A nurse is teaching a client who has peripheral arterial disease. Which of the following statements should the nurse include in the teaching to explain peripheral arterial disease?

"Blood flow is altered and causes blood to pool in the legs."

"Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood."

"Blood flow is altered due to incompetent valves causing increased venous pressure."

"Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract."

Answer and Explanation

The Correct Answer is B

A. "Blood flow is altered and causes blood to pool in the legs." This statement inaccurately describes venous insufficiency rather than peripheral arterial disease (PAD). In PAD, blood flow is reduced or obstructed due to atherosclerosis, leading to inadequate oxygen supply to tissues rather than pooling of blood in the legs.

B. "Blood flow is altered due to atherosclerosis affecting the tissues' ability to receive oxygen-rich blood." This statement correctly explains the underlying pathology of peripheral arterial disease (PAD). Atherosclerosis, characterized by the buildup of plaque in the arteries, narrows or blocks blood flow, impairing the delivery of oxygen-rich blood to the tissues. This can result in symptoms such as pain, cramping, and tissue damage, especially during activity when oxygen demand increases.

C. "Blood flow is altered due to incompetent valves causing increased venous pressure." This statement describes venous insufficiency rather than PAD. In venous insufficiency, faulty valves in the veins result in increased venous pressure, leading to symptoms such as swelling, heaviness, and varicose veins, but it does not involve arterial obstruction as seen in PAD.

D. "Blood flow is altered due to excessive stretching of the ventricles impairing the heart to contract." This statement describes a condition related to the heart's function rather than peripheral arterial disease. Excessive stretching of the ventricles may occur in conditions such as heart failure, but it does not directly affect blood flow in the peripheral arteries as seen in PAD.

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Correct Answer is D

Explanation

A. Lie on your back when sleeping: Lying on the back when sleeping may be recommended initially after cochlear implant surgery to avoid putting pressure on the surgical site. However, this instruction should not be included in the plan of care indefinitely. Once the client is comfortable and the surgical site is healing well, they should be allowed to sleep in any position that is comfortable for them.

B. Lie on your front when sleeping: Lying on the front when sleeping is not typically recommended after cochlear implant surgery, as it may put pressure on the surgical site and disrupt healing. This position could potentially cause discomfort and increase the risk of complications. Therefore, this instruction should not be included in the plan of care.

C. Resume your exercise routine: Resuming the exercise routine immediately after cochlear implant surgery may not be advisable. The client should be instructed to avoid strenuous activities and heavy lifting for a certain period as advised by the healthcare provider. Engaging in vigorous exercise too soon after surgery could potentially disrupt the healing process and increase the risk of complications. Therefore, this instruction should not be included in the plan of care immediately after surgery.

D. Wash your hair 24 hr after surgery: After cochlear implant insertion, it is important to keep the surgical site clean to prevent infection. Washing the hair 24 hours after surgery helps to maintain cleanliness and hygiene without disrupting the surgical site. It is typically safe to wash the hair after this period as long as gentle care is taken to avoid excessive manipulation of the implant site.

A. Atrial fibrillation B. Sinus bradycardia C. Supraventricular tachycardia D. First-degree heart block

Correct Answer is A

Explanation

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and irregular ventricular response. The heart rate in atrial fibrillation can be variable, and the absence of identifiable P waves indicates disorganized atrial electrical activity.

B. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute (bpm) and normal P waves preceding each QRS complex. In sinus bradycardia, the PR interval and QRS duration are typically within normal limits.

C. Supraventricular tachycardia: Supraventricular tachycardia (SVT) is characterized by a regular rhythm with a heart rate greater than 100 bpm. SVT typically presents with narrow QRS complexes and may or may not have discernible P waves.

D. First-degree heart block: First-degree heart block is characterized by a prolonged PR interval (>0.20 seconds) but maintains a regular rhythm with normal QRS duration. In first-degree heart block, P waves are typically identifiable, and the rhythm is not irregular.

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A nurse is teaching a client who has peripheral arterial disease. Which of the following statements should the nurse include in the teaching to explain peripheral arterial disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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