prevention. Since surgical clients have an
increased risk of developing a pulmonary embolism postoperatively, instructions should include
ways to encourage movement, such as leg exercises, and the need for pneumatic compression
devices to maintain lower extremity circulation and prevent the development of a deep vein
thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage
wound healing, or prevent contractures.
C) The best care for a pulmonary embolism is prevention. Since surgical clients have an
increased risk of developing a pulmonary embolism postoperatively, instructions should include
ways to encourage movement, such as leg exercises, and the need for pneumatic compression
devices to maintain lower extremity circulation and prevent the development of a deep vein
thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage
wound healing, or prevent contractures.
D) The best care for a pulmonary embolism is prevention. Since surgical clients have an
increased risk of developing a pulmonary embolism postoperatively, instructions should include
ways to encourage movement, such as leg exercises, and the need for pneumatic compression
devices to maintain lower extremity circulation and prevent the development of a deep vein
thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage
wound healing, or prevent contractures.
Page Ref: 1214
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pulmonary embolism.

130
Copyright © 2015 Pearson Education, Inc.
8) The nurse is preparing to discharge a client recovering from a pulmonary embolism. How
should the nurse instruct this client?
Select all that apply.
A) Limit the use of over-the-counter medications.
B) Diet to include green leafy vegetables
C) Symptoms of recurrence
D) Anticoagulant administration schedule
E) Resume normal activity level.
Answer: C, D
Explanation: A) The client being discharged after treatment for a pulmonary embolism needs to
be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K,
adhering to the physician's prescribed activity level, and avoiding all over-the-counter
medications. The nurse should instruct the client in symptoms of bleeding or recurrence of a
pulmonary embolism and the schedule for anticoagulation administration.
B) The client being discharged after treatment for a pulmonary embolism needs to be instructed
in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the
physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse
should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and
the schedule for anticoagulation administration.
C) The client being discharged after treatment for a pulmonary embolism needs to be instructed
in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the
physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse
should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and
the schedule for anticoagulation administration.
D) The client being discharged after treatment for a pulmonary embolism needs to be instructed
in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the
physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse
should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and
the schedule for anticoagulation administration.
E) The client being discharged after treatment for a pulmonary embolism needs to be instructed
in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the
physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse
should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and
the schedule for anticoagulation administration.
Page Ref: 1215
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with pulmonary embolism and
his or her family in collaboration with other members of the healthcare team.

131
Copyright © 2015 Pearson Education, Inc.
9) Which client is at highest risk for a nonthrombotic pulmonary embolism?
A) The pregnant client with gestational diabetes
B) The client who postoperative from a femur fracture repair
C) The client with a primary lung tumor
D) The client who uses intravenous illicit drugs
Answer: B
Explanation: A) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat
embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow
fat into the circulation. The other clients may be at risk for pulmonary embolism; however, they
are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.
B) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually
occurs after fracture of long bone (typically the femur) releases bone marrow fat into the
circulation. The other clients may be at risk for pulmonary embolism; however, they are
incorrect choices for the most common cause of nonthrombotic pulmonary emboli.
C) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually
occurs after fracture of long bone (typically the femur) releases bone marrow fat into the
circulation. The other clients may be at risk for pulmonary embolism; however, they are
incorrect choices for the most common cause of nonthrombotic pulmonary emboli.
D) Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually
occurs after fracture of long bone (typically the femur) releases bone marrow fat into the
circulation. The other clients may be at risk for pulmonary embolism; however, they are
incorrect choices for the most common cause of nonthrombotic pulmonary emboli.
Page Ref: 1212
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 2. Identify risk factors and prevention methods associated with pulmonary
embolism.

132
Copyright © 2015 Pearson Education, Inc.
10) A nurse caring for a client with a pulmonary embolism expects to find which diagnostic
result?
A) Patchy infiltrates on chest x-ray
B) Metabolic alkalosis on arterial blood gas
C) Elevated CO2 level found on end-tidal carbon dioxide monitor
D) Tachycardia and nonspecific T-wave changes on EKG
Answer: D
Explanation: A) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur
on EKG. The client with a pulmonary embolism will likely have respiratory alkalosis from rapid
breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO 2) will be
decreased, not increased, due to rapid breathing.
B) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The
client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not
metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not
increased, due to rapid breathing.
C) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The
client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not
metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not
increased, due to rapid breathing.
D) With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The
client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not
metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not
increased, due to rapid breathing.
Page Ref: 1214
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pulmonary embolism.

