Online Practice Test 51

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 51 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 5:07 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		A neighbor recently has been diagnosed with congestive heart failure, and seeks information on the cause of the disease. In a discussion with the neighbor, it is related that the functional mechanism for heart failure is: Your Answer: That the heart is not able to keep up with the body's needs for oxygen and nutrients to tissues, due to a variety of reasons
		Objective: Discuss the manifestations of cardiovascular disorders. Rationale: Heart failure may develop if the heart isn't able to keep up with the body's need for oxygen and nutrients to the tissues. Heart failure usually occurs because of myocardial infarction, chronic overwork of the heart, or cardiac muscle impairment. Smoking and being overweight are risk factors related to this problem. A normally functioning heart conduction system should not interfere with the heart's ability to pump unless the muscle that it is acting upon is damaged severely. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		A middle-aged woman presents to a primary care provider's office with a complaint of aching legs and swelling every evening. Her occupation is waitress. She wears walking shoes at work, is 30 pounds over weight, and smokes half a pack of cigarettes a day. Which of the following interventions, restated to the nurse by the client, shows that there is still a misunderstanding in the concepts being presented?  Your Answer: Resting as much as possible with legs crossed
		Objective: Identify major risk factors for the development of coronary heart disease. Rationale: Activity is encouraged because leg exercises help promote circulation in the extremities and the return of venous blood to the heart. Crossing legs sets up the possibility of blocking blood flow and allowing stasis to form. It is discouraged. Smoking alters the size of the vessels constricting them, causing more work needed to pump fluid through them. Maintaining ideal weight does not add any extra workload to the heart or vessels. Antiembolic stockings provide varying degrees of leg compression to the vessels, assisting the venous return of blood to the heart. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		When evaluating the size and shape of the heart and great vessels of a client with congestive heart failure, a number of assessment techniques can be performed. Which technique noted below would not be included in the assessment of this client?  Your Answer: Visual assessment for eye refraction
		Objective: Outline the structure and function of the cardiovascular system. Rationale: Although the eye is supplied by blood vessels, certainly these have an impact on the overall health. Visual assessment for eye refraction is not routinely performed for a client with congestive heart failure. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Which person is most at risk for experiencing sudden cardiac event? Your Answer: A 50-year-old hypertensive, high-lipid profile male
		Objective: Identify major risk factors for the development of coronary heart disease Rationale: Research has identified hypertension and high lipid levels as relevant risk factors to cardiovascular disease, setting up the possibility of a sudden cardiac event. The infant's description seems normal. The 10-year-old may see consequences of the illness later in life. The elderly client is at risk and should be monitored over time, but with normal blood pressures, the risk is slightly diminished over the 50-year-old. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		A client with chest pain and shortness of breath has arrived in the Emergency Department. The nurse is about to perform a physical assessment on this person. Data to be obtained in the nursing history of relevance to heart disease includes:  Your Answer: History including diabetes and smoking
		Objective: List signs of alterations in cardiovascular function. Rationale: Diabetes accelerates the development of cardiac disease, and smoking (nicotine) causes constriction of vessels, changing the diameter of the vessels through which blood is flowing. Broken bones, gum chewing, and multivitamins have no overall effect on this issue. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
6.		The cardinal signs of cardiac arrest include all of the following signs except: Your Answer: Dilated pupils Correct Answer: Gurgling sounds in the lungs
		Objective: Describe the critical nature of cardiopulmonary resuscitation. Rationale: Gurgling sounds in the lung represent the accumulation of fluid in the lungs, and are not a sign that the heart stops beating. The remaining signs noted are all recognized by the author and the American Heart Association as the cardinal signs of cardiac arrest. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Evaluation Strategy: ABCs: airway, breathing, circulation
7.		When assessing any client coming to see a primary care provider, a heart rate assessment is common practice. Of the client assessments performed, for which client would most concern the nurse? Your Answer: The 50-year-old hypertensive executive with a heart rate of 130
		Objective: Identify factors influencing cardiovascular function. Rationale: Pulse rates are normally highest and most variable in newborns, decreasing throughout infancy and early childhood, and reaching the adult rate of 55 to q100 beats about age 10. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
8.		The leading indicator and contributor of cardiac disease as the cause of death in North America is: Your Answer: Atherosclerosis
		Objective: Identify major risk factors for the development of coronary heart disease. Rationale: Atherosclerosis, the buildup of fatty plaque within the arteries, is the major contributor to cardiovascular disease, and the leading cause of death in North America. Aging and gender are considered to be risk factors that can lead to the development of cardiac diseases. Congenital heart defects usually show consequences in relation to heart muscle problems. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		Which practices promote a healthy heart? (Select all that apply.) Your Answer: Regular Exercise Correct Answer: Low carb/High fat diet
		Objective: Identify and describe nursing measures to promote circulation. Rationale: Exercise regularly, eliminate smoking, low fat diet, alcohol in moderation, reduce stress and manage anger, manage diabetes and hypertension. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and health promotion activities.
10.		An individual who has had a cardiac arrest has how much time before the lack of oxygen causes brain damage? Your Answer: Eight to Ten Minutes Correct Answer: Less than Four minutes
		Objective: Describe the critical nature of cardiopulmonary resuscitation. Rationale: 4 to 6 minutes without oxygen can cause permanent brain damage. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge to answer question.