MULTIPLE RESPONSE
1. The nurse assessing a client knows that endocrine disorders can present with
which of the following manifestations? (Select all that apply.)
a. Dark or tea-colored urine
b. Decreased libido
c. Impotence or infertility
d. Irregular menstrual cycle
e. Muscle wasting and atrophy
ANS: B, C, D
Other manifestations of endocrine disorders include loss or premature development of secondary
sex characteristics. Visual changes such as bulging eyes may occur from hyperthyroidism.
2. Important aspects of the social history the nurse should include when examining a
client are (Select all that apply)
a. alcohol intake.
b. food preferences.
c. sexual activities.
d. use of items contaminated with body fluids.
e. use of recreational drugs.
ANS: A, C, D, E
The client’s social history can give important information as to risks for diseases. All the above
options except b are included in a social history.
1. During a physical exam, the nurse asks the client about medical problems that can impact
vascular health, including (Select all that apply)
a. diabetes.
b. heart disease.
c. stroke or TIA.
d. gallbladder disease.
e. prior frostbite.
ANS: A, B, C, E
The nurse should specifically question the client about hypertension, diabetes, stroke, TIAs,
changes in vision, phlebitis, history of blood clots, pulmonary emboli, varicose veins, or a
previous history of frostbite.
, 2. Age-related changes the nurse incorporates into interpreting the physical
assessment for vascular disorders include (Select all that apply)
a. blood pressure readings are often inaccurate in older people.
b. dorsalis pedis and posterior tibial pulses may be more difficult to palpate.
c. peripheral vascular disease is common among the elderly.
d. skin changes, such as dependent rubor, are often seen in people over 65.
ANS: B, C
Atherosclerosis and peripheral vascular disease are both more common in the elderly population.
Also, the dorsalis pedis and posterior tibial pulses may be more difficult to palpate. Blood
pressure readings should not be inaccurate in older people, and dependent rubor is not seen in
older clients in the absence of venous disorders.
1. To prevent possible complications from cardioversion, before administering the
shock, the nurse would ensure that the (Select all that apply)
a. emergency equipment is nearby and in working order.
b. joules are set to 50-100 joules initially on a monophasic machine.
c. machine is set to synchronize with the client’s QRS complex.
d. the Code Blue team has arrived and is prepared.
ANS: A, B, C
Before cardioversion, the nurse selects the appropriate joules to deliver (50-100 initially),
ensures that the machine is “synching” with the client’s QRS complex, and has ensured that
emergency resuscitation equipment and supplies are ready to use if needed. Cardioversion is an
elective procedure (usually) and does not require the presence of the Code Blue team.
DIF: Application/Applying REF: p. 1458 OBJ: Intervention
MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment
2. A client is being discharge after having a pacemaker implantation. Self-care
instructions the nurse should provide the client include (Select all that apply)
a. carry a pacemaker identification card with you; wear a medical alert bracelet.
b. do not lift more than 5-10 pounds for the first 2 weeks after discharge.
c. take your pulse as directed and notify the doctor if it is less than the pacer rate.
d. you can safely operate most appliances, tools, and office equipment.
ANS: A, C, D
A client with a permanent pacemaker needs to follow the advice in options a, c, and d. the client
should not lift more than 5-10 pounds for the first 6 weeks after surgery. See the Client
Education Guide on The Client with a Permanent Pacemaker for more self-care measures.
, 3. Before the insertion of a temporary pacemaker, the nurse should assess the
client’s (Select all that apply)
a. anxiety level.
b. coping mechanisms.
c. knowledge level.
d. past experience with temporary pacers.
ANS: A, B, C
A client getting a temporary pacemaker may well be anxious because of the emergent need for
this procedure and because it signifies that the client’s heart rate and rhythm is unstable.
Assisting the client to manage anxiety includes assessing anxiety, knowledge of the procedure,
and coping methods. Clients most likely have not had past experiences with temporary pacing;
the need for a temporary pacer often precedes a permanent pacemaker.
1. Important health promotion measures a nurse could teach a client in order to
avoid another episode of DVT include (Select all that apply)
a. avoiding prolonged sitting.
b. elevating the legs when sitting.
c. maintaining an ideal body weight.
d. remaining hydrated.
ANS: A, C, D
Virchow’s triad describes the pathophysiologic conditions that have to exist in order to have a
DVT. The components are venous stasis (caused by immobilization, prolonged travel, pregnancy,
lack of use of the calf muscle pump, and heart disease, among others), hypercoagulability
(caused by dehydration, blood dyscrasias, and oral contraceptives, among other things), and
vascular injury (caused by fractures, trauma, dislocations, and chemical irritation, among other
things). Two of the three factors must be present to form a DVT.
2. A client who is receiving IV heparin has a PTT reported by the lab as 101.
Appropriate actions by the nurse include (Select all that apply)
a. continuing to monitor the heparin infusion.
b. instituting safety precautions.
c. notifying the physician.