133
Copyright © 2015 Pearson Education, Inc.
11) The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism.
The nurse anticipates the client will need anticoagulant therapy. What is true regarding this
therapy for the treatment of this condition?
A) It is considered second-line treatment.
B) Major hemorrhage is common.
C) Heparin and warfarin (Coumadin) are usually initiated at the same time.
D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.
Answer: C
Explanation: A) Heparin and warfarin are usually initiated at the same time for the treatment of
pulmonary embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary
embolism. While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin,
alters the synthesis of vitamin K-dependent clotting factors.
B) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism.
While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the
synthesis of vitamin K-dependent clotting factors.
C) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism.
While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the
synthesis of vitamin K-dependent clotting factors.
D) Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary
embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism.
While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the
synthesis of vitamin K-dependent clotting factors.
Page Ref: 1214
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with pulmonary embolism.

134
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.12 Shock

1) The nurse is concerned that a client is demonstrating early signs of hypovolemic shock. What
did the nurse assess in this client?
Select all that apply.
A) Slight increase in pulse
B) Prolonged capillary refill time
C) Rapid weak pulse
D) Normal respirations
E) Normal blood pressure
Answer: A, B, D, E
Explanation: A) Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid
pulse is a characteristic of the irreversible stage of hypovolemic shock.
B) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
C) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
D) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
E) Manifestations of early hypovolemic shock include a slight increase in pulse, normal
respirations, prolonged capillary refill time, and normal blood pressure. A weak rapid pulse is a
characteristic of the irreversible stage of hypovolemic shock.
Page Ref: 1224
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of shock.

135
Copyright © 2015 Pearson Education, Inc.
2) A young client with a history of multiple allergies is prescribed epinephrine (EpiPen) for
prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was
about heart failure." What is the best response by the nurse?
A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart
failure, and liver failure."
B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and
loss of blood."
C) "There are many kinds of shock that also include infection, nervous system damage, and loss
of blood."
D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and
respiratory failure."
Answer: C
Explanation: A) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal
cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent
infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms
may suggest anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not
a type of shock. Liver failure is not a type of shock.
B) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
C) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
D) Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests
neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may
indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest
anaphylactic shock. Kidney failure is not a type of shock. Respiratory failure is not a type of
shock. Liver failure is not a type of shock.
Page Ref: 1222-1224
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with shock.

136
Copyright © 2015 Pearson Education, Inc.
3) An older client is experiencing hypovolemic shock. Which treatment measure would be given
the highest priority for this client?
A) Administering analgesics for control of pain
B) Assessing the cause of bleeding
C) Providing replacement of volume
D) Establishing invasive cardiac monitoring
Answer: D
Explanation: A) With aging, there is a decrease in cardiac sympathetic activity. Older clients can
have secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta
blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older client will
require early invasive monitoring in order to avoid excessive or inadequate volume restoration.
This should be done early in the treatment phase. Replacement of volume would occur after
invasive cardiac monitoring is established. Pain would be a consideration but would not be
attended to as a first priority. Assessing the cause of bleeding would also occur after establishing
invasive cardiac monitoring.
B) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta
blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older client will
require early invasive monitoring in order to avoid excessive or inadequate volume restoration.
This should be done early in the treatment phase. Replacement of volume would occur after
invasive cardiac monitoring is established. Pain would be a consideration but would not be
attended to as a first priority. Assessing the cause of bleeding would also occur after establishing
invasive cardiac monitoring.
C) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta
blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older client will
require early invasive monitoring in order to avoid excessive or inadequate volume restoration.
This should be done early in the treatment phase. Replacement of volume would occur after
invasive cardiac monitoring is established. Pain would be a consideration but would not be
attended to as a first priority. Assessing the cause of bleeding would also occur after establishing
invasive cardiac monitoring.
D) With aging, there is a decrease in cardiac sympathetic activity. Older clients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a beta
blocker, tachycardia may not occur as an early sign of hypovolemic shock. The older client will
require early invasive monitoring in order to avoid excessive or inadequate volume restoration.
This should be done early in the treatment phase. Replacement of volume would occur after
invasive cardiac monitoring is established. Pain would be a consideration but would not be
attended to as a first priority. Assessing the cause of bleeding would also occur after establishing
invasive cardiac monitoring.
Page Ref: 1223
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with shock.

