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MCA II Exam 2 Questions and Correct
Answers/ Latest Update / Already Graded
Which clinical finding would the nurse expect to identify when caring
for a client with a left leg venous thrombosis? select all that apply.
a. pain in the left calf
b. intermittent claudication
c. redness in the affected area
d. swelling of the lower left leg
e. ecchymotic areas at the left ankle
f. localized warmth in the lower left leg
Ans: A, C, D, F
pain is related to the edema associated with the inflammatory
response. Redness is related to vasodilation and the
inflammatory response. Edema distal to the venous thrombosis
occurs because of increased venous pressure. Warmth in the
affected part of the leg occurs due to the inflammator y
response. Intermittent claudication (pain when walking,
resulting from tissue ischemia) may occur with peripheral
arterial disease. Ecchymosis is a sign of bleeding and would not
be seen with venous thrombosis.
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A nurse is caring for a client admitted with cardiovascular disease.
During the assessment of the client's lower extremities, the nurse
notes that the client has thin, shiny skin, decreased hair growth, and
thickened toenails. The nurse understands that this may indicate:
a. Venous insufficiency
b. Arterial Insufficiency
c. Phlebitis
d. Lymphedema
Ans: b. Arterial Insufficiency
clients experiencing arterial insufficiency present with
extremities that become pale when elevated and dusky red
when lowered. Lower extremities may also be cool t o touch,
pulses may be absent or mild, and skin may be shiny and thin
with decreased hair growth and thickened nails. Clients with
venous insufficiency often have normal-colored extremities,
normal temperature, normal pulses, marked edema, and brown
pigmentation around the ankles. Phlebitis is an inflammation of
a vein that occurs most often after trauma to the vessel wall,
infection, and immobilization. Lymphedema is swelling in one
or more extremities that is a direct result of impaired flow of
the lymphatic system.
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a client is admitted to the hospital with a long history of uncontrolled
hypertension. which laboratory result will be important for the nurse to
review?
a. blood glucose level
b. white blood cell count
c. blood urea nitrogen
d. lactic dehydrogenase
Ans: c. blood urea nitrogen
hypertension leads to changes in renal blood flow and
eventually to decreased renal function, which is tested with
blood urea nitrogen levels. all of the other results would also be
reviewed by the nurse, but they are no associated with
complications of hypertension. Changes in blood glucose level
are not associated with hypertension, although if the client also
has diabetes then there will be more risk for kidney disease.
White blood cell count is not affected by hypertension, but it
would be assessed for any possible infectious or inflammatory
process. Lactic dehydrogenase is an enzyme associated with
multiple other diagnoses, but it is not affected by hypertension.
which clinical finding would the nurse expect for a client with
hypertensive emergency?
a. increased urine output
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b. severe pounding headache
c. heart rate 110 beats/min
d. weak & thready radial pulses
Ans: b. severe pounding headache
hypertensive emergency often causes hyperte nsive
encephalopathy because of increased cerebral capillary
permeability, leading to severe headache, nausea, vomiting,
and confusion or coma. Increased urine output would not be
expected because acute kidney injury can occur with
hypertensive emergency. Tachycardia is not typically seen with
hypertensive emergency; high blood pressure can lead to
bradycardia because of increased pressure on the carotid sinus
and bodies. Radial pulses would be bounding with hypertensive
emergency.
The nurse is teaching pursed-lip breathing to a client with COPD. The
client asks about the benefit of the exercises. Which explanation would
the nurse give?
a. prevents complications that are associated with COPD
b. relieves shortness of breath by increasing the breath rate
c. increases the amount of air that the client can inhale with each
breath
All rights reserved © 2025/ 2026 |
MCA II Exam 2 Questions and Correct
Answers/ Latest Update / Already Graded
Which clinical finding would the nurse expect to identify when caring
for a client with a left leg venous thrombosis? select all that apply.
a. pain in the left calf
b. intermittent claudication
c. redness in the affected area
d. swelling of the lower left leg
e. ecchymotic areas at the left ankle
f. localized warmth in the lower left leg
Ans: A, C, D, F
pain is related to the edema associated with the inflammatory
response. Redness is related to vasodilation and the
inflammatory response. Edema distal to the venous thrombosis
occurs because of increased venous pressure. Warmth in the
affected part of the leg occurs due to the inflammator y
response. Intermittent claudication (pain when walking,
resulting from tissue ischemia) may occur with peripheral
arterial disease. Ecchymosis is a sign of bleeding and would not
be seen with venous thrombosis.
All rights reserved © 2025/ 2026 |
, Page |2
A nurse is caring for a client admitted with cardiovascular disease.
During the assessment of the client's lower extremities, the nurse
notes that the client has thin, shiny skin, decreased hair growth, and
thickened toenails. The nurse understands that this may indicate:
a. Venous insufficiency
b. Arterial Insufficiency
c. Phlebitis
d. Lymphedema
Ans: b. Arterial Insufficiency
clients experiencing arterial insufficiency present with
extremities that become pale when elevated and dusky red
when lowered. Lower extremities may also be cool t o touch,
pulses may be absent or mild, and skin may be shiny and thin
with decreased hair growth and thickened nails. Clients with
venous insufficiency often have normal-colored extremities,
normal temperature, normal pulses, marked edema, and brown
pigmentation around the ankles. Phlebitis is an inflammation of
a vein that occurs most often after trauma to the vessel wall,
infection, and immobilization. Lymphedema is swelling in one
or more extremities that is a direct result of impaired flow of
the lymphatic system.
All rights reserved © 2025/ 2026 |
, Page |3
a client is admitted to the hospital with a long history of uncontrolled
hypertension. which laboratory result will be important for the nurse to
review?
a. blood glucose level
b. white blood cell count
c. blood urea nitrogen
d. lactic dehydrogenase
Ans: c. blood urea nitrogen
hypertension leads to changes in renal blood flow and
eventually to decreased renal function, which is tested with
blood urea nitrogen levels. all of the other results would also be
reviewed by the nurse, but they are no associated with
complications of hypertension. Changes in blood glucose level
are not associated with hypertension, although if the client also
has diabetes then there will be more risk for kidney disease.
White blood cell count is not affected by hypertension, but it
would be assessed for any possible infectious or inflammatory
process. Lactic dehydrogenase is an enzyme associated with
multiple other diagnoses, but it is not affected by hypertension.
which clinical finding would the nurse expect for a client with
hypertensive emergency?
a. increased urine output
All rights reserved © 2025/ 2026 |
, Page |4
b. severe pounding headache
c. heart rate 110 beats/min
d. weak & thready radial pulses
Ans: b. severe pounding headache
hypertensive emergency often causes hyperte nsive
encephalopathy because of increased cerebral capillary
permeability, leading to severe headache, nausea, vomiting,
and confusion or coma. Increased urine output would not be
expected because acute kidney injury can occur with
hypertensive emergency. Tachycardia is not typically seen with
hypertensive emergency; high blood pressure can lead to
bradycardia because of increased pressure on the carotid sinus
and bodies. Radial pulses would be bounding with hypertensive
emergency.
The nurse is teaching pursed-lip breathing to a client with COPD. The
client asks about the benefit of the exercises. Which explanation would
the nurse give?
a. prevents complications that are associated with COPD
b. relieves shortness of breath by increasing the breath rate
c. increases the amount of air that the client can inhale with each
breath
All rights reserved © 2025/ 2026 |