1. The nurse assessing a client knows that endocrine disorders can present with
which of the following manifestations? (Select all that apply.)
a. Dark or tea-colored urine
b. Decreased libido
c. Impotence or infertility
d. Irregular menstrual cycle
e. Muscle wasting and atrophy
ANS: B, C, D
Other manifestations of endocrine disorders include loss or premature development of secondary
sex characteristics. Visual changes such as bulging eyes may occur from hyperthyroidism.
2. Important aspects of the social history the nurse should include when examining a
client are (Select all that apply)
a. alcohol intake.
b. food preferences.
c. sexual activities.
d. use of items contaminated with body fluids.
e. use of recreational drugs.
ANS: A, C, D, E
The client’s social history can give important information as to risks for diseases. All the above
options except b are included in a social history.
1. During a physical exam, the nurse asks the client about medical problems that can impact
vascular health, including (Select all that apply)
a. diabetes.
b. heart disease.
c. stroke or TIA.
d. gallbladder disease.
e. prior frostbite.
ANS: A, B, C, E
The nurse should specifically question the client about hypertension, diabetes, stroke, TIAs,
changes in vision, phlebitis, history of blood clots, pulmonary emboli, varicose veins, or a
previous history of frostbite.
, 2. Age-related changes the nurse incorporates into interpreting the physical
assessment for vascular disorders include (Select all that apply)
a. blood pressure readings are often inaccurate in older people.
b. dorsalis pedis and posterior tibial pulses may be more difficult to palpate.
c. peripheral vascular disease is common among the elderly.
d. skin changes, such as dependent rubor, are often seen in people over 65.
ANS: B, C
Atherosclerosis and peripheral vascular disease are both more common in the elderly population.
Also, the dorsalis pedis and posterior tibial pulses may be more difficult to palpate. Blood
pressure readings should not be inaccurate in older people, and dependent rubor is not seen in
older clients in the absence of venous disorders.
1. To prevent possible complications from cardioversion, before administering the
shock, the nurse would ensure that the (Select all that apply)
a. emergency equipment is nearby and in working order.
b. joules are set to 50-100 joules initially on a monophasic machine.
c. machine is set to synchronize with the client’s QRS complex.
d. the Code Blue team has arrived and is prepared.
ANS: A, B, C
Before cardioversion, the nurse selects the appropriate joules to deliver (50-100 initially),
ensures that the machine is “synching” with the client’s QRS complex, and has ensured that
emergency resuscitation equipment and supplies are ready to use if needed. Cardioversion is an
elective procedure (usually) and does not require the presence of the Code Blue team.
DIF: Application/Applying REF: p. 1458 OBJ: Intervention
MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment
2. A client is being discharge after having a pacemaker implantation. Self-care
instructions the nurse should provide the client include (Select all that apply)
a. carry a pacemaker identification card with you; wear a medical alert bracelet.
b. do not lift more than 5-10 pounds for the first 2 weeks after discharge.
c. take your pulse as directed and notify the doctor if it is less than the pacer rate.
d. you can safely operate most appliances, tools, and office equipment.
ANS: A, C, D
A client with a permanent pacemaker needs to follow the advice in options a, c, and d. the client
should not lift more than 5-10 pounds for the first 6 weeks after surgery. See the Client
Education Guide on The Client with a Permanent Pacemaker for more self-care measures.
, 3. Before the insertion of a temporary pacemaker, the nurse should assess the
client’s (Select all that apply)
a. anxiety level.
b. coping mechanisms.
c. knowledge level.
d. past experience with temporary pacers.
ANS: A, B, C
A client getting a temporary pacemaker may well be anxious because of the emergent need for
this procedure and because it signifies that the client’s heart rate and rhythm is unstable.
Assisting the client to manage anxiety includes assessing anxiety, knowledge of the procedure,
and coping methods. Clients most likely have not had past experiences with temporary pacing;
the need for a temporary pacer often precedes a permanent pacemaker.
1. Important health promotion measures a nurse could teach a client in order to
avoid another episode of DVT include (Select all that apply)
a. avoiding prolonged sitting.
b. elevating the legs when sitting.
c. maintaining an ideal body weight.
d. remaining hydrated.
ANS: A, C, D
Virchow’s triad describes the pathophysiologic conditions that have to exist in order to have a
DVT. The components are venous stasis (caused by immobilization, prolonged travel, pregnancy,
lack of use of the calf muscle pump, and heart disease, among others), hypercoagulability
(caused by dehydration, blood dyscrasias, and oral contraceptives, among other things), and
vascular injury (caused by fractures, trauma, dislocations, and chemical irritation, among other
things). Two of the three factors must be present to form a DVT.
2. A client who is receiving IV heparin has a PTT reported by the lab as 101.
Appropriate actions by the nurse include (Select all that apply)
a. continuing to monitor the heparin infusion.
b. instituting safety precautions.
c. notifying the physician.