137
Copyright © 2015 Pearson Education, Inc.
4) The nurse has just completed the assessment of a client admitted with a gunshot wound to the
femoral artery. Which of the following would be the priority nursing diagnosis for this client?
A) Deficient Fluid Volume
B) Ineffective Coping
C) Ineffective Airway Clearance
D) Decreased Cardiac Output
Answer: D
Explanation: A) The client sustained a gunshot wound to the femoral artery, which would lead
to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a
priority for the client is Decreased Cardiac Output because of low blood volume. There is not
enough information to determine whether the client has ineffective airway clearance. The client
will most likely have deficient fluid volume; however, cardiac output is the first priority at this
time. There is not enough information to determine whether the client is experiencing ineffective
coping.
B) The client sustained a gunshot wound to the femoral artery, which would lead to significant
bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for
the client is Decreased Cardiac Output because of low blood volume. There is not enough
information to determine whether the client has ineffective airway clearance. The client will
most likely have deficient fluid volume; however, cardiac output is the first priority at this time.
There is not enough information to determine whether the client is experiencing ineffective
coping.
C) The client sustained a gunshot wound to the femoral artery, which would lead to significant
bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for
the client is Decreased Cardiac Output because of low blood volume. There is not enough
information to determine whether the client has ineffective airway clearance. The client will
most likely have deficient fluid volume; however, cardiac output is the first priority at this time.
There is not enough information to determine whether the client is experiencing ineffective
coping.
D) The client sustained a gunshot wound to the femoral artery, which would lead to significant
bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for
the client is Decreased Cardiac Output because of low blood volume. There is not enough
information to determine whether the client has ineffective airway clearance. The client will
most likely have deficient fluid volume; however, cardiac output is the first priority at this time.
There is not enough information to determine whether the client is experiencing ineffective
coping.
Page Ref: 1231
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
shock.

138
Copyright © 2015 Pearson Education, Inc.
5) The nurse is administering albumin 5% to a client in shock. What should the nurse include in
this client's plan of care?
A) Auscultate breath sounds for inspiratory stridor.
B) Auscultate breath sounds for crackles.
C) Auscultate breath sounds for hyperresonance.
D) Auscultate for an absence of breath sounds in the lower lobes.
Answer: B
Explanation: A) Because albumin 5% is a volume expander and pulls fluid into the vascular
space, circulatory overload is a serious complication. The nurse must monitor breath sounds;
crackles will be heard with pulmonary congestion. An absence of breath sounds is heard with a
pneumothorax, not with pulmonary edema. Hyperresonance is assessed by percussion, not
auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.
B) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard
with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with
pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is
auscultated with airway obstruction, not pulmonary edema.
C) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard
with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with
pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is
auscultated with airway obstruction, not pulmonary edema.
D) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory
overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard
with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with
pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. Stridor is
auscultated with airway obstruction, not pulmonary edema.
Page Ref: 1229
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with shock and his or her
family in collaboration with other members of the healthcare team.

139
Copyright © 2015 Pearson Education, Inc.
6) The nurse explains the purpose of an infusion of albumin 5% to a client recovering from
hypovolemic shock. Which statement indicates that the client understands the instructions?
A) "It is a protein that causes my kidneys to conserve fluid."
B) "It is a protein that pulls water into my blood vessels."
C) "It is a liquid that has electrolytes in it to pull water into my blood vessels."
D) "It is a super-concentrated salt solution that helps me conserve body fluid."
Answer: B
Explanation: A) Colloids are proteins or other large molecules that stay suspended in the blood
for long periods because they are too large to easily cross membranes. They draw water
molecules from the cells and tissues into the blood vessels through their ability to increase
plasma oncotic pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not
proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and
promote urine output. Albumin 5% does not act on the kidneys. Albumin 5% is not a
concentrated saline solution.
B) Colloids are proteins or other large molecules that stay suspended in the blood for long
periods because they are too large to easily cross membranes. They draw water molecules from
the cells and tissues into the blood vessels through their ability to increase plasma oncotic
pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in
concentrations resembling those of plasma. They are used to replace lost fluids and promote
urine output. Albumin 5% does not act on the kidneys. Albumin 5% is not a concentrated saline
solution.
C) Colloids are proteins or other large molecules that stay suspended in the blood for long
periods because they are too large to easily cross membranes. They draw water molecules from
the cells and tissues into the blood vessels through their ability to increase plasma oncotic
pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in
concentrations resembling those of plasma. They are used to replace lost fluids and promote
urine output. Albumin 5% does not act on the kidneys. Albumin 5% is not a concentrated saline
solution.
D) Colloids are proteins or other large molecules that stay suspended in the blood for long
periods because they are too large to easily cross membranes. They draw water molecules from
the cells and tissues into the blood vessels through their ability to increase plasma oncotic
pressure. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in
concentrations resembling those of plasma. They are used to replace lost fluids and promote
urine output. Albumin 5% does not act on the kidneys. Albumin 5% is not a concentrated saline
solution.
Page Ref: 1229
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with shock.

140
Copyright © 2015 Pearson Education, Inc.
7) A client being treated for hypovolemic shock is prescribed a low dose of dopamine. What will
the nurse assess after administering this medication?
A) Stabilization of fluid loss
B) Increased cardiac output
C) Vasoconstriction and increased blood pressure
D) Urinary output of at least 30 mL/hour
Answer: D
Explanation: A) At low doses, dopamine stimulates dopaminergic receptors, especially in the
kidneys, leading to vasodilation and an increased blood flow through the kidneys. Increased
cardiac output occurs with high, not low, doses of dopamine when beta1-adrenergic receptors are
stimulated. Vasoconstriction and increased blood pressure occur with high, not low, doses of
dopamine when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or
stabilize fluid loss.
B) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading
to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs
with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated.
Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine
when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid
loss.
C) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading
to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs
with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated.
Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine
when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid
loss.
D) At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys, leading
to vasodilation and an increased blood flow through the kidneys. Increased cardiac output occurs
with high, not low, doses of dopamine when beta1-adrenergic receptors are stimulated.
Vasoconstriction and increased blood pressure occur with high, not low, doses of dopamine
when alpha-adrenergic receptors are stimulated. Dopamine does not prevent or stabilize fluid
loss.
Page Ref: 1228
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with shock.

141
Copyright © 2015 Pearson Education, Inc.
8) A client is receiving intravenous nitroprusside (Nipride) as part of treatment for shock. For
what adverse effects should the nurse assess the client during this infusion?
Select all that apply.
A) Nausea, muscle spasms, and disorientation
B) Confusion, dizziness, and tachycardia
C) Intravenous site for infiltration
D) Gastrointestinal bleeding
E) Shortness of breath
Answer: A, B
Explanation: A) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
should be reported immediately, with the infusion slowed to a keep-open rate. Although the
intravenous site should be assessed for infiltration, the local tissue reaction is less severe than
that which can occur with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness
of breath are not adverse effects of this medication.
B) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can
occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be
reported immediately, with the infusion slowed to a keep-open rate. Although the intravenous
site should be assessed for infiltration, the local tissue reaction is less severe than that which can
occur with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not
adverse effects of this medication.
C) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can
occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be
reported immediately, with the infusion slowed to a keep-open rate. Although the intravenous
site should be assessed for infiltration, the local tissue reaction is less severe than that which can
occur with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not
adverse effects of this medication.
D) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can
occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be
reported immediately, with the infusion slowed to a keep-open rate. Although the intravenous
site should be assessed for infiltration, the local tissue reaction is less severe than that which can
occur with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not
adverse effects of this medication.
E) Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can
occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia should be
reported immediately, with the infusion slowed to a keep-open rate. Although the intravenous
site should be assessed for infiltration, the local tissue reaction is less severe than that which can
occur with a vasoconstrictor or inotrope. Gastrointestinal bleeding and shortness of breath are not
adverse effects of this medication.
Page Ref: 1228
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 6. Plan evidence-based care for an individual with shock and his or her
family in collaboration with other members of the healthcare team.

