Free NCLEX-RN Exam Braindumps (page: 189)

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A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

  1. "Would you describe the intensity, duration, and symptoms associated with your pain?"
  2. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
  3. "Have you had any lesions of the affected leg that have been difficult to heal?"
  4. "Do your muscle spasms occur following rest, walking, or exercising?"

Answer(s): D

Explanation:

(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.



A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:

  1. "Would you describe the intensity, duration, and symptoms associated with your pain?"
  2. "Do you experience swelling at the end of the day in the affected and unaffected leg?"
  3. "Have you had any lesions of the affected leg that have been difficult to heal?"
  4. "Do your muscle spasms occur following rest, walking, or exercising?"

Answer(s): D

Explanation:

(A) Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. (B) Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. (C) Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. (D) With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.



A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

  1. Place the client in a supine position.
  2. Draw a blood sample for arterial blood gases.
  3. Start O2 at 4 L/min.
  4. Establish a patent airway.

Answer(s): D

Explanation:

(A) During impending respiratory failure or asthmatic complications, the client is placed in the high-Fowler position to facilitate comfort and promote optimal gas exchange. (B) Arterial blood gases are monitored in the treatment of respiratory failure during an asthma attack, but it is not an initial intervention. (C) O2 therapy is used during an asthma attack, but it is not the initial intervention. The usual prescribed amount is a cautiously low flow rate of 1­2 L/min. (D) Wheezing is a characteristic clinical finding during an asthma attack. If wheezing suddenlyceases, it usually indicates a complete airway obstruction and requires immediate treatment for respiratory failure or arrest.



A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

  1. Place the client in a supine position.
  2. Draw a blood sample for arterial blood gases.
  3. Start O2 at 4 L/min.
  4. Establish a patent airway.

Answer(s): D

Explanation:

(A) During impending respiratory failure or asthmatic complications, the client is placed in the high-Fowler position to facilitate comfort and promote optimal gas exchange. (B) Arterial blood gases are monitored in the treatment of respiratory failure during an asthma attack, but it is not an initial intervention. (C) O2 therapy is used during an asthma attack, but it is not the initial intervention. The usual prescribed amount is a cautiously low flow rate of 1­2 L/min. (D) Wheezing is a characteristic clinical finding during an asthma attack. If wheezing suddenlyceases, it usually indicates a complete airway obstruction and requires immediate treatment for respiratory failure or arrest.



Page 189 of 431



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