142
Copyright © 2015 Pearson Education, Inc.
9) A nurse is caring for a client who was involved in a motor vehicle accident and has lost
approximately 1,500 mL of blood. Which type of hemorrhagic shock describes this client?
A) Class I
B) Class II
C) Class III
D) Class IV
Answer: C
Explanation: A) This client is in Class III (moderate) hemorrhagic shock, which is defined as a
loss of 1,500-2,000mL or 30% to 40% of blood volume.
B) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
2,000mL or 30% to 40% of blood volume.
C) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
2,000mL or 30% to 40% of blood volume.
D) This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-
2,000mL or 30% to 40% of blood volume.
Page Ref: 1219
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of shock.

143
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in the ICU is caring for a client in progressive hemorrhagic shock. Which
clinical manifestation is likely present?
A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP)
B) A blood loss of 25%
C) A change from aerobic to anaerobic metabolism
D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space
Answer: C
Explanation: A) In intermediate or progressive hemorrhagic shock, there is a change from
aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of
shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a
blood loss of 35% to 50%. The acid by-products of anaerobic metabolism causes an increase, not
decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
B) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when
there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to
50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in
hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
C) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when
there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to
50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in
hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
D) In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic
metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when
there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35% to
50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in
hydrostatic pressure within the capillary, shifting fluid into the interstitial space.
Page Ref: 1219
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of shock.

144
Copyright © 2015 Pearson Education, Inc.
Exemplar 16.13 Stroke

1) While completing a health history with an older client, the nurse learns that the client
experienced a transient ischemic attack several months ago. What does this information suggest
to the nurse?
A) The client is at risk for an ischemic thrombotic stroke.
B) The client will have minimal symptoms should a stroke occur.
C) The client will not experience a stroke in the future.
D) The client is at high risk for a hemorrhagic stroke.
Answer: A
Explanation: A) Transient ischemic attacks are often warning signs of an ischemic thrombotic
stroke. One or many transient ischemic attacks may precede a stroke, with the time between the
attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the
rupture of a cerebral blood vessel and is not related to a transient ischemic attack. There is no
way to predict the symptoms the client will experience after a stroke.
B) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or
many transient ischemic attacks may precede a stroke, with the time between the attack and the
stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral
blood vessel and is not related to a transient ischemic attack. There is no way to predict the
symptoms the client will experience after a stroke.
C) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or
many transient ischemic attacks may precede a stroke, with the time between the attack and the
stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral
blood vessel and is not related to a transient ischemic attack. There is no way to predict the
symptoms the client will experience after a stroke.
D) Transient ischemic attacks are often warning signs of an ischemic thrombotic stroke. One or
many transient ischemic attacks may precede a stroke, with the time between the attack and the
stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral
blood vessel and is not related to a transient ischemic attack. There is no way to predict the
symptoms the client will experience after a stroke.
Page Ref: 1235
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of stroke.

145
Copyright © 2015 Pearson Education, Inc.
2) While teaching a wellness class on the warning signs of stroke, a participant asks the nurse,
"What's the most important thing for me to remember?" What is an appropriate response by the
nurse?
A) "Be alert for sudden weakness or numbness."
B) "Know your family history."
C) "Keep a list of your medications."
D) "Call 911 if you notice a gradual onset of paralysis or confusion."
Answer: A
Explanation: A) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of
speech, confusion, dizziness, unsteadiness, and loss of balance–the key word is sudden. Family
history and past medical history can be indicators for risk, but they are not warning signs of
stroke. Gradual onset of symptoms is not indicative of a stroke.
B) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech,
confusion, dizziness, unsteadiness, and loss of balance–the key word is sudden. Family history
and past medical history can be indicators for risk, but they are not warning signs of stroke.
Gradual onset of symptoms is not indicative of a stroke.
C) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech,
confusion, dizziness, unsteadiness, and loss of balance–the key word is sudden. Family history
and past medical history can be indicators for risk, but they are not warning signs of stroke.
Gradual onset of symptoms is not indicative of a stroke.
D) Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech,
confusion, dizziness, unsteadiness, and loss of balance–the key word is sudden. Family history
and past medical history can be indicators for risk, but they are not warning signs of stroke.
Gradual onset of symptoms is not indicative of a stroke.
Page Ref: 1235
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors and prevention methods associated with stroke.

146
Copyright © 2015 Pearson Education, Inc.
3) An older client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client
and family, the nurse will provide teaching in which areas?
Select all that apply.
A) Time adjustment to complete activities
B) How to use a sign board
C) Nutrition support
D) Transfer techniques
E) Information about impulse control
Answer: A, B, D
Explanation: A) The left cerebral hemisphere is responsible for the language center, calculation
skills, and thinking/reasoning abilities. Reading and speaking could be compromised if there is
left-sided brain damage. The client also might display over-cautious behavior and might be slow
to respond or complete activities. Transfer techniques would apply regardless of the side
involved. Impulse control problems can arise with right-sided involvement. Nutritional support
may or may not be an issue with this client.
B) The left cerebral hemisphere is responsible for the language center, calculation skills, and
thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided
brain damage. The client also might display over-cautious behavior and might be slow to
respond or complete activities. Transfer techniques would apply regardless of the side involved.
Impulse control problems can arise with right-sided involvement. Nutritional support may or
may not be an issue with this client.
C) The left cerebral hemisphere is responsible for the language center, calculation skills, and
thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided
brain damage. The client also might display over-cautious behavior and might be slow to
respond or complete activities. Transfer techniques would apply regardless of the side involved.
Impulse control problems can arise with right-sided involvement. Nutritional support may or
may not be an issue with this client.
D) The left cerebral hemisphere is responsible for the language center, calculation skills, and
thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided
brain damage. The client also might display over-cautious behavior and might be slow to
respond or complete activities. Transfer techniques would apply regardless of the side involved.
Impulse control problems can arise with right-sided involvement. Nutritional support may or
may not be an issue with this client.
E) The left cerebral hemisphere is responsible for the language center, calculation skills, and
thinking/reasoning abilities. Reading and speaking could be compromised if there is left-sided
brain damage. The client also might display over-cautious behavior and might be slow to
respond or complete activities. Transfer techniques would apply regardless of the side involved.
Impulse control problems can arise with right-sided involvement. Nutritional support may or
may not be an issue with this client.
Page Ref: 1245
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with stroke.

147
Copyright © 2015 Pearson Education, Inc.
4) A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should
the nurse do?
A) Teach the client the "chin tuck" technique when swallowing.
B) Assist the client to a 90° sitting position, or as high as tolerated, during meals.
C) Check the client's mouth for pocketing of food.
D) Assist the client in maintaining a sitting position for 30 minutes after the meal.
Answer: D
Explanation: A) Keeping the client upright for a time after the meal will help prevent food from
being regurgitated back into the esophagus. The position of the client during the meals as well as
teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help
with regurgitation. Pocketing food does not cause regurgitation.
B) Keeping the client upright for a time after the meal will help prevent food from being
regurgitated back into the esophagus. The position of the client during the meals as well as
teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help
with regurgitation. Pocketing food does not cause regurgitation.
C) Keeping the client upright for a time after the meal will help prevent food from being
regurgitated back into the esophagus. The position of the client during the meals as well as
teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help
with regurgitation. Pocketing food does not cause regurgitation.
D) Keeping the client upright for a time after the meal will help prevent food from being
regurgitated back into the esophagus. The position of the client during the meals as well as
teaching the "chin tuck" technique will assist with the swallowing mechanism but will not help
with regurgitation. Pocketing food does not cause regurgitation.
Page Ref: 1245
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
stroke.

148
Copyright © 2015 Pearson Education, Inc.
5) The nurse is planning care for a client admitted with a stroke. Which intervention would
support the client's sensorimotor needs?
A) Encourage use of non-affected arm to feed self, bathe, and dress.
B) Speak in normal conversational pattern and tones.
C) Provide complete care.
D) Talk loudly and distinctly.
Answer: A
Explanation: A) To address the client's alteration in sensory and motor statuses, the nurse should
encourage the client to use the non-affected arm to feed self, bathe, and dress. The nurse should
not provide all care for the client. The nurse should not talk loudly to the client but should
articulate slower and face the client when speaking. Speaking in normal conversational patterns
and tones may not be adequate when communicating with the client.
B) To address the client's alteration in sensory and motor statuses, the nurse should encourage
the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide
all care for the client. The nurse should not talk loudly to the client but should articulate slower
and face the client when speaking. Speaking in normal conversational patterns and tones may not
be adequate when communicating with the client.
C) To address the client's alteration in sensory and motor statuses, the nurse should encourage
the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide
all care for the client. The nurse should not talk loudly to the client but should articulate slower
and face the client when speaking. Speaking in normal conversational patterns and tones may not
be adequate when communicating with the client.
D) To address the client's alteration in sensory and motor statuses, the nurse should encourage
the client to use the non-affected arm to feed self, bathe, and dress. The nurse should not provide
all care for the client. The nurse should not talk loudly to the client but should articulate slower
and face the client when speaking. Speaking in normal conversational patterns and tones may not
be adequate when communicating with the client.
Page Ref: 1244
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with stroke and his or her
family in collaboration with other members of the healthcare team.

149
Copyright © 2015 Pearson Education, Inc.
6) A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During
discharge teaching, which statement by the client would reflect an understanding of the effects of
this medication?
A) "It will be okay for me to eat anything, as long as it is low-fat."
B) "I will stop taking this medicine if I notice any bruising."
C) "I'll check my blood pressure frequently while taking this medication."
D) "I will not eat spinach while I'm taking this medicine."
Answer: D
Explanation: A) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors.
Green, leafy vegetables contain vitamin K and will therefore interfere with the therapeutic effects
of the drug. Bruising is a common side effect, and the drug should not be stopped unless
prescribed by the physician. Low-fat foods do not interfere with warfarin sodium therapy.
Anticoagulants do not affect the blood pressure.
B) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy
vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.
Bruising is a common side effect, and the drug should not be stopped unless prescribed by the
physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not
affect the blood pressure.
C) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy
vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.
Bruising is a common side effect, and the drug should not be stopped unless prescribed by the
physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not
affect the blood pressure.
D) Warfarin sodium suppresses the synthesis of vitamin K coagulation factors. Green, leafy
vegetables contain vitamin K and will therefore interfere with the therapeutic effects of the drug.
Bruising is a common side effect, and the drug should not be stopped unless prescribed by the
physician. Low-fat foods do not interfere with warfarin sodium therapy. Anticoagulants do not
affect the blood pressure.
Page Ref: 1133
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with stroke.

150
Copyright © 2015 Pearson Education, Inc.
7) A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using
the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the
client's family about the use of this medication?
A) Used to treat thrombotic and hemorrhagic strokes
B) Not associated with serious complications
C) Indicated if the stroke symptoms have occurred within the last 6 hours
D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish
circulation to the involved part of the brain
Answer: D
Explanation: A) Thrombolytic therapy using recombinant tissue plasminogen activator is used to
dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral
circulation. The treatment can be used if the symptoms have occurred within the last 3 hours.
Bleeding is a complication associated with the treatment, which may result in cerebral
hemorrhage causing extensive brain damage and disability. The treatment is only used with
thrombotic strokes.
B) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the
clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The
treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a
complication associated with the treatment, which may result in cerebral hemorrhage causing
extensive brain damage and disability. The treatment is only used with thrombotic strokes.
C) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the
clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The
treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a
complication associated with the treatment, which may result in cerebral hemorrhage causing
extensive brain damage and disability. The treatment is only used with thrombotic strokes.
D) Thrombolytic therapy using recombinant tissue plasminogen activator is used to dissolve the
clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The
treatment can be used if the symptoms have occurred within the last 3 hours. Bleeding is a
complication associated with the treatment, which may result in cerebral hemorrhage causing
extensive brain damage and disability. The treatment is only used with thrombotic strokes.
Page Ref: 1241
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with stroke.

151
Copyright © 2015 Pearson Education, Inc.
8) The nurse is instructing the spouse of a client with a stroke on how to do passive range of
motion to the affected limbs. What should the nurse explain regarding the purpose of these
exercises?
A) Improve muscle strength.
B) Maintain cardiopulmonary function.
C) Improve endurance.
D) Maintain joint flexibility.
Answer: D
Explanation: A) Passive range-of-motion exercises help to maintain joint flexibility. Active
range-of-motion exercises improve muscle strength, improve endurance, and can help maintain
cardiopulmonary functioning. The nurse should instruct the spouse that the exercises will help
with joint flexibility.
B) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary
functioning. The nurse should instruct the spouse that the exercises will help with joint
flexibility.
C) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary
functioning. The nurse should instruct the spouse that the exercises will help with joint
flexibility.
D) Passive range-of-motion exercises help to maintain joint flexibility. Active range-of-motion
exercises improve muscle strength, improve endurance, and can help maintain cardiopulmonary
functioning. The nurse should instruct the spouse that the exercises will help with joint
flexibility.
Page Ref: 1244
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Learning Outcome: 6. Plan evidence-based care for an individual with stroke and his or her
family in collaboration with other members of the healthcare team.

152
Copyright © 2015 Pearson Education, Inc.
9) A client with a suspected TIA presents to the Emergency Department with aphasia. Which is
the pathophysiology causing aphasia?
A) Middle cerebral artery involvement
B) Posterior cerebral artery involvement
C) Ischemia of the left hemisphere
D) Ischemia of the right hemisphere
Answer: C
Explanation: A) Aphasia occurs due to ischemia of the left hemisphere. The other choices may
be involved in a TIA, but are not the causative pathology of aphasia.
B) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in
a TIA, but are not the causative pathology of aphasia.
C) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in
a TIA, but are not the causative pathology of aphasia.
D) Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in
a TIA, but are not the causative pathology of aphasia.
Page Ref: 1238
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Assessment
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of stroke.

153
Copyright © 2015 Pearson Education, Inc.
10) A nurse working in the Emergency Department is aware that there are various cultural and
ethnic risk factors for stroke. The nurse understands that which of the following is an example of
this?
A) African-Americans have an increased incidence of intracerebral hemorrhage.
B) Hispanics have almost twice the number of first-ever strokes compared with whites.
C) African-Americans are more likely to die following a stroke than whites.
D) The prevalence of hypertension among Hispanics is the highest in the world.
Answer: C
Explanation: A) African-Americans are more likely to die following a stroke than whites. Also,
African-Americans have the highest prevalence of hypertension in the world and almost twice
the number of first-ever strokes compared with whites. Hispanics have an increased incidence of
intracerebral hemorrhage.
B) African-Americans are more likely to die following a stroke than whites. Also, African-
Americans have the highest prevalence of hypertension in the world and almost twice the
number of first-ever strokes compared with whites. Hispanics have an increased incidence of
intracerebral hemorrhage.
C) African-Americans are more likely to die following a stroke than whites. Also, African-
Americans have the highest prevalence of hypertension in the world and almost twice the
number of first-ever strokes compared with whites. Hispanics have an increased incidence of
intracerebral hemorrhage.
D) African-Americans are more likely to die following a stroke than whites. Also, African-
Americans have the highest prevalence of hypertension in the world and almost twice the
number of first-ever strokes compared with whites. Hispanics have an increased incidence of
intracerebral hemorrhage.
Page Ref: 1237
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with stroke.

154
Copyright © 2015 Pearson Education, Inc